Social Policy and Professional Ethics Flashcards
Definition of the Institution of Social Welfare: Social Policy
a constellation of laws, regulations, customs, traditions, mores, folkways, values, beliefs, ideologies, roles, role expectations, occupations, organizations, and history, all centering on the fulfillment of vital social functions
Definition of the Institution of Social Welfare: The Functions and Domains of Social Policy
subjective of vigorous debate in western societies
social policy analysts note that there are numerous perspectives and definitions based on varying beliefs about the role of government and society in providing nurturance, care and protection to citizens
Views on Social Policy
major functions of social policy are redistributive; social policy in this view, a vehicle through which harsher consequences of global capitalism and modernism are redressed
other views identify social policy within a network of specific functionals and domains that are more closely resemble traditional social services; these include education, personal social services, housing, health care, employment, and income support
some argue social policy is synonymous with social welfare institutions; social policy deals with residual social functions which are activities not addressed through normal market forces; operate a minimal safety net or programs and supports designed to prevent individuals and families from falling below a loosely defined basic minimum standard
Functions and Domains of Social Policy: Modern Societies
complex socialization requirements that must be delegated to the state
Functions and Domains of Social Policy: Normal Family Functions
no longer be relied upon to provide the full range of opportunities for socialization and protection possible in previous periods
The Societal Context for the Provision of Services: Characteristics of Social Welfare Activities
communal provisions of resources for citizens
social welfare is one spaced of the social contract between citizens and the society
promotes social stability by preventing individuals and families from falling below a minimum standard of health adn welfare
social invetment promotes certain outcomes that are socially desirable and essential
welfare programs focus on target groups who cannot meet their needs through their own efforts or who require social welfare intervention
Major Characteristics of Social Welfare Provisions: Institutional Programs
programs, services, and institutions provided by government as integral social functions
Characteristics of Institutional Programs
services available to all societal members and have broad, inclusive eligibility criteria; they are universal
services and benefits that are not means-tested
Major Characteristics of Social Welfare Provisions: Residual Programs
provided when the market or family is not equipped to provide necessary assistance
Characteristics of Residual Programs
means-tested
also known as the safety net
Majors Characteristics of Social Welfare Provisions: Universal Programs
programs available to everyone regardless of income
non-means tested
significant political insurance against the winds of policy change
they unify diverse political groups since everyone benefits
Universal Programs: Social Security Old Age Programs
insurance programs rather than charity, and are universal since everyone in covered occupation is eligible for benefits
Major Characteristics of Social Welfare Programs: Selective Programs
available to people with certain defined characteristics
usually income-tested
provisions available to people who cannot afford benefits
Characteristics of Social Welfare Activities: Purposes of Social Welfare Programs
benefit target groups, but also express wider interests of the larger society
-society’s image of itself as humane and caring
-desire for social stability
-genuine altruistic impulses
Purposes of Social Welfare Programs: Social Development
certain social welfare programs have a developmental philosophy
they emphasize positive or developmental social goals such as literacy, infant health, maternal well-being, full employment, a higher or a lower birth rate
Purposes of Social Welfare Programs: Social Control
other social welfare programs are more reactive to social deviance and emphasize the control of aberrant behavior
Relationship to Large Social Order: Restoration of Stability/Social Control
-Pacification or rehabilitation of threatening individuals, groups and communities
-Removing target groups from public visibility
Relationship to Large Social Order: Social Change
-Advancing social and technological agendas
-Expanding civil rights and liberties
-Redistributing power and resources
-Supporting and enabling potentially disruptive economic changes by mitigating the worst effects of unemployment and poverty
Traditional Domains of Social Welfare
-Incoming maintenance
-Housing
-Health
-Education
-Employment
-Personal social services
Social Welfare Delivery Systems: Occupational
social welfare benefits provided through the workplace
Social Welfare Delivery System: Fiscal
social welfare benefits provided through tax breaks
Social Welfare Delivery System: Private Market
services are purchased from profit making organizations
Social Welfare Delivery System: Social Services
services received free or on a sliding scale (ability to pay) through public or nonprofit private agencies
Social Policy Issues: 21st Century
focus on the extent to which social programs encourage behaviors that are not socially sanctioned
belief that welfare entitlements promote dependency and cause recipients to leave the job market permanently
some states debated refusing to pay increased benefits for children conceived while the mother was receiving public support
others increased efforts to locate absent fathers to force them to pay for their children
frustration within the system has led to new legislation designed to address these questions
effect has been to place limits on the duration of welfare benefits and to require work or work training as part of the requirement for coninuation
Social Policy Issues: Policy Discussions Invariable Center on Standards of Need
How should the standard be established and by whom?
Should there be a national standard or should each state have the widest flexibility?
To what extent should standards conform to local conditions?
The criteria used for setting benefit levels have many implications
states with more generous benefits or easier eligibility criteria could become magnets for the poor, attracting poverty-stricken recipients from more penurious jurisdictions
local conditions differ
rural areas in many states are far less expensive than large urban centers
uniform benefits would have to account for differing local standards
Social Policy Issues: Other Controversies Continue to Boil Around Social Priorities
How can government mediate between the competing interests of various groups?
For example, does affirmative action discriminate against the white poor?
Should society provide relatively high benefit levels for the elderly, when the numbers of children and young mothers in poverty are rapidly growing?
Should costly medical treatments from seriously ill patients take prioirty over preventative care?
Social Policy Issues: Costs and Taxation
Who should pay for social programs?
How can costs be limited?
Can welfare recipients shoulder more of the burdens?
Should government rely more on user fees?
Should social security taxes become more progressive?
Social Policy Issues: Residual View
services should be rendered on temporary case basis as a response to catastrophe, personal misfortune, or mismanagement
residual social services are to be available only when normal market forces, family resources, or other private resources are overhwlemed or break down
residual services or programs are means-tested or based on some deficiency
they usually fight a stigma
Social Policy Issues: Institutional View
social services are a central function of the society and must be available to all, not just for emergencies or abnormalities in individual, family, or community functioning
services are only rehabilitative but developmental and preventative
geared towards helping individuals reach their fullest human potential
these services are not means-tested and carry no stigma
Income Maintenance: Social Security Act of 1935 with Many Amendments
provides Old Age, Survivors, Disability, and Health Insurance
a federal program operated by the Social Security Administration, a part of the Department of Health and Human Services
the nation’s largest social program and covers 90 percent of the workforce
employers and employees contribute to workers’ Social Security retirement fund
there is a maximum contribution tied to a maximum eligible salary
tax regressive since it has its highest impact on lower wage workers, while the highest paid workers, particularly those over the Social Security maximum, pay at a very low rate
under social security, the basic benefit paid to a retired or permanently disabled worker is related to retirement age and the level of covered earnings
dependents and survivors receive a proportion of the benefit is not means-tested
in the last decade, Social Security rules changed and eligible recipients may continue to work and earn income
Social Security Analysts
concerned about the fiscal health of the Social Security system as the large “baby boom” generation becomes eligible for benefits
begun claiming cash and medical benefits
Income Maintenance: Survivors’ Insurance
paid to surviving minor children (and those still in school and under age 22) and their surviving parent, and to dependent parents of deceased worker
Income Maintenance: Disability Insurance
paid to disabled adults who are unable to work; most people over 65 are entitled to Medicare and voluntary supplemental medical insurance for physician fees
Income Maintenance: Unemployment Insurance
originally passed in 1935 as part of the Social Security Act
employers contribute to a state unemployment fund that benefits workers who are dismissed
the states administer UI
programs and benefits very from state to state
workers must register with the U.S. Employment Service and show willingness and ability to work
benefits are time-limited and are based on past earnings and length of employment
Income Maintenance: Workman’s Compensation
a social insurance program providing cash payments and medical benefits to workers who are injured on the job and suffer a significant disability
the states operate the program, and its coverage varies
Income Maintenance: Supplemental Security Income
passed in 1972 and administered by the Social Security Administration
a program for certain categories of the poor: the aged, blind, and disabled
individuals who are single, healthy, and employable are not eligible for SSI
since the program is administered by a federal agency, eligibility requirements are identical for all states
many states add small cash supplements to the government’s minimum payment
Income Maintenance: Aid to Families with Dependent Children
replaced in 1996 by Temporary Assistance for Needy Families (TANF)
variation in payment levels and some states provide benefits below subsistence levels
“Man in House” Rule 1968
Supreme Court struck down the rule under which families with a man in residence were ineligible for child support, even if the man was not the child’s biological father
The Personal Responsibility and Work Opportunity Reconciliation Act of 1996: Summary
the law has far-reaching implications for Medicaid and family cash assistance programs
it eliminates the open-ended federal entitlements (for state reimbursement) of the Aid to Families with Dependent Children program (AFDC) and creates a block grant for states to provide time-limited cash assistance for needy families
make extensive changes in child care, food stamps, SSI for children, benefits for legal immigrants, and the Support Enforcement Program
modifications to child nutrition programs and reductions in the social services block grant
current laws for child welfare and child protection programs are unchanged
the legislation will reduce federal expenditures with the majority of savings due to changes in the Food Stamp Program and reductions in benefits for legal immigrants
states will have increased flexibility in setting benefit levels and providing related services
Temporary Assistance for Needy Families (TANF) Block Grant (Title I)
provides block grants to the states
Temporary Assistance for Needy Families (TANF) Block Grant (Title I): Use of Block Grant Funds
states may use block grant allocations for any “manner reasonably calculated to accomplish the purpose of Title I (TANF)” activities authorized under Title IV-A and IV-F as of September 30, 1995, are also eligible uses
the bill ends the federal entitlement of individuals to cash assistance under the old AFDC program, and states have complete flexibility to determine eligibility and benefit levels
welfare payments are limited to a 5-year lifetime maximum; states may request waivers
states are expected to provide job training and child care to unemplyed mothers receiving welfare payments
if a two-parent family receives federally funded child care, then both parents must work, with exceptions for parents of severely disabled children or parents who are themselves disabled
states will continue to experiment with measures to control the fertility of mothers on welfare by limiting or restricting benefits to unmarried women who continue to bear children while on welfare
Temporary Assistance for Needy Families (TANF) Block Grant (Title I): Under Age One Exemption
states may exempt single custodial parents with a child under one year from the work requirement
a parent may only receive this exemption for a total of 12 months
Temporary Assistance for Needy Families (TANF) Block Grant (Title I): Sanctions Against the Individuals
assistance may be reduced if adult family members refuse to work
a state may terminate assistance and Medicaid for the individual whose cash assistance is terminated for failure to work
Temporary Assistance for Needy Families (TANF) Block Grant (Title I): Teen Parents
to receive assistance, unmarried teen parents of a minor child at least 12 weeks of age must participate in educational activities directed toward receiving a high school diploma or GED, or participate in an alternative education or training program approved by the state
states must also deny assistance if the teen is not living at home or in an approved adult-supervised setting
Temporary Assistance for Needy Families (TANF) Block Grant (Title I): Paternity Establishment
a state must reduce a family’s grant by 25 percent or may terminate it completely, if the parent fails to cooperate in establishing paternity or in establishing, modifying, or enforcing support order
Temporary Assistance for Needy Families (TANF) Block Grant (Title I): Person Convicted of Drug-Related Felony
cash assistance and food stamp benefits may be denied to individuals convicted of drug possession, use, or distribution, though other family members can receive benefits
to circumvent this provision, states must pass legislation
Temporary Assistance for Needy Families (TANF) Block Grant (Title I): Contingency Fund
the federal government federal matching funds for states experiencing an economic downturn, states must have met one of two triggers to access the fund:
an unemployment rate of 6.5 percent
the number of food stamp recipients must reach a certain legislatively established number
Temporary Assistance for Needy Families (TANF) Block Grant (Title I): Work Requirements
adults in families receiving assistance under block grants are required to participate in work activities after receiving assistance for 24 months
recipients must participate in community service within two months of receiving benefits if they are not working
Temporary Assistance for Needy Families (TANF) Block Grant (Title I): Additional State Options
states may deny assistance to additional children born or conceived while the parent is on welfare (family cap)
states may deny assistance to unmarried teen parents and their children, and require school attendance by parents and children in a family
Temporary Assistance for Needy Families (TANF) Block Grant (Title I): Benefits for Immigrants (Title IV)
-SSI and Food Stamps are limited for legal resident aliens
-the law allows for some exceptions: refugees, asylees, or those granted withhholding of deportation are eligible only for their first five years
-lawful permanent residents with 40 qualifying quarters of work may receive benefits
Temporary Assistance for Needy Families (TANF) Block Grant (Title I): Legal Immigrants
-States can determine eligibility of current legal immigrants for federal cash assistance under Title IV-A (TANF), Medicaid, and services under the Social Services Block Grant (SSBG)
-states decide to provide or deny services at their option
-Immigrants arriving after the bill was enacted are first subject to the five year federal bar, and then states may provide services
-General assistance originally mandated by the Social Security Act, but funded by the states and localities
-To receive federal subsidies for TANF and Social Security Programs, states must offer local financial aid to those poor who do not fit into any federal assistance category; each state administers the program differently
Temporary Assistance for Needy Families (TANF) Block Grant (Title I): Public Housing
initiated in 1937
provides federal subsidies for construction of low-income public housing
public housing is subsidized and means-tested
as a result more successful families are often forced to leave their housing
a central criticism of public housing arises from this policy, since every housing project ultimately concentrates the poorest and least successful of the poor
Temporary Assistance for Needy Families (TANF) Block Grant (Title I): Subsidized Housing
1969 federal law subsidizes the difference between the operating costs of public housing and tenants’ ability to pay
Temporary Assistance for Needy Families (TANF) Block Grant (Title I): Section 8 Benefits (Housing and Community Development Act of 1974)
gives communities more opportunity to use federal block grant aid, and recipients of rent subsidies greater than housing choice
Temporary Assistance for Needy Families (TANF) Block Grant (Title I): Issues
the most problematic questions regarding public housing rest with the growing problem of violence and drug use that seems difficult to control in many large high-risk projects
many cities have demolished large projects built in the 1950s that have become centers of social problems
few new projects are under consideration, as agencies move to scattered site development and housing subsidies to reduce concentrations of poor people in large projects
Temporary Assistance for Needy Families (TANF) Block Grant (Title I): Medical Care
the initiation of Obamacare or ACA altered the landscape for healthcare
programs and dimensions are not fully understood at this time and its major features are being debated
Congress, Unions and large corporations have sought exemption from the act causing some doubt about its popularity
Health: Medicaid
added to Social Security Act (SSA) in 1965
a combined federal and state program that pays for physicians and other health-related services
states administer the program and set policies within federal guidelines
states differ in eligibility requirements but must cover TANF families, SSI recipients, and other poor
Health: Medicare
added to SSA in 1965
funded partly by contributions from the elderly and by general tax revenues
a universal health program to help elderly
not means-tested
covers hospital and medical costs for persons 65 and over and for disabled Social Security beneficiaries
provides basic hospital insurance and optional supplementary medical insurance
patients pay small fees to discourage unnecessary use
new recent drug benefits provide limited benefits and are largely administered by profit-making corporations
Health: Procedures to Limit Costs – PSROs (Professional Standards Review Organizations)
efforts to limit costs of Medicare and Medicaid led to a variety of cost control strategies
1983, DRGs (Diagnostic Related Groups) were introduced and had set maximum reimbursements rates for hospital care under Medicare
HMOs are major providers of medical care for large groups of elderly with the encouragement of the Department of Health and Human Services
Health: Catastrophic Health Insurance
individuals responsible for medical bills up to some limit, after which insurance pays
Health: Employer Contributed Insurance
employment related health care insurance
Health: HMOs vs. Fee-For-Service
the 1973 HMO Act offers federal assistance to independent organizations providing comprehensive health care for those enrolled
members pay fees that entitle them to hospital and physician care
many communities, under pressure from federal policy makers and seeking to control the costs of health care for the poor, are currently emphasizing managed care as a solution for providing health services
What are the cons to HMOs?
costs are uprising as the population ages and many new treatments are developed
analysts claim HMOs have squeezed out most of the waste and their costs will rise dramatically over the next few years
complaints about HMOs and their tendency to deny expensive treatments in some instances are leading to additional regulation (example: minimum hospital stays for childbirth and others are developing oversight mechanisms)
Health: Community Health Centers
first begun under Great Society’s Office of Economic Opportunity
federally-funded health centers are found in many low income areas
many health centers are affiliated with hospitals and managed care organizations, and are able to offer a widespread spectrum of health services
Health: Prospects for National Health Insurance
efforts to enact a comprehensive national health insurance system with universal and mandatory coverage begin with the original SSA in 1935
the Patient Protection and Affordable Care Act, signed into law March 23, 2010 represents that latest development of the drive for universal health care
Nutrition: Food Stamp Program
first federal program from 1939-1943
revised in 1963 and significantly expanded in 2010
largest federal food subsidy program
federal and state government operate the program jointly
How does the Food Stamp Program work?
-Federal government pays the direct cost of food stamps and some state administrative costs
-States administer the program; some have requirements for childless families; able-bodied adults must register and accept work that pays prevailing local rates
-Recent statistics suggest that the program now provides assistance to 40 percent of American families
Nutrition: Women, Infants, and Children (WIC)
special supplemental nutrition program operated by Food and Nutrition Services of the Department of Agriculture through local agencies and health clinics
pregnant and nursing high in important nutrients
Nutrition: School Nutrition Programs for Children
federal reimbursement provided assistance is provided for meals served free or at reduced cost to poor children
Nutrition: Meals for the Elderly
includes Meals on Wheels program and congregate meals in institution
What’re considered the new epidemics?
-Teenage sex, pregnancy, and parenthood
-Acquired Immune Deficiency Symptoms (AIDS)
-HIV and other sexually transmitted diseases
-Alcoholism and drug abuse
-Smoking
Employment: Minimum Wage Legislation
most direct way of increasing earnings of working poor, but farm and domestic workers are not necessarily covered
liberal view is that raising minimum wage will ease poverty
conservatives argue that increasing minimum wage will increase poverty because employers will reduce hiring and will not hire entry level workers
Employment: Vocational Rehabilitation
for mentally and physically disbale who have a reasonable chance of being employed
states run programs according to federal guidelines, supplemented with federal funding
each recipient is assigned a counselor to develop an individualized plan
Employment: Bill of Rights for the Handicapped (Title V of the Rehabilitation Act of 1973)
integrate disabled people into society
all federally subsidized programs and facilities must have affirmative action programs to hire, promote and not discriminate against qualified disabled persons and provide access
Education
-Affirmative Action
-Desegregation
-Head Start: initiated under 1964 Economic Opportunity Act; provides compensatory preschool education for poor children
-Mainstreaming: educating special needs children with other children to the extent feasible
Personal Social Services: Child Welfare
Title IV E of Social Security Act provides child welfare services for disabled, abused, and homeless children
Child Welfare: Child Abuse Prevention and Treatment Act of 1974
requires states to mandate reporting of child abuse and neglect
all states have relatively similar reporting laws, though some variation exists as to who is required to report
Child Welfare: Adoption Assistance and Child Welfare Act of 1980
created a network of regional centers to encourage adoption of children
encourages alternatives to foster placement, and mandates case planning and periodic reviews, etc.
Adoption Assistance and Child Welfare Act of 1980: Introduced Concept of Permanency Planning
a policy initiative supported by Title 2e of the Social Security Act, it required public child welfare agencies to establish standards of accountability and practice designed to insure that children in placement or likely to require placement will receive services designed to insure a permanent home is found
Child Welfare: The Adoption and Safe Families Act of 1997
-Amends previous child welfare reform legislation
-Established national goals for children in the child welfare system; seeks to make the system more responsive to children and families, reaffirms the need for linkages between the child welfare system and other systems of support for families, as well as between the child welfare system and the courts, and encourages removal of barriers that prevent permanency
What’re the key principles in the Adoption and Safe Families Act of 1997?
-Safety of children is of paramount concern and must guide all child welfare services when making service provision, placement and permanency planning decisions
-Foster care is a temporary setting and not a place for children to grow up
-Permanency planning efforts for children should begin as soon as a child enters foster care and should be expedited by the provision of services to families
-The child welfare system must focus on results and accountability (law requires annual reports on state performance; creation of adoption incentive)
-Innovative approached and demonstrations are encouraged to achieve the goals of safety, permanency and well-being (expands authority for child welfare demonstrations; allows states greater flexibility to develop innovative strategies; requires criminal record checks for prospective foster and adoptive parents; health insurance coverage for children with special needs)
Child Welfare: Foster Care Independence Act of 1999
-Benefits youths who have aged out of foster care or are preparing to leave foster care
-Requires states to create job-training and college guidance programs directed to teenagers both before and after leaving foster care
-States will be able to extend Medicaid coverage from 18-21 years of age as well as raise the personal asset level so teenagers in foster care can save for such things as a car or down-payment on an apartment, to ensure smoother transitions between foster care and independent living
Services for the Elderly: Federal Older American Act 1965
to improve quality of life for the elderly
Services for the Elderly: “Aging Network” and Services
coordinated by federal government
lifting of mandatory retirement caps to enable workers to retire at a later time of their own choice
Child Welfare: Mental Health Services
-Alcohol, Drug Abuse, and Mental Health Administration
-Community mental health centers
-Deinstitutionalization and its aftermath (supportive community services were inadequate and failed to provide necessary services to stabilized mentally ill released from inpatient care; led to increase in numbers of homeless mentally ill and remission-reinstitutionalization cycles)
-Rights of mental health patients
Child Welfare: The Title XX Social Services Block Grant
grants to states for providing personal social services such as child welfare services and family planning
state and local governments direct the spending of block grants
Child Welfare: Other Forms of Social Services
-Individual, marital, and family counseling
-Homemaker services
-Alcohol and drug abuse rehabilitation
-Tenant organizing
-Advocacy and legal aid service
-Information and referral service
-Crisis hotline and walk-in services
-Shelters and Counseling for Domestic Violence
-Family Planning Services
-Youth Centers and Programs
-Ethnic Mutual Aid Associations
-Senior Centers
How does Medicare work for its recipients?
select a standard program in which doctor visits are covered by Medicare Part B
Part B has been significantly cut with the advent of the Patient Protection and Affordable Care Act
hospital care is paid through Part A
if an HMO is selected there are no additional fees, though recipients may be required to pay co-payments for doctor visits
managed care plans receive 95 percent of what the government expects it would spend in traditional Medicare
prescription benefits are available under Medicare Part D
What is Managed Care?
broad term for any kind of health insurance where the insurer manages or oversees the care a patient gets – as opposed to traditional “indemnity insurance,” where the patient goes to a doctor and the doctor bills the insurance company, which pays without questioning
What is management like in Managed Care?
insurers may required that patients start out with a general practitioner or primary care doctor instead of going straight to a specialist
insurers may pay primary care doctors to become care managers by being paid a monthly fee for each member-patient who signs up with them, instead of getting a fee for each service rendered
patient may be required to use certain hospitals
doctors may have to seek permission from the insurer regarding a patient’s hospital stay, surgery or specialty care
common forms of care are HMOs and PPOs
Managed Care: Health Maintenance Organization (HMO)
broad term for managed care systems that provide health care services for a monthly premium
people who join HMOs get full medical care, but only from doctors and hospitals that belong to their HMO
HMOs require patients to see primary care doctor assigned to manage the patient’s care, ideally seeing the patient has good preventive care so the patient’s overall health care costs will be low
Types of HMOs: Staff-model HMO
most integrated type of HMO
doctors are full-time employees of the HMO and work on salary
facilities or clinics are owned by the HMO, and patients go to hospitals owned by the HMO
tend to be the largest HMOs; they have fewer enrollees overall than other types
Types of HMOs: Group-Model HMO
contracts with groups of doctors to provide care
second most popular type of HMO, behind IPAs
Types of HMOs: IPAs
doctors contract with HMOs to provide services
depending on the arrangement with the HMO, the doctors may be paid a monthly fee for each member or for each services provided
doctors in IPA finance, who run their own offices, are often in contract with more than one HMO
IPAs have more members than any other type of HMO
Types of HMOs: PPOs (Preferred Provider Organizations)
have been called “managed care lite” because they have fewer restrictions than conventional HMOs
PPOs consist of doctors, hospitals, and other health care providers who have made a deal with insurer to provide patient care at a reduced fee to the insurer
most PPOs allow people who belong to go to any doctor or hospital in the network for, at most, a low co-payment
members may also go directly to a specialist
PPOs allow members to go to doctors or hospitals outside their network for an extra payment
Types of HMO Plans: POS (point-of-service) Plans
fastest growing form of managed care
members can receive regular HMO care or be partly subsidized if they want to use a doctor or hospital not in the HMO
allow patients to go to doctors or hospitals that are not part of the plan, for an extra charge
Types of HMO Plans: PSNs/PSOs (Provider-Sponsored Networks/Organizations
groups of doctors and hospitals who have joined together to offer managed care
act like a full-fledged HMO, selling their services as a full-service health insurer to businesses and individuals
patients will not necessarily know they are in a physician or hospital-owned plan unless they ask
specialty PSNs also contract with HMOs, for example, providing all the obstetrical and gynecological care to the HMO members
The Health Maintenance Organization (HMO): Managed Care Populations
in 2012, approximately 15 million Medicare beneficiaries, were in HMOs
149 million people were part of managed care plans according to the American Association of Health Plans, the industry trade group; strongest in the Western part of the country
individuals as well as group participants may join managed care plans; eligibility and costs depend on the managed care company and the state
since 1997 insurers have been required to sell individual policies to people who have been covered before under a group policy even if they have a history of illness
under Obamacare, existing medical conditions may not be used to refuse coverage
Types of HMO Plans: Indemnity Insurance
previsouly the predominant form of helath insurance
patients may use any doctor or hospital, and the insurance company pays some or all of the cost
doctors and hospitals have complete flexibility when indemnity insruance applies
there is no management of care by the insurer
Types of HMO Plans: Capitation
an HMO innovation in which HMOs pay doctors and hospitals a monthly fee for every HMO member they agree to care for – whether the member spends months in the hospital or no time at all, and whether the patient goes to the doctor weekly or not at all
thought to increase the incentive for preventative care
Types of HMO Plans: Adverse Selection
when insurers recruit the healthiest people and avoid insuring people with serious and costly existing conditions
some states have laws against overt adverse selection (also known as “cherry picking”)
Types of HMOs Plans: Physicians and Managed Care
doctors in staff-model HMOs do not have to set up and run their own office or deal with billing
many primary care doctors prefer managed care organizations as they emphasize primary and preventative care
doctors are concerned that the managed care companies will drop them if they complain about the company to patients
some managed care companies offer incentives to limit patient care
Issues Concerning Social Work Clients: Gag Rules
rules in HMO contracts that limit what doctors can say to their patients
some contracts say doctors cannot impugn the quality of an HMO
some go further, prohibiting doctors from informing patients about medical services that are not covered by the HMO, or any financial deals between the doctor and the HMO
Issues Concerning Social Work Clients: Incentives
a payment from an HMO to a doctor for limiting the number of procedures, or for limiting of referrals to specialists
Issues Concerning Social Work Clients: Cherry Picking
when managed care plan markets its services to healthy people, avoiding those who are sick and would cost the plan a lot of money
Issues Concerning Social Work Clients: Carve-Out
when a health care provider contracts with a managed care plan to provide a particular type of care
a member of the managed care plan who needs psychiatric care might be sent to a contracted clinic
members are generally not aware of a carve-out
Issues Concerning Social Work Clients: Managed Care Mental Health Coverage
some states require a prescribed level of mental health coverage
most plans have lower lifetime limits for mental illness compared to physical illness
some plans provide mental health parity in which health plans treat mental health equivalently to physical health
Issues Concerning Social Work: Pre-Existing Conditions
an illness or condition diagnosed before an insurance policy went into effect
conditions can include pregnancy, diabetes, cancer, and high blood pressure
some states limit what can be considered pre-existing conditions
some states do not allow insurers to charge extra
Pre-Existing Conditions: Pre-Existing Condition Exclusions in Managed Care
when in force, contract provisions can eliminate coverage for a particular condition for six months, a year, or forever
for people who work for larger companies, where the costs of their pre-existing condition will be spread over many workers, the limit may ony be for a few months, if it is there at all
people who have been covered in the previous 12 months for a pre-existing condition are not required to have a waiting period
Prescription Drug Programs: Prescription Drugs
-January 1, 2006, Medicare offered Part D, a new prescription drug insurance program replacing existing drug plans, either as an add-on to the government’s traditional fee-for-service or as part of a comprehensive managed care plan
-The program has income limitation and qualification features
-Most prescription drug plans limits which medications are covered, a system known in the private sector as a preferred drug list formulary
-In most cases coverage stops once recipients have spent $3,600 of their own money and will not resume until those out-of-pocket costs reach $5,100
-There are complicated requirements for changing prescription drug insurance carriers, and many seniors are having difficulty understanding requirements
Prescription Drugs: Coverage
covered drugs include any drug available only by prescription, approved by the Food and Drug Administration (FDA), used and sold in the U.S., and used for a medically accepted indication, such as prescription drugs, biological products, insulin, vaccines, and certain medical supplies associated with the injection of insulin
Prescription Drugs: Not Covered Drugs
certain drugs or classes of drugs are excluded by law (drugs when used for anorexia, weight loss, or weight gain; drugs used to promote fertility; drugs when used for cosmetic purposes or hair growth; drugs when used for the sypmtomatic relief og cough and colds; prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations; nonprescription drugs; outpatient drugs for which the manufacturer seeks to require the associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale; barbiturates; and benzodiazepines)
plans are required to include at least two drugs in every therapeutic category under their umbrella of coverage
Approaches to Social Welfare Policy Making: Rational
an idealized and structured approach that includes identifying and understanding a social problem, specifying alternative solutions and their consequences for consumers and society, and rationally choosing the best alternatives
the rational approach minimizes ideological issues, a seemingly impossible task
Approaches to Social Welfare Policy Making: Political
an approach that acknowledges the importance of power, compromise, competing interests, and partial solutions
those most affected by social policies often have the least political power to promote change
those with political power are often influenced by interests seeking to protect their own position
policy makers are often concerned with retaining power and privilege
the needs of the disadvantaged can become marginalized unless aggressive advocacy is available
Identifying Policy Problems: Public Issues vs. Private Troubles
a constant struggle in social policy involves the conditions under which a problem affecting individuals is converted into a social issue that warrants public attention
the criteria are unclear but the process always involves publicity, interest groups pressuring for amelioration of the problem, social research, and mobilizing public and media support
Identifying Policy Problems: Blaming the Victim vs. System Accountability
many problems are seen largely as the problems of individuals, rather than as symptoms of system dysfunctions
the social system is more comfortable resolving social problems by treating persons who exhibit behavioral symptoms than altering or reforming the social institutions that contribute to individual failures
Formulating Policy Alternatives: Research
-Target population demographics; locate the at-risk population and catalogue any special characteristic
-Review previous policies; perform historical analysis
-Identify social science theories that explain the problem’s causes and solutions
-Create demonstration projects or other practice-based experiments to support alternative policies; identify international models to support domestic innovations
Formulating Policy Alternatives: Synthesize Data
-Developing position papers
-Stimulate debate, discussion, and feedback
-Revise mission, goals, strategies, objectives, methods, etc
Formulating Policy Alternatives: Propose Policy in an Appropriate Format
-Prepare a report describing findings and recommendations
-Identify required legislative or policy changes
-Review and amend specific policies, program protocols, measures of success, workloads etc
Legitimating Policy: Lobbying
essential to create a climate of acceptance for policy or legislative changes
Implementing Policy: Organization Capacity Building
-“re-tooling” existing organization/system
-Building organizational commitment
-Establishing revised organizational mission
-Obtaining necessary funding
-Creating and staffing new agencies
Implementing Policy: Issuing and Carrying Out Directives to Translate Policies Into Actions
-Reviewing rules and regulations
-Creating guidelines for carrying out new plans and directives
Implementing Policy: Coordinating Resources and Expenditures
-State, federal, municipal, and nonprofit organizations
-Linking goals and methods to implementation strategies and resources
Implementing Policy: Obstacles to Implementation
-Inadequate, incomplete, or faulty communications
-Inadequate Resources
-Organizational Competition
-Rigid Bureaucratic Structures That are Unable to Adapt to New Assignments
Monitoring and Evaluating Policy Using Program Evaluation: Summative
evaluation to measure program results
Monitoring and Evaluating Policy Using Program Evaluation: Formative
evaluation designed to improve the intervention or the methods as the program develops
Ethical and Legal Considerations in Practice: Privacy and Confidentiality
privacy is the general ethical and cultural framework for the rules that guide the more limited, but explicit concerns of social workers
clients have a right to privacy but understand the limitations of confidentiality
What is a common practice when disclosing the limits of confidentiality with clients?
Ask clients to review and sign informed consent forms that describe the limits of the confidential relationship with the agency
What’re agencies required to do to keep confidentiality?
-Secure and lock records
-Develop policies that insure records are not left where unauthorized persons can read them
-Computerized records need to be secured with the same care given to written records
-Conversations about clients should be held where they cannot be overheard
Limits to Confidentiality: Informed Consent
clients may provide consent for information to be shared with family members, or other professionals or agencies for referral purposes
Limits to Confidentiality: Child Abuse
all states have laws that mandate social workers to report mere suspicion of child abuse to appropriate local authorities
Limits to Confidentiality: Sexual Abuse
reporting of sexual abuse follows the same general rules as child abuse reports
Limits of Confidentiality: Danger to Self or Others
the client’s mental state is such that s/he might deliberately or accidentally cause harm to him/herself
the client has made a direct threat to harm someone else and there is a reasonable possibility that the client can carry out the threat
duty to warn of intent to harm
clients with communicable diseases such as AIDS (still unclear where practice leans)
Limits of Confidentiality: Elder Abuse
many states now require social workers to report cases of abuse or exploitation of elders by family members and other caretakers
Limits of Confidentiality: Defense Against Malpractice
a social worker sued for malpractice may reveal material discussed by clients
limited to statements that are needed to support an effective defense
