摘要：The substantial disparities in health and poorer outcomes in the United States relative to peer nations suggest the need to refocus health policy. Through direct contact with the most vulnerable segments of the population, social workers have developed an approach to policy that recognizes the importance of the social environment, the value of social relationships, and the significance of value-driven policymaking. This approach could be used to reorient health, health care, and social policies. Accordingly, social workers can be allies to public health professionals in efforts to eliminate disparities and improve population health. Despite spending the most on health care, the United States lags behind a majority of its peer countries in life expectancy and other major health indicators across the life course. US infant mortality rates are more than triple those of the Organisation for Economic Co-operation and Development countries with the lowest rates (Iceland and Finland), 1 and later in life levels of obesity and cardiovascular disease far exceed those of other countries. 2 Given the many similarities between the United States and England, comparisons of risk factor biomarkers and objective indicators of health between residents of the 2 countries are particularly instructive: US residents fare worse on nearly every health indicator, and this situation persists even after differences in individual risk behaviors (e.g., smoking and alcohol consumption) and insurance coverage have been taken into account. 2,3 Coupled with consistent evidence on the sizable socioeconomic, racial/ethnic, and geographic disparities in morbidity and mortality within the United States, 4 these comparisons suggest that higher levels of health care spending, the continued narrow focus on individual behaviors, and expansion of insurance, although likely important, are not sufficient to significantly improve health in the United States. There is a growing consensus that policies can respond to these important disparities. The American Public Health Association has adopted a health in all policies mantra, developing a series of recommendations for state and local governments to “incorporat[e] health considerations into decision-making across sectors and policy areas.” 5 The US Patient Protection and Affordable Care Act (ACA; Pub L No. 111-148) has created a number of opportunities for innovative care provision, many of which acknowledge the particular needs of the poor and the medically underserved, including expanded opportunities for community health centers, community health workers, and patient-centered medical homes. 5,6 Consonant with an emphasis by key federal entities on the importance of social factors, 7 researchers have begun to investigate whether a focus on the social determinants of health can reduce hospital readmissions and improve patient outcomes. 8 Also, attention has turned to the use of innovative payment mechanisms such as federal waivers that allow Medicaid reimbursement for nonmedical services (e.g., housing). 5 However, the predominant focus of the ACA has been the expansion of insurance coverage. Although insurance increases access to and use of various health services, 9 and coverage expansions under the ACA have been linked to better self-reported well-being and health, the extent to which expanded health care coverage can substantially improve population health remains unclear. 9 Furthermore, many of the innovations noted here focus exclusively on clinical interactions, limiting their potential to effect meaningful changes in population health. This concentrated policy focus on insurance and the health care delivery system is uniquely American, and despite the number of innovations in recent years that endorse a broader view of health policy, the continued predominant focus on insurance (to the exclusion of other policies) has important effects on health. Indeed, social policy differences between the United States and peer countries probably contribute to both the “American health disadvantage” internationally and the within-country health disparities just noted. 10 For instance, UK antipoverty policies are more expansive than comparable US policies, 1 with Britain’s package of social policies representing a far greater commitment to poverty reduction and social redistribution of wealth. 11 Although both countries spend roughly 8% of their gross domestic product (GDP) on public health care, UK family policy expenditures, directed toward family allowance, parental leave, early childhood education, and child care, exceed US expenditures nearly 6-fold (4.0% vs 0.7% of GDP). 1 These comparisons highlight the urgent need for US policymaking to more actively target the social determinants of health, including the “upstream” social structures that activate and maintain health disparities. Reflective of a number of core principles that will be familiar to many in the public health audience, a social work approach to health policy could help redirect attention toward social determinants. Social work has developed a perspective on the relationship between policy and health that is driven by a primary mission of promoting human well-being. 12 This perspective is informed by social work training, which emphasizes systemic influences on behavior, health, and well-being. It is further reinforced by social work practice; social workers are often responsible for frontline implementation of health policy 13 (more than half of the 650 000 practicing social workers in the United States are employed in health settings 14 and engage in activities across the full range of the policy process), and their work frequently places them in close interaction with the most vulnerable segments of the population, 15 both of which provide natural insights into the design and effectiveness of health policies. Consonant with an idea that has recently gained currency in social epidemiological scholarship, 16 a social work approach would suggest the need to refocus policies on “what matters.” From a social work perspective, “what matters” includes social factors that often fall beyond the traditional foci of health policymaking and are instead consistent with some of the novel approaches to public health promotion noted here. Indeed, although recent efforts to repeal and replace the ACA have created an air of uncertainty around federal health policymaking, the advent of many of these innovations has served to formalize an emphasis on the social determinants of health, creating an opportunity for the perspective we articulate in the remainder of this article. We argue that social workers are natural allies of public health policymakers, and in the sections to follow we describe 3 themes that constitute a social work approach to health policy: the importance of the social environment, the importance of social relationships, and the importance of values. In doing so, we adopt a definition of health policy that includes a broad range of government activities spanning programs, formal policies, and regulations at the local, state, and federal levels and encompassing “traditional” health policies and programs such as the ACA, Medicare, and Medicaid, as well as “nontraditional” policies such as antipoverty programs. We also clarify that these themes are not intended to be an exhaustive illustration of a social work approach; others, including an emphasis on strengths, a commitment to vulnerable populations, and a focus on cultural competence are also emblematic. However, the themes we discuss here have salience for health policy, particularly in light of recent developments and policy innovations. After our introduction of the themes, we discuss their implications, summarize key challenges involved in implementing our approach, and provide recommendations for health policy consistent with the themes.
