key: cord-1006894-um8pn1x2
authors: Yingling, Marissa E.
title: COVID-19: Social Work’s Opportunity to Revitalize Advocacy for a Universal, Single-Payer Healthcare System
date: 2020-10-23
journal: J Hum Rights Soc Work
DOI: 10.1007/s41134-020-00143-z
sha: c84bee2841ce59518127798b77c662f4257a7d52
doc_id: 1006894
cord_uid: um8pn1x2

The COVID-19 pandemic is exposing failures of the for-profit health insurance system in the USA. This social commentary briefly reviews short-term policies that have been enacted to address immediate health insurance needs during the pandemic as well as long-term policies that have been implemented and proposed to solve the shortcomings of this system. Prior to the Patient Protection and Affordable Care Act of 2010, the National Association of Social Workers advocated for a single-payer health care system. The author argues that the COVID-19 pandemic is a watershed moment offering social work an ideal opportunity to revitalize its advocacy and commitment to a single-payer health care system grounded in the Universal Declaration of Human Rights, which asserts that health care is a human right.

The next opportunity to support "reformist reform" (Linhorst 2002, p. 202) arose in the Obama era. In 2009, although NASW endorsed a single-payer proposal reintroduced in Congress (Owen 2009 ), it also abandoned idealism and backed the Patient Protection and Affordable Care Act (National Association of Social Workers [NASW] 2009). With the primary goal of expanding insurance coverage (Centers for Medicare and Medicaid Services n.d.), this legislation represented the largest presidential accomplishment in health care in decades. Still, nearly a quarter century since some social workers urged political pragmatism toward health care reform, the shortcomings of the 2009 reform are evident. It eliminated discrimination of preexisting conditions, provided states with the opportunity to expand Medicaid, and increased the age at which children are covered by parents' plans. However, it failed to achieve universal coverage and millions remain underinsured (Carrasquillo and Mueller 2018) , marketplaces lack choice in many states , and costs continue to rise (Centers for Medicare and Medicaid Service 2019). The principal reason for these failures? Reform ensured that a convoluted, avaricious system remains intact, one that is profiting amidst national suffering: as jobless numbers surpass the Great Depression, totaling 40 million in less than 3 months (Romm 2020), as local restaurants and small businesses shutter their doors and scramble for aid, and as tens of thousands die from the virus, health insurance companies report high profits due to the suspension of elective procedures (Appleby and Findlay 2020) . Meanwhile, they warn of premium hikes, maintaining that COVID-19 hospitalizations could depress profits (Covered California 2020; Scott 2020). The virus is exposing flaws of a for-profit industry given permission by Congress to exploit our nation's health for the indefinite benefit of its executives and shareholders (McGreal 2009 ).

Though the proposal for Medicare for All reemerged in 2016, the broader issue does not begin and end with Senator Bernie Sanders (I-VT) (Medicare for All Act of , S.1129 , 116th Cong, 2019 . If enacted more than 100 years after politicians first proposed the idea, single-payer reform would align the USA with most industrialized Western allies such as Canada, the United Kingdom, and Australia. Diluted versions of this proposal, such as a public option, are "politically attractive but economically unworkable" (Woolhandler & Himmelstein, 2019 , p. 2400 . While single-payer would reduce costs by an estimated $450 billion annually (Fitzpatrick et al., 2020) , half-way proposals would add costs (Woolhandler & Himmelstein, 2019) and perpetuate a wasteful system that is a primary driver of national debt (Congressional Budget Office 2019). Ignoring empirical evidence, Joe Biden, the Democratic nominee for president, has proposed a public option and a reduction in Medicare eligibility to 60 years of age (Rovner 2020). Although the Democratic Party Platform includes support for an eligibility age of 55 years (Democratic National Committee 2020), the nominee's less ambitious proposal was also recommended by the Biden-Sanders Unity Task Force (Biden-Sanders Unity Task Force Recommendations 2020). Regardless of a 5-or 10-year reduction in eligibility, neither would meaningfully reduce the number of the uninsured because Americans with higher rates of coverage are older (Moon and Uccello 2020) . Indeed, the nominee has promised top donors that if elected "nothing would fundamentally change" (Derysh 2019, para. 7); in March, as COVID-19 patients began flooding hospitals, he claimed that even if Medicare for All passed Congress, he would veto it, blaming its cost (Higgins 2020) . His selected running mate reinforces his stance. An original co-sponsor of Sanders' Medicare for All Act (Hart 2017) , during the Democratic primaries Harris shifted her position and no longer supports the legislation. Notably, the incumbent president does not support a single-payer system or reducing the Medicare eligibility age (Republican National Committee 2020).

Constrained by a complex system in which Americans concerned about COVID-19 symptoms but worried about health costs may not visit a doctor, including six out of ten adults with annual incomes higher than $50,000 , some legislators proposed expanding the Consolidated Omnibus Budget Reconciliation Act and opening health care exchanges so that laid-off workers could purchase for-profit insurance plans. This proposal assumed that the pandemic's economic victims have hundreds (or thousands) of dollars each month and the luxury of "choosing" a highdeductible plan when 40% of American families cannot afford a $400 emergency (Bahney 2018) . It is well known that the primary argument against a single-payer system is its cost. Yet, at the same time that legislators were proposing a patchwork of health insurance solutions, the Federal Reserve effectively printed an additional $3 trillion into the economy, which in effect re-inflated stock market prices with little representation in the real economy (Schneider 2020), a market in which only 55% of Americans are privileged to invest (Gallup, Inc 2019) . In May, the Federal Reserve began buying billions worth of "fallen angel bonds" from corporations whose debts were downgraded to junk or speculative status (Cox 2020) . Interestingly, though not surprisingly, unlike proposals for single-payer, most politicians were not citing the national deficit or asking, "how will you pay for it?" Instead, the federal government subsidized the investor class, enriching billionaires while the working and middle classes suffered from unprecedented job and health insurance loss.

The NASW recognizes the social justice implications of the pandemic (Wilson 2020) and has actively supported legislation for affordable treatments and future vaccines as well as a special enrollment period for health care exchanges for the uninsured (NASW 2020). Advocacy for these short-term practical measures is reasonable. Yet, as social workers have always understood, the daily prepandemic health care crises faced by all Americans, especially the most vulnerable, require considerably more than band-aids.

COVID-19 is a watershed moment offering social work an ideal opportunity to revitalize its advocacy and commitment to a single-payer health care system. The legislative challenge of passing sweeping reform necessitates social work involvement. Health care as a human right is a position in the Universal Declaration of Human Rights (1948) consistent with the NASW Code of Ethics. Firmly rooted in the value of social justice, which emphasizes social change especially for those experiencing oppression, and the value of the dignity and worth of each person (NASW 2017), which aligns with rights-based approaches that view all people as "fully human" (Mapp et al. 2019, p. 263) , social work has a responsibility to proclaim support and campaign for fundamental reform.

In the year 2020, the USA has never been more ready for change. The proportion of Americans who enjoy generous employer-sponsored health insurance has been decreasing while costs increase (Collins et al. 2019; Enthoven and Fuchs 2006) . In the past 10 years, the average cost of employer plans doubled (Rae et al. 2019) , and due to the pandemic, an estimated 12 million have lost them . Nearly 13% of adults are uninsured, 43% are inadequately insured, approximately 10% are uninsured at some point during the year, and half of adults who are uninsured at any time during the year or underinsured report difficulty paying their medical bills or are making long-term payments toward medical debt that is harming their credit and draining their savings . Moreover, younger generations who came of age during the Great Recession and Occupy Wall Street favor singlepayer (Bailey 2019) . This is understandable, as they are more likely to be working in the gig economy (Tran and Sokas 2017) and to be weighed down by unprecedented loads of student debt (Looney et al. 2020) , they have witnessed obscene economic inequality worsening during the pandemic (PBS NewsHour 2020), and they have a less favorable view of capitalism than their elders (Kight 2019).

As they age, their influence on national discourse and elections will only increase (United States Census Bureau 2017).

Certainly, evolving public sentiment does not eradicate all barriers. It makes sense that Americans would desire to pay less for health care , especially as they endure worse average outcomes compared to similar societies that spend roughly half for better results (Organisation for Economic Co-operation and Development (n.d.). Yet, instead of being presented with a straightforward choice-for instance, to pay $2000 in taxes or $8000 in premiums, deductibles, and other costs for the same care-explanations offered by politicians and the mainstream media about how single-payer would impact household budgets are often incorrect and disingenuous and ignore the popularity of other universal social programs, such as Social Security (Waggoner 2020) . Overworked Americans, nearly half of whom work lowwage jobs with a median income of $18,000 (Ross & Bateman 2019), many employed in multiple jobs to pay their bills (Beckhusen, 2019) , have other demands on their attention than sifting nuanced research regarding our distended system from a morass of misinformation. Insurance companies control 34% of health care payouts in an industry that represents 17% of GDP (Hartman et al. 2020 ) and thrive on inertia while annually charging more, accruing record revenue, and paying to lobby about their own supposed indispensability while avoiding accountability about what value they add as intermediaries (Dey and Bach 2019). Influential media who rely on billions in advertising dollars coax viewers into fearing comprehensive reforms, branding them as fantastical impossibilities rather than featuring substantive debate. Rather than discussing how in-network limitations hurt Americans and hinder provider choice (Giovanelli et al. 2016) , ignoring that Americans find exercising choice difficult in such a complicated system (Bhargava and Loewenstein 2015) , news networks across the political spectrum entertain "communist" or "socialist" wordplay for single-payer setups that already benefit many citizenries of the free world. A prime example is the series of ads mainstream news networks chose to run during the 2020 Democratic primary debates. The industry-backed organization Partnership for America's Health care Future paid millions to air commercials attacking Medicare for All (Otterbein and King 2020) as a government take-over threatening health coverage that would do nothing but increase taxes, among other claims (Partnership for America's Health Care Future 2020). This is not surprising given the scale of medical marketing (Schwartz and Woloshin 2019) , including the approximately 8% of major television network revenue derived from direct-to-consumer pharmaceutical advertising, in which companies invest hundreds of millions of dollars annually (Sekerka and Benishek 2018) .

False claims about a single-payer system are easy to deny. For instance, when opponents of reform, including Biden, cite the cost of the current Medicare for All proposal, they either omit the important fact that it would save Americans money overall or make false statements, such as that it would exceed "the entire federal budget on a yearly basis" (McDonald et al. 2019 ). It would not (Pollin et al. 2018) . Democrats and Republicans alike continuously make misleading and incorrect claims about tax increases. Recently, Trump suggested that the proposal would apply a 52% tax rate on incomes of $29,000. To the contrary, one proposed method of financing reform is a 52% tax rate on income that exceeds the first $10 million (Horsley 2018) . Misleading claims are not restricted to finances. Among the most common is that wait times would be extensive and health care would be rationed (Horsley, 2018 ). Yet, research demonstrates that publicly insured patients wait only 1 or 2 days longer than privately insured patients (Candon et al. 2018; Tipirneni et al. 2015) , and the USA is not an international leader in wait time measures (Organisation for Economic Co-operation and Development 2020). Importantly, while billing costs in the USA are nearly four times that of Canada (Morra et al. 2011) , health insurance companies engage in their own form of rationing by denying millions of claims (Pollitz et al. 2019) . Furthermore, the USA already rations care based on who can afford to pay for it, a shortcoming especially acute during a pandemic when the people who are less likely to have health insurance are the same people who are more likely to work outside their homes, placing them at greater risk of contracting COVID-19 (Raifman & Raifman, 2020) .

Emotional ploys of fear that dominate curated public discussions are admittedly effective (Herman & Chomsky, 2011 ). Yet, these exaggerations must not overshadow real stories of inhumanity, unfairness, and struggle that would resonate most with everyday citizens. Statistics alone may be insufficient. Reading that serious reform would save physicians and hospitals billions or that an estimated 68,000 patients die annually due to lack of insurance (Fitzpatrick et al., 2020) appeals to abstractions. A focus on people must accompany high-quality economic analyses. Unlike corporations, Americans do not make decisions based solely on their bottom line. Social workers know well the incentive of altruism; hearing from a family who is homeless because a parent suffered cancer and could not afford treatment, or from the grieving child of an underinsured parent who died because of delayed care, would speak to the greater motivator of empathy, especially in the context of a pandemic that has reminded Americans of human vulnerability to illness and chance. Of course, people make decisions in their own self-interest as well. However, COVID-19 has exposed human interdependence. Citizens recognize that their neighbor's health impacts their own health, and overwhelmingly, they support masks, regular testing, and access to health care for those who have lost it due to the pandemic ). Using what is sure to be one of the most striking and unforgettable historical moments in modern history, social work can lead the effort to appeal to empathy and self-interest for positive social change.

How social work revitalizes its advocacy for health care as a human right and demands a single-payer system guaranteeing health care to all people is an open question for the profession to answer. Beyond recommendations for social workers that Owen (2009) made before the Affordable Care Act was signed into law, to begin, NASW could establish a dedicated task force to generate a strategy for social work to lead change efforts. To succeed in guaranteeing health care as a human right, it would be important for this task force to ground its work in the Universal Declaration of Human Rights, which asserts that human rights are indivisible and interdependent, including that:

Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control. (United Nations,1948, para. 33) .

Historically, NASW has worked alongside other professions advocating for universal health care. Prioritizing alliances with organizations that advocate solely for a singlepayer system will be important; partnering with and learning from existing campaigns led by doctors and nurses who have recently advanced their advocacy efforts, such as Physicians for a National Health Program (Physicians for a National Health Program 2020) and National Nurses United (National Nurses United 2012), would likely be prudent. Among other strategies, on January 21, 2020, Physicians for a National Health Program purchased the front page of the New York Times to "prescribe" Medicare for All to Americans, and throughout 2020, their Kitchen Table Campaign is highlighting an issue each month that demonstrates how Medicare for All would resolve Americans' health care problems. The organization also supports a student advocacy group. National Nurses United is a leader in legislative advocacy, organizing activists across the USA. Given that the associations of these professions have opted not to stand for singlepayer, NASW could establish social work as a professional leader in advancing the right to health care. In addition to issuing a highly visible statement of support, like two state chapters (NASW-Massachusetts Chapter 2017; NASW-Mississippi Chapter 2018), the NASW could encourage and facilitate the formation of a network of social workers dedicated to advocating for single-payer reform. Regardless of the means, social work is ideally suited to uplift the injustices of the current health care system and to help the American public connect the pandemic-generated health care crisis to the everyday crises that will endure long after the distribution of a COVID-19 vaccination.

Trump says hospitals will be paid for treating uninsured coronavirus patients-The New York Times. The New York Times

Total Cost of Her COVID-19 Treatment: $34,927.43 | Time

Coronavirus boosts health insurance profits, for now

40% of Americans can't cover a $400 emergency expense

Young adults may drive support for Medicare for All

About 13M U.S. workers have more than one job. The United States Census Bureau

Choosing a health insurance plan: Complexity and consequences

Unity Task Force Recommendations

Health insurance and the COVID-19 shock. Economic Policy Institute

Supply of primary care providers and appointment availability for Philadelphia's Medicaid population

Refinement of the Affordable Care Act: A progressive perspective

National Health Expenditure Data: Historical

What Are Americans' Views on the Coronavirus Pandemic? NBC News/Commonwealth Fund Health Care Poll

An early look at the potential implications of the COVID-19 pandemic for health insurance coverage

Trends in Employer Health Care Coverage

AP fact check: Trump is wrong about insurers covering coronavirus

The potential national health cost impacts to consumers, employers and insurers due to the Coronavirus (COVID-19)

The Fed is starting its program to purchase corporate bond ETFs

Nothing would fundamentally change" if he's elected | Salon

The 6 functions of health insurance

Employment-based health insurance: Past, present, and future

Families First Coronavirus Response Act

Insurer Participation on ACA Marketplaces

Improving the prognosis of health care in the USA

What Percentage of Americans Owns Stock? Gallup

Regulation of health plan provider networks

Universal health care coverage in the United States: Barriers, prospects, and implications

Teen whose death may be linked to coronavirus denied care for not having health insurance, mayor says

Woman who died of COVID-19 refused to go to hospital, worried about bills, her son says

Sen. Kamala Harris backs single payer heatlh care. The Sacramento Bee

National health care spending in 2018: Growth driven by accelerations in Medicare and private insurance spending

Manufacturing consent: The political economy of the mass media

Medicare for All" over its price tag

Trump's false claims on

Exclusive poll: Young Americans are embracing socialism

Federalism and Social Justice: Implications for Social Work

Who owes all that student debt? And who'd benefit if it were forgiven? Brookings

Social Work Is a human rights profession

FactChecking Biden's CNN Town Hall

Revealed: Millions spent by lobbyists fighting Obama health reforms. The Guardian

Medicare for All Act of 2019, S.1129, 116th Cong

Lowering the Medicare eligibility age-Simple approach, complex decision

US physician practices versus Canadians: Spending nearly four times as much money interacting with payers

The problem of choice: From the voluntary way to Affordable Care Act health insurance exchanges

NASW, MS Chapter Position Statement on Universal Health Care. Advocacy. https :// naswm s.socia lwork ers.org/Advoc acy National Association of Social Workers

Anti-Medicare for All ad campaign launches in South Carolina

Consumer-driven health care: Answer to global competition or threat to social justice?

Claims denials and appeals in ACA marketplace plans. Kaiser Family Foundation

Tracking the rise in premium contributions and cost-sharing for families with large employer coverage. Peterson-Kaiser Health System Tracker

Disparities in the population at risk of severe illness from COVID-19 by race/ethnicity and income

Americans have filed more than 40 million jobless claims in past 10 weeks, as another 2.1 million filed for benefits last week

Low-wage work is more pervasive than you think, and there aren't enough "good jobs" to go around

What did eight weeks and $3 trillion buy the U.S. in the fight against coronavirus? Reuters

Medical marketing in the United States

Coronavirus: Are health insurance premiums going to increase in 2021

Thick as thieves? Big pharma wields its power with the help of government regulation

Primary care appointment availability for new Medicaid patients increased after Medicaid expansion In Michigan

The gig economy and contingent work: An occupational health assessment

Voting Rates by Age. The United States Census Bureau

AARP Poll Finds 96 Percent Support Social Security

Implications of Coronavirus (COVID-19) for America's vulnerable and marginalized populations. National Association of Social Workers

Single-payer reform-"Medicare for All

The rationale behind the Clinton health care reform plan

2 million workers likely lost their employer-provided health insurance in the past four weeks. Economic Policy Institute