Social workers and the tradition of charity in the changing health care system.

Current changes in the health care system promise upheaval not only for individuals and families, but also for entire communities. Attempts by government to provide universal health insurance have failed, with policymakers opting to rely on the market system to stimulate lowered costs and greater access to health care services. Hospitals, historically the bulwark of the U.S. health care system, have become the objects of intense market-driven pressures toward reform. Financial incentives, organizational structures, and public policy are combining to drastically alter the relationship of hospitals to their surrounding communities. Competition resulting in mergers, acquisitions, conversions of nonprofit hospitals to for-profit entities, and possible closings of hospitals will dramatically transform the health care delivery system for poor and medically indigent people. Working people who do not receive health insurance benefits from their employers may be affected also. Ongoing federal and state attempts to lower Medicaid costs will increase financial pressures on hospitals serving communities with large populations of low-income people. Moreover, public policy that once sanctioned the charitable role of hospitals in communities has become fragmented as the nonprofit status of many health care institutions becomes blurred because of fierce competition for patients in the managed care marketplace. Social workers have the responsibility to understand the scope and depth of these changes and to provide service to people who are compromised by them, as well as to conduct research that may provide a basis for advocating social policies that address the needs of the growing number of people without health insurance and the broad range of problems facing communities in distress. Traditionally, social workers have played key roles as health care professionals working with patients and families to secure medical and social services and as community organizers working with citizen groups and agencies to take better advantage of the social, economic, and political benefits available from local hospitals (Ell, 1996). As hospital social workers have advocated on behalf of poor people to broker resources to serve the medically indigent, community organizers have worked through collaboration, and when necessary, confrontation to maximize the charitable mission of hospitals to serve the broad community. Although hospitals traditionally have been regarded as dominant charitable institutions, they have had mixed success in meeting the needs of their communities. For example, tragically high rates of infant mortality occur in urban areas that are served by one or more tertiary hospitals. To many observers it is not clear whether hospitals operate more as charities or as businesses (Kuttner, 1997). Nevertheless, hospitals have historically claimed a central position in the social welfare arena in the United States by providing health care for poor people and broader charitable benefits to their communities (Rosenberg, 1987; Stevens, 1989). The current wave of health care reform threatens these traditions. Local hospitals that may have once been responsive to their communities are being absorbed by larger integrated delivery systems (IDSs) that threaten local autonomy and weaken ties to the nearby citizens (Schlesinger, Gray, & Bradley, 1996). The goal of an IDS is to manage the care of populations of health care consumers that may not include significant portions of the residents of the community once served exclusively by the local hospital. HOSPITAL CHARITY AND PUBLIC POLICY As applied to the activities of hospitals, charity has been defined traditionally in both narrow and broad terms. In its most narrow sense, charity refers to the relief of poverty by providing free or below-cost service to poor people. More broadly, it has come to include any benefit provided to the community at large (Pauly, 1996). The dual expectation that hospitals would provide free or below-cost care to poor people and benefits to the community, such as comprehensive health assessments and projects to improve overall health status (Sigmond, 1995), has been translated historically through a number of public policy initiatives. …