At the millennium, the health care system in the United States continues to be in crisis. The United States, to its shame, is the only industrialized country in the world that has not established universal health coverage. It is estimated that 42.6 million people have no health insurance--10 million are children (U.S. Census Bureau, 1999). The loss of health coverage and delays in care have resulted in thousands of deaths. (Himmelstein & Woolhandler, 1994). Despite the numbers, we can never calculate all of the human suffering that results from not having access to medical care. As social workers in the health care industry, we are eyewitnesses to this suffering on a daily basis. Medical social workers are expected to alleviate much of this suffering. We are on the front lines of the health care crisis in the United States. We explain the eligibility requirements for insurance programs and how to enroll in programs to purchase low-cost medication and counsel patients who cannot pay medical bills. Medical soc ial workers have a vast knowledge base and access to resources in the community to help patients and their families cope with illness and disability.
PROFESSION UNDER ATTACK
The profession of medical social work itself has come under attack. Social workers are laid off when hospitals and clinics close or merge. Entire social work departments have been eliminated in hospitals, and nurse discharge planners or case managers have assumed the role of social worker. Social work as a discipline in the medical setting is struggling to survive (Globerman, 1999). Health care administrators often do not value the role social work plays because they do not see how it contributes to profitability. Social worker's "productivity" is increasingly measured by the number of patients seen (patient contacts) and how quickly the patient was discharged. Shortened length of stay and other efforts to lower acute-care costs have greatly affected social work practice in hospitals (Hammer & Kerson, 1998). It is becoming more difficult, and at times impossible, for social workers to do comprehensive and patient-centered discharge planning. Downsizing and hiring freezes leave social workers with higher casel oads and less time to spend with more patients and families.
In the current health care environment, which is driven by the pursuit of profit not patient need, the social work code of ethics is being profoundly challenged (Riffe, 1998). Access to health care in the United States is not a right but instead a commodity to be bought and sold. If you cannot afford it, you cannot have it. Worse, if you are sick, if you have a "pre-existing condition" you can be denied insurance coverage. If you need health care you are less likely to get it. This is the perverse logic at the center of for-profit health care provision--insurers do not want to insure groups that are considered "high-utilizers." Among the groups targeted as heavy users are chronically ill and elderly people. Social workers reject this categorization of patients as dehumanizing and stigmatizing.
MEDICARE AND MEDICAID
Wilbur Cohen, assistant secretary of health, education, and welfare under President John F. Kennedy, and other social workers played leading roles in the development of Medicare. Medicare finances health care for 38 million people and pays 20 percent of the U.S. health care bill (McFall & Teitelman, 1998/1999). From its inception the Medicare program has had serious limitations and gaps in coverage. Most notably, Medicare does not pay for prescription medication. Recent statistics indicate that 18 percent, or 7 million, of the 38 million Medicare recipients are enrolled in managed care (McFall & Teitelman, 1998/1999). Seniors chose to enroll in HMOs because of the prescription drug benefit as well as little to no co-payments and deductibles. After many years of Medicare managed care, we know it is a disaster for elderly people and people with disabilities. …