SW 150—Dinis--Handout
Ch2--Popple & Leighninger—Defining Social Welfare Policy
Social Welfare Policy—a Definition
Social welfare---the institution in society that deals with the problem of dependency (i.e., the
actions in which individuals are not fulfilling social roles like a parent not caring for a child, a
person unable to support themselves, child or adult breaking the law).
Social institutions may not support people in their role performance (high unemployment and
those with qualifications can’t find a job). Social welfare institutions help to maintain
equilibrium.
1) Policy---principle, guidelines, or procedures that serve the purpose to maximize
uniformity in decision making (social welfare policy) is the above definition of
policy…in regards to the problem of dependency.
What factors complicates the definition of social welfare policy?
1) Social welfare policy and social policy terms used interchangeably.
2) Social policy is used in a philosophic sense.
3) Social welfare policy as academic discipline and social work curriculum area. Social
welfare policy also refers to the professional social work curriculum. (CSWE—p.28-29).
4) Social workers are interested in social welfare policy in all sectors of the economy
5) Multiple Levels of Social Welfare Policy
 macrolevel policy—(Social Security Act regulations)
 mezzolevel (midlevel) Policy—personnel policy manual
 microlevel policy—therapeutic services, WIC coupons
 Lipsky—Street Level Bureaucracy—if social workers make a decision about
fewer persons actually receiving a particular benefit, then the policy is that people
do not get the benefit even though the law provides for the service and the
regulations by local agencies is to deliver the benefit.
Social Welfare Policy—A Working Definition (p.34)—principles, guidelines, and
procedures to deal with dependency…
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Ch3--Popple & Leighninger—Social Welfare Policy Analysis: Basic Concepts
The Many Meanings of Policy Analysis ----policy analysis is broad and general as shown on
Table 3.1 pg. 44. It is more sophisticated at the top of the table and then diminishes as it goes
down in terms of policy analysis education necessary to do the analysis.
Methods of Policy Analysis
1) Descriptive Analysis
 Content Analysis—agency reports, manuals, brochures
 Choice Analysis—a process of looking at options available to planners to deal
with social welfare problems that may be transformed into proposals, laws, or
statutes that form programs.
 Bases of Allocations—What are the bases of allocations? Universal or based
on economic need.
 Types of Benefits—What are the types of social benefits to be provided? InCash (monthly unemployment checks) or in-kind (tax credits, free clothing,
job training, subsidized housing).
 Delivery Structure—How are services or benefits delivered? Will benefits be
centralized? Decentralized, centralized, or coordinated services
 Financing Benefits—How are benefits financed? Taxation (social security),
voluntary contributions (private agencies), or fees (for services charged by
both private nonprofit and for-profit agencies).
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Comparative analysis—involves comparing policies across two or more settings
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Historical Analysis—is based on the assumption that current policies can be fully
understood if we have an understanding of their evolution.
2) Process Analysis—the interactions of many political actors like public officials,
bureaucrats, media, professional associations, and special interest groups that may be
affected by the policy positively or negatively. (See pg. 55).
3) Evaluation—Demand for evaluation to see if the program is effective or analyze the
policy’s logical consistency.
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Logical Evaluation—Are the goals in conflict between getting Mom’s to work
when they have small kids and yet want the children to be well taken care? (p.56).
Quantitative Evaluation—effectiveness (outcome) and efficiency (costeffectiveness) evaluations.
Ethical Evaluation—Previous evaluations are theoretically value-free.
4) Policy Analysis Methods as Ideal Types—comparative.
Policy Analysis as Science, Art, and Politics—policy analysis is an art because definitive
answers are rarely found and it is political. (p. 61).
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Ch4--Popple & Leighninger—Policy Analysis from a Historical Perspective
Historical Context of Social Welfare Policies
 The historical analysis is important to understand, maintain or change a policy
The Role of History in Understanding a Policy
 The role is to demonstrate the evolution of policies over time
 The role of history is to evaluate present proposals and claims for success
 History helps to understand current policies--it gives us the “how” and “why”
1) Manifest (drop-in day activities for mentally ill is socialization)
2) Latent (function of center is to keep “crazy” people from downtown)
 Critics say that historical analysis lacks “scientific precision” of other methods
Examples of Policy History—(questions asked by researcher, sources used, and conclusions)
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Colonial Poor Relief—How did the boarding-out policy actually work? Court records. It
was more cost effective to board the poor than to institutionalize them
The Use of Orphan Asylums—Did institutions such as orphanages function in the past? How
well did they work? Are they appropriate models for today’s needs? Annual reports of
orphanages, magazine articles, govt. reports, and social welfare conference speeches. Little
evidence that orphanages of the past would be appropriate for children today.
Policies for Those with Handicaps—How does US public policy respond to the situation of
physical disability? How have these responses developed? Records of US Social Security
Administration and of state offices and interviews. Conclusion: Each program developed
problems that policymakers did not anticipate even when they tried to avoid them. Lack of
coordination of service between the programs.
Historical Analysis of Agency Policy—knowing the development of the policy and key actors in
that development is essential to getting it changed.
Methods of Policy History
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Formulation of hypotheses or guiding questions about issue or program. Q: How did the
policies on sexual harassment in an agency x come about? How are these policies
developed? Or Ho: Sexual harassment policies are most likely to develop in agencies with
women administrators at the top level.
 Gather primary or secondary data to answer your Q or Ho. Best to use a combination of
primary. Secondary sources are good to summarize and synthesize material. (p.76 for
questions about the evidence). Use multiple sources (inaccuracies, inconsistencies or biases).
 Have to decide what the evidence has to say in relationship to the Ho or Q’s of study.
Interpretation of data must be systematic and avoid errors (cross-cultural, presentism error,
and generalizing beyond the facts available in the data).
The Benton Park Crisis Center (An example): The history of center shows: needs of the
community and clients, the requirements of funding and licensing agencies, the social and
economic conditions of the community, and the traditions of the staff that shape the direction of
the agency.
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Ch5--Popple & Leighninger—Social/Economic Analysis
The task of social/economic analysis is …p.89
Delineation of the Policy Under Analysis
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Specify the boundaries of policy you intend to analyze.
After the topic, select the policy realm (area). Ex. child welfare
Major problem for students is that they fail to specify the boundaries of their analysis,
change focus more than once during the analysis like starting in public sector of
adoptions and ending in the private sector of adoptions.
First rule of policy analysis: specify the policy and keep that specification during the
analysis like the researcher who states a Research Question or hypotheses to answer.
Social Problem Analysis
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How is the problem defined? Clearly identify and define the problem
When defining a problem by a social welfare policy, ask, For whom is this a problem?
Who will benefit as a result of this policy?
Break down the problem into primary and derivative problems. Primary problem may be
folks drinking and derivative may be employees who are not productive, abandoning
their kids, homeless, etc. Social welfare policies deal with derivative problems.
A policy is often a response to more than one problem that creates tensions and
inconsistencies in the policy. If requiring welfare moms to go to work may result in
lower quality of care to their kids.
Facts Related to the Problem
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Completeness of Knowledge Related to the Problem—How many Facts do we know
about it and what is the state of knowledge regarding cause and effect relationships?
Population Affected by the Problem
o Characteristics of population affected by the problem, how large they are, trends
Theory of Human Behavior Undergirding the Policy
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Rational choice theory—views people making choices based on self-interest.
o Social Exchange Theory—people make choices based on assessment of which
course of action, will minimize costs and maximize rewards.
Social Values Related to the Problem–what values support or offends the policy?
 Achievement and Success—occupational achievement.
 Activity and Work—Americans place high value on being busy.
 Moral Orientation—Right and wrong views of the world, good and bad.
 Humanitarian Mores—1/3 of the population participates in voluntary service.
 Efficiency and Practicality—Value good stewardship of time and material resources.
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Progress—believing that things can change and can get continually better.
Material Comfort—lack of material comfort urges people to solve their own problems
and gain the comforts they desire.
Equality—Americans mean equality of opportunity, not of outcome.
Freedom—preference from control of excessive and arbitrary external restraint.
External Conformity—Low tolerance for people not conforming to standards
Science and Secular Rationality—Faith science methods will solve all our problems.
Nationalism—Patriotism Ethnocentrism—the belief that membership in this group
is preferable to membership in any other group.
Democracy—If everything is done by majority rule, then the minority group suffers
when the majority is not sensitive to their problems.
Individual Personality—credit the person for their success and blame them for failure.
Racism, Sexism, and Related Group Superiority Themes—We pass legislation to deal
with them like affirmative action, minority scholarships, etc.
Goals of the Policy Under Analysis—Social Welfare policies have goals, multiples goals.
 Goals—a statement that provides general direction to the activities of the programs. EX.
To assure that all neglected kids receive the highest possible quality of services.
 Objectives—are derived from goals and are concrete, measurable. Ex. Increase your
GPA by 2 points by Dec. or pg. 102.
 Stated goals==official or manifest goals and unstated goals are operative or latent goals.
Ex. Manifest goal is to educate kids in high school even if they are not interested but the
latent goal is to keep them off the street and out of the job market until they are 18.
Hypotheses Underlying the Policy
 If-then statement: If we do x, then y will happen. If we require welfare mom’s to work,
then they will learn work skills necessary for employment. See pg. 104.
 Behind every hypotheses there is a theory correct or not: the theory in TANF is that
welfare dependency is the result of individual shortcomings in the recipients. Social
policies may then add services or skills to address their own theories.
Economic Analysis—Concept of scarcity in economics=never enough resources to satisfy our
needs and wants. We decide on effectiveness (does the program work?), efficiency (How much
benefit do we get for the resources spent?), and equity (Are resources divided fairly?).
Policy issue: Social welfare benefits are financed by taxes and people may feel the $ is not spent
effectively, efficiently, and equitably.
 Macroeconomic Analysis—looks at aggregate economic performance of output, income,
inflation, and unemployment.
 Opportunity Cost—We are concerned with the cost of certain policy and how that
compares to policy alternatives.
 Effects of Individual Consumer Behavior—We seek to do what is in our own best
interest. Economists don’t explain behavior of the individual, but of the aggregate (all of
the people). Historically, the economic analysis of less eligibility means that people
living on welfare should be worse off than the lowest paid working person.
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Ch6--Popple & Leighninger—Politics and Social Welfare Policy
The stages of the political context of policy: Problem definition, politics influences,
enactment or legitimization of a policy (lobbying, compromise), political players like
advocates, professionals etc.—the stakeholders are the actors interested and may be affected
by the policy.
The Politics of Policy Making
Politics has to do with who gets what, when, and how. Power is a component of this activity.
Foucault=Universality of power (people kept under constant scrutiny like the prison) and the
shape it takes in bureaucracies and institutions in which social workers work. Positive aspects
of power when the circle of decision making is widen by elections.
Models of Policy Making
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Who Makes Policy? --Theories about who makes policy or influences social change:
o Pluralism—Political scientists have portrayed policy as the output of govt.
institutions. Pluralism assumes a “marketplace of ideas” which groups and
interests compete for power and influence in making policy. Power is
diffused and not centralized. Critiques: branding a proposal “socialist” like
for health care is a way to discredit the proposal and prevent discussion.
Public Choice Theory—Different version of pluralism because brings in the
economic dimension. Public choice theorists assume that all political actors—
voters, taxpayers, legislators, interest groups, bureaucracies, and govt.—seek
to maximize their personal benefits in politics.
o Elitist Model—of policy development and social change contrasts with
pluralist approach. Rather than policy being the product of groups and
interests, this model sees it reflecting the goals of an elite group of individuals
or the power elite (C. Wright Mills).
How are policies made? –Models address the issue of how change comes about.
o Rational Decision Making—Similar to the problem-solving model in social
work where the problem is identified, organized groups citizens are identified
to gather information about the problem, they develop general policy solutions
and lobby for change, identify goals and values, consequences of each policy
and then one approach is selected.
o Incrementalism—Change occurs in small steps, based on compromises rather
than big changes all at once. Policy shifts in society are incremental.
o Conflict Theory—But sometimes change does occur all at once and conflict
theorists deal with how and why such changes take place.
Phases in the Policy Process
o Problem Definition—How is the problem/issue perceived? How does the
problem get defined? Stakeholders have a political dimension in problem
definition.
o Policy Formulation—How are responses formulated? Stakeholders play a
role in formulating the policy they want. Mandated expansion of Medicaid to
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include kids was not accepted because people didn’t want new entitlements.
Private insurance offered poor families subsidies to buy private insurance and
they would gain by new programs bypassing Medicaid.
o Legitimation—Formalized policy solution or set of solutions are formally
enacted or legitimized. Policy receives refinement and definition by
negotiating and compromise.
o Policy Implementation—Regulations, personnel procedures, program
guidelines, and other specifications to implement the policy. What affects
policy implementation?
Conclusion: Successful policy creation, implementation, and revision demands an
understanding of what’s at stake, for whom, and why.
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Ch7--Popple & Leighninger—Welfare Reform: Temporary Assistance to Needy
Families
Historical Analysis
Look at Pg. 146 Lowell statement of welfare.
 Indoor relief—assistance provided only through institutions (poor houses).
 Outdoor relief—direct cash benefits
 Urbanization, industrialization, and immigration increased levels of poverty
Mother’s pensions were for widowed and deserted women or had disabled
husbands—only 3% of female-headed households received benefits. Changed
with the Great Depression and Social Security Act of 1935 to include more
people.
 Providing benefits to “undesirable” folk has led to welfare reform to limit eligible
people such as “suitable home” and “man in the house” rules of residency
requirements. Supreme ct. declared these unconstitutional in 1968 and 1969! The
second reform strategies have been to rehabilitate the recipient or remove
environmental barriers.
o Social Services Strategies—social workers help clients to solve problems.
o Institutional Strategies—public housing and rolls did not decrease.
o Human Capital Strategies—job training like WIN or JOBS are popular.
o Job Creation and Subsidization Strategies—Works Progress
Administration and Civilian Conservation Corps during 1930s and now
providing subsidies to employers to create new jobs for low-skill workers.
o Child Support Strategies— Federal legislation in 1984 and 1988 where
AFDC woman had to identify the father when applying for a grant and file
a child support order and if father was delinquent after the order then she
was required to swear out a warrant for collection.
Recent Welfare Reform Efforts
 1988—Family Support Act—employment and training program (Job
Opportunities and Basic Skills [JOBS]). Provided education, training, and childcare. Rolls went up and no state met the goals of having 20% on jobs or training.
 TANF-1996 pg. 152-153!
Social Analysis
 Problem Description—The issue is that to give benefits to kids will increase adult
dependency and to cut benefits will increase child poverty.
 Population—the stereotype is a never-married minority-group woman having kids at
early age and living in the inner city on aid permanently.
o Size—2.5% of the population in 1999 receive aid in TANF (Table 7.1 in pg.
155). Table 5.2 shows the rate increasing between 1960-1970 and decreasing
until 1990 and increasing until 1995.
o Cost—When adjusting for inflation, the cost has declined since 1976 from
$676 in 1970 to $358 in 1998 both to size of families and grants declining
(Table 7.3).
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o Race of Recipients—67% are minority and 33% are whites. The stereotype
that the program is for minorities.
o Family size—AFDC have 2.6 kids by 1995 and all others 2.1.
o Age of Mothers—TANF moms are younger than non-TANF moms (30 on
average vs.34). 6% are teens and 19% are 40+.
o Education—54% of TANF never completed high school compared with only
14.5% of nonrecipients and TANF is lower than AFDC.
o Length of Time on Welfare (Spells)—TANF can only be 2 years for any one
spell and 5 years of total spells
o The Onion Metaphor—Outer layer is the short-term (2 or less years) help for
groups going through some event in their lives until they regain entry into
labor market. The middle layer is for those staying 2-8 years and is on-andoff-again. They have basic skills and education, but jobs don’t exist to pull
them out of poverty on a permanent basis. The core of onion is for systemsdependent for more than 8 years. They have lack of education, training, and
job experience plus drug abuse, psychological problems, health problems,
abusive relationships, etc. They require extensive interventions to achieve
self-sufficiency than the other 2 layers. The very inner core people are limited
due to severe physical and emotional impairment. Self-sufficiency is not
realistic objective and we need to develop nonstigmatizing ways to provide
income support.
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Relevant Research—The Earned Income Tax Credit—workers can deduct job-related
expenses (child care) from taxes and get back more than they paid in to IRS. For
states with low benefit levels, welfare moms were more likely to live with their
parents than high-benefit states. The explanation for receiving long-term welfare was
low earnings from available jobs. The research evidence has not impacted welfare
policy because this research is conflict with some of U.S. values.
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Values and Welfare Reform (The antagonistic to welfare)
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The U.S. as the Land of Opportunity
Individualism—Credit for success and blame for their problems.
Work—Work as a moral virtue.
The Traditional Nuclear Family—Moral virtue for this family type.
Values in support of welfare: Humanitarianism—Consider a sin.
Sense of Community—The desire for community is strong.
Economic Analysis
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Macroeconomic Issues
o How Much Does Public Assistance Actually Cost? AFDC about 1% (23B in
1995) of the federal budget of 1.4 trillion.
o Is the Cost of Public Assistance Growing? Figure 7.2 p. 167 shows that rate of
growth is about the same as the economy for 20 years.
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o Prospects for Employment of Welfare Recipients—If economy is good,
prospects are good, but a downturn in economy will increase unemployment
rate for those w/o education or training.
 Microeconomic Analysis
o Is Public Assistance a Work Disincentive? The notion that when taking into
consideration food stamps, Medicaid, cash grant, and housing, the total
package exceeded the compensation from low-wage work.
o Economic Survival Strategies of Welfare Recipients—Level of need is what
states determine as the minimum amount families of various sizes need to
survive.
o The Effects of Public Assistance on Family Structure—A shift in US mores
now defines unwed parenthood as acceptable.
o Another explanation is that the increase number of unwed mothers has to do
with economic incentives not to marry by welfare programs. Welfare benefits
have declined but the problem is lack of employment for those with low
education, little experience, and few job skills
Evaluation
Do recipients who are provided with services actually get jobs? Do they earn enough to
get out of poverty? Welfare-to-work evaluations assume that welfare recipients do not
want to work and need motivation like a time limit on welfare and provision of few
resources such as brief education, training, and job counseling. The problems are that
programs underestimate the barriers to employment: low ability, low skills level,
physical and emotional problems, child-care, lack of job experience, transportation, etc.
Govt. needs to create jobs for welfare clients when economy has a downturn.
 Is TANF Succeeding? 44% decline of recipients on welfare from 1996-99 because
the economy has been good and these are the people who have education, job
experience and few problems in terms of health, mental illness, or substance abuse.
For others, we know that they skip meals to make ends meet, only 30-50% of those
leaving welfare ever find work and 40% report having trouble paying their bills.
Conclusion
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Welfare is Not the Problem, Poverty is the Problem—TANF is directed at the welfare
problem and not the poverty problem.
Even More Attention Should Be Directed toward Making Work Pay—Necessary for
govt. to create jobs of last resort for people with low skills and education levels. It
will be necessary to make work pay wage and benefits.
Public Assistance is a Social Condition, Not a Social Problem—Poverty as an urban
condition that will need to be managed. Check out WEB SITES in your text (p. 176)!
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Ch8--Popple & Leighninger—Aging: Social Security as an Entitlement
What are the assumptions, values, pros, and cons underlying in these examples? p.182
Entitlement—right to a certain benefit not based on need. What benefits do you think/
believe we are entitled? Health insurance, protect the poor & old, & reduce crime & racism.
The Problem That Social Security Was Developed to Solve
 To provide for old age since the Great Depression ended most sources of incomes
from savings, pensions, or their kids unable to help because of being unemployed.
The Social Security Act of 1935
 Signed by Roosevelt on 8/14/35.
 Title II: Federal Old-Age Benefits=social security (old age insurance from a federal
trust fund to provide monthly payments for those retired at 65 and older. The amounts
of benefits are given on pg. 185.
 Title VIII described the source of funding for the old-age insurance program. Federal
taxes paid by the employers and employees.
 Titles III and IX was a joint federal/state unemployment insurance for workers.
Title IV, Grants to States of Aid to Dependent Children (ADC) to cover 1/3 of state’s
costs to support kids with one caretaker (usually widowed or divorced mother).
 Title X, Aid to the Blind was half federal and half state funds.
Historical Development of Social Security Programs in the United States
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Precedents of the Social Security Act—the federal govt. established public pensions
for Civil war veterans.
1900s: pensions for firemen and police officers.1916—retirement plans for teachers.
By 1880s, corporations had pension plans, but covered only 14% of US workers by
1932.
Social reformers like Isaac Rubinow and Jane Addams promoted social insurance
programs for the govt. to use tax money to protect people against work accidents, ill
health, unemployment, etc. But Americans held to beliefs in self-help and private
responses to need.
Creation of the Social Security Act—1929 stock market crash led to high
unemployment and elderly were devastated.
Roosevelt created the Committee on Economic Security (CES) to come up with a
program for unemployed and old age.
The staff of CES formulated the legislation. Two conflicting social policy objectives
about social security were social adequacy (referring to assisting people based on
their actual need) and equity (giving assistance based on what people put into the
system). The work of CES was to integrate the two approaches. Old age insurance
and unemployment tied to wage contributions (equity approach) and public
assistance measures (social adequacy) and lower income workers got a larger
percentage of their wages back in benefits than higher-income workers. Values and
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systems: wage-based old age insurance and unemployment compensation supported
the work ethic.
Changes in Social Security—1939 amendments in the social security to include
survivors of active and retired workers and dependent kids of retired workers.
Began paying benefits in 1940 rather than ’42; lowered employer taxes from 3 to 2%.
1950—benefits were raised to match old insurance with Old Age Assistance (OAA).
1954—farm and domestic workers were brought into the system and self-employed.
1956—benefits were extended to workers with permanent disability aged 50+ and
once they were 65, then they received regular old-age insurance benefits.
Disability was linked with retirement (reflecting the equity, or work-related,
approach to social insurance).
By 1961—all workers could retire with reduced benefits by age 62!
1965—Medicare (for 65+) and Medicaid (those in social security assistance
programs and old age assistance).
1975—Tie benefits to rises in the annual cost-of-living adjustments. Extend
Medicare coverage to the disabled and transform the jointly funded state-federal
OAA into a federally funded Supplemental Security Program (SSI).
First crisis in the 80s due to inflation of the 70s was that benefits might exceed
incoming tax revenues. Congress and Reagan advanced the retirement age to 67 by
2017; increased payroll tax paid by workers and taxed benefits of people with certain
incomes.
Contemporary Analysis of Social Security
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Beginning of 1960s, 35% of elderly were poor and by end of decade 25% were
below poverty line, and 15% by 1979.
Social Analysis—27m retirees and 5m widows and widowers receive benefits.
Average monthly is $804 in 2000 while widows is $775 and the aid is almost 40% of
income to those 65+ (See Figure 8.1 p. 195). Figure 8.2 shows the number of poor
with and without social security.
The conflict between equity and social adequacy: Do you deserve help because you
are poor or because you worked hard and contributed to the system? The question of
who “deserves” help is connected to discussions of “entitlement” (the idea that
society has obligations to provide support and the individual is entitled to that
support as a right [p. 198-199 for discussion]).
Political Analysis—Stakeholders (retirees, employers, govt. folks, unions, etc) have
concerns about the reforms of the system. The elderly represent a large voting group
(AARP), with 32M in the organization. Voters are ambivalent about supporting stock
market investments; they resent payroll deductions to support retirees, although some
are their own parents. What stakeholders worry about is how to maintain the system?
Economic Analysis and Proposals for Reform—Are changes necessary or not?
1936—the ratio of dependency was 15 workers per retiree; 1998—it was 3.3 workers
per retiree and by 2030 the projection is 2 workers to 1 retiree. The privatization
proposal to place money in the stock market has been controversial because lower
income folks have fewer resources to get good advice in investing than higher
income people. People earning above $76,200 do not pay payroll taxes for social
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security, but if all earnings were taxed then ¾ of the shortfall would be eliminated.
This approach increases the redistribution of earnings and the collective
responsibility for people in welfare.
Conclusion
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If we choose social adequacy value, then we fund it through general taxation which
spreads the burden to all. If the goal is the value of social equity, then we focus on
supporting people who worked or were eligible for benefits through relationship to a
worker and we might tax on 100% of their earnings. What is the fair thing to do? To
tax higher-income at a higher rate than middle- and lower-income earners to
distribute resources or to privatize the system but place the poor in jeopardy.
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Ch9--Popple & Leighninger—Mental Health: Managed Care
The Problem That Managed Mental Health Care Was Developed to Solve
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Cost? Improving services?
The Costs of Mental Health Care—13.5% of GNP spent on health care (more than defense
budget), with 10% of the 1-trillion-dollar health care bill going to mental health. 1/3 of the
bill is spent on severely mentally ill.
Incidence and Treatment of Mental Health Problems—10% of adults in US have a mental
disorder in any one-year and 12% of kids suffer from mental and emotional problems. 60%
of those given meds for schizophrenia improve.
Managed Mental Health Care
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Managed care is the private (and public) regulation and financing of the delivery of
health care with the goals of controlling costs and assuring quality.
Capitation—the Managed Care Organization (MCO) pays a fixed, per person amount
to providers during a specific time period regardless of the services they provide.
Preauthorization review—provider seeks approval from the insurer before delivering
care.
The important reason for managed care was to contain costs by managing (1) access
to services, (2) the amount and types of services delivered, and (3) the choice,
characteristics, and activities of health care providers.
How Does Managed Mental Health Care Work? (Interview with a Social Work Provider
p.218-221).
 Positive factors: therapists must be competent, up-to-date, and accountable to stay
with the MCO provider panels.
 Drawbacks for therapist: reviewers rarely know providers; patient-therapist matches
can suffer; a lot of paperwork for authorization and reauthorization; no built-in pay
raises and providers in order to get in the pool may agree to work for les and lower
the rates for all.
Managed Care in an Agency Setting (Interview with a Social Work Staff Member p. 221223).
 Problems: Too many forms. Agency did not pay the clinicians until the MCO paid
them, but that practice was stopped. The agency had the contract with MCO, but
individual staff members also had to contract with MCO and could be denied
certification because they worked with unreliable population like those who abuse
drugs/alcohol.
 Positive: the MCO recognized the importance of environmental or “collateral
contracts”(social work function of brokerage, advocacy, and case management) work.
The state replaced the agency’s MCO with one that had more stringent rules and
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fewer sessions. Refusing treatment became a conflict with social work code of ethics
for the social worker and agency’s policies.
Managed Mental Health Care in the Public Sector
 Managed care has expanded into govt. agencies that serve Medicaid and other public
funded health care. By 1996, 27 states had behavioral health manage care. Medicaid
includes poor elderly, public welfare clients, & people just above the poverty line
with employment, housing, and transportation problems.
 The challenges of Medicaid managed mental health care is cutting costs, maintaining
or increasing quality of care, and creating an effective system of community
resources for folks with mental illness.
The History of Managed Care
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Health Maintenance Organizations (HMOs) were developed in 1930s with fixed
monthly dues mostly paid by employers and covered all services provided.
Industrialist Henry J. Kaiser established Kaiser-Permanente in 1942. By 1950s,
Kaiser had half million members, clinics, hospitals, doctors, etc.
Legislation passed in ’71 (Nixon) to support the growth of HMOs and the HMO Act
of 1973 required businesses with 25+ workers to offer at least one qualified HMO
plan, if available in their locality.
The Clinton health care reform also had managed care to be operated under state
control and the national health board would set the prices, but the bill was never
passed with opposition from AMA, business community, & Republicans.
Due to expansion of mental health services and high costs in the ‘80s, MCOs became
the tool to control expenses. The federal 1115 waiver allows Medicaid managed care
plans with mandatory participation of Medicaid population.
The Economics of Managed Care
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Does managed care save money? Since it is in the doc’s best interest to limit services
because they get paid a set amount, MCOs restrict health and mental health costs.
But then costs increased again possibly because the benefit of enrolling most people
in MCOs was achieved through the “one-time savings” switch.
Increasing prices for prescription drugs are a big part of this issue, with 17% in 1999
for managed care vs. 6% of total care costs.
Social Analysis of Managed Care
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What are the values, assumptions, and goals of managed care? MCOs view mental
illness as a medical or disease model or as a set of reactions to “problems in living.”
MCOs in the private sector tend to use medical model maybe because of therapist
trained in specialized treatments and in the public sector with folks with economic
and social stresses, then community-based and preventative services.
Managed care builds on values and assumptions of our society on the belief that
market forces have the ability to solve both economic and social problems while
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being suspicious of the govt.’s ability to do it. Clinton’s health care reform was
viewed was “big govt.”
The manifest goal of mental health is cut health costs while maintaining quality care.
Latent goals are to expand into new markets, even when general health market is
saturated, and gaining control over providers.
The Political Context of Managed Care
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The stakeholders are many: clients, employers, state health officials, providers,
MCOs, federal and state legislatures, govt. leaders, advocacy groups, and the broader
public.
Most mental health consumers are not organized with other clients or families and the
employers and state administrators are driving mental health care since they purchase
these plans.
Managed care uses cheaper providers like social workers more than psychiatrists and
all receive fewer fees.
Lawsuits from doctors and social workers towards MCOs have protected the
professions and overlap with advocacy for clients to maintain services and seeing
their same providers.
Social Workers and Managed Care
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Social workers play many roles in MCOs: provider, gatekeeper, planner, and
advocate.
3rd party insurance reimbursement for social workers is likely to involve MCOs.
Major issue for social workers is ethics and to insure confidentiality since managed
care workers approve treatment based on the information social worker gives them.
Another issue is what constitutes adequate and effective treatment. MCOs are good
for short-term treatment, but some clients need long-term.
The problems with MCOs: A lot of paperwork, constant phone calls to gatekeepers to
approve treatment plans and allow more sessions, and the application and review
procedures to become a member of an MCO’s provider pool.
Influencing the System (Interview with an Advocate p. 240-241)

Shannon Robshaw (MSW advocate) played a role in organizing a coalition of
advocacy groups and state chapter of NASW to influence the goals and provisions of
mental health services legislation in Louisiana.
Current Proposals for Policy Reform
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Mental Health Parity Act—the equal insurance coverage of mental and physical
conditions has been sought since 1950 and it was passed in 1996.
Laws to protect patients’ rights in managed care have become an arena for future
reform in areas such as: right to information about health plan’s procedures and
policies, right to access to medical specialist w/o approval of primary care doctor,
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right to an independent appeals process, and right to sue a health plan for damages
when improperly denies care.
A bill on the patients’ rights measure does not allow patients to sue MCOs for
damages from the Republican version, but the Democrats yes! The House bill would
cover more people than the Senate measure. While the bill has been passed, the
conference committee of House and Senate members has not resolved their
differences.
Supreme Ct. ruled against a plaintiff attempting to sue her HMO for restricting access
to an essential medical procedure, which has intensified the pressure patients’ rights
legislation.
Conclusion
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Even after mental health parity legislation and if we pass a patient rights act, we will
still need to ensure high level of quality for health and mental health care from
MCOs.
National health insurance has not disappeared from the political arena.
Social workers will still need to help make present policy and program arrangements
useful for clients and work toward new and better systems.
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Ch10--Popple & Leighninger—Substance Abuse Policies

See the vignettes about the problems of substance abuse p.252. From the 1998
National Survey on Drug Abuse, 13.6% of Americans age 12+ (6% of the population)
were current illicit drug users. 10% are heavy drinkers. Table 10.1 shows how few
people receive treatment that has alcohol/drug problems.
The Problem of Substance Abuse
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Definitions range from maladaptive to non-therapeutic uses of alcohol/drugs (p. 254).
There is difficulty with differentiating recreational drug use with serious addiction.
Alcohol and tobacco are legal and yet cause most of the harm.
In the ‘80s, the myth babies being permanently damaged because mom used crack is
really about poverty, poor maternal health, and the use of multiple substances by
pregnant women.
Codependency (the idea that one family member “enables” another to abuse
alcohol/drugs is not supported by research.
Arrests are 4 times as often for African Americans for crack (5-yr sentences for 5
grams vs. 500 grams of powdered cocaine—smoking vs. sniffing) than for Whites
with Coke.
The History of Substance Abuse Policies
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In the mid-1800s, opium, codeine, heroin and morphine were used in cough syrups
and used for pain relief.
As long as the these substances were medically based and confined to middle and
upper classes, little public concern.
Colonists drank 6 gallons of alcohol per year vs. less than 3 in 1980s, but it was
common and accepted.
Dr. Benjamin Rush and other docs viewed alcohol addiction as a moral issue and by
1855, the prohibition movement was important in US, with 13 states passing
temperance laws.
The change in attitudes in the late 1800s was connected with race, class, and religion
(Indians, Irish Catholics, Italians, ant others).
Charity Org’s blamed alcohol as the cause of poverty for families.
Chinese immigrants were scapegoated because they smoked opium and laws were
passed against the street use of the drug, although medical use was ok—these
reactions are similar to today.
WCTU and other moral crusade temperance organizations supported prohibition
(1919—Volstead Act and repealed in 1933).
1914—the Harrison Narcotics Act was meant to regulate not prohibit heroin,
morphine, and cocaine by imposing a tax to those who produce, import, sell,
manufacture, etc.
By 1960s, the US govt. had established 2 policies to control drugs: reduction in
supply of drugs through law enforcement and reduction in demand through
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prevention and treatment. For the “demand approach,” the Narcotic Addict
Rehabilitation Act of 1996 allowed for non-punitive incarceration of addicts to treat
them. The dominant policy was the “supply approach” of federal and state statutes
that define “controlled substances” and prohibit their possession, use, manufacture,
and distribution (See Figure 10.1 p. 260 for the legislation on the federal
Comprehensive Drug Abuse Prevention and Control Act of 1970).
NIDA—1973 and NIAAA—1970 (major federal agency since repeal of Prohibition)!
“JUST SAY NO” campaign of Nancy Reagan to deal with drugs, MADD org. for
drunk driving, and drug czar (cabinet-level official in charge of national efforts to
control supply and demand for drugs)=Reagan years!
The focus was that drug use was a problem for lower class, inner city African
Americans, which turned into a moralistic attitude of personal failing for this group
and they were in jail from 35% in ’83 to 48% in ‘89!
Now fewer people are using crack and the focus has shifted to “club drugs” or
“designer drugs” such as Ecstasy and marijuana use with malt liquor. One type of
drug use declines and another increases!
Social and Economic Analysis of Substance Abuse Policies
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Treatment and prevention approaches are difficult to evaluate and no one knows how
much is genetic or environmental.
Conflicting values: criminal behavior (the response=moral campaigns and
incarceration) and moral failing (therapeutic interventions, and community
development programs).
There are different views: the libertarian view of behavior as an individual right
(policies of free drug markets and accepting recreational use of drugs) vs. the
responsibility of govt. to protect citizens from threats to health and safety (support
control to incarcerate offenders to deterrence through law enforcement and
rehabilitation.
Political Analysis

Stakeholders: self-help groups like AA & NA; citizen groups like MADD;
professional and direct care staff (although a small number of social workers work in
substance abuse area); credentialing of substance abuse counselors from psychology,
social work and alcohol and drug field; law enforcement groups; lobbyists for the
beverage industry; companies and farms that produce drugs, traffickers, and dealers
exert force under the table with bribery; and the citizen and taxpayer through public
opinion polls that may influence policymakers and voting.
Analysis of Two Policies: Drug Tests for Welfare Clients and Separation of Treatment for
Those Who Are Dually Diagnosed
Drug Tests for Welfare Clients—can be to penalize people or refer them for help.
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2-3% of US work force abuses legal and illegal drugs.
Drug testing is conducted on “captive audiences” like those receiving welfare to deny
them services and/or force them into treatment.
Little is known about the deterrence of drug testing or the lasting effects of treatments
for clients.
Policy supporters stress that treatment will enable welfare folks to lead more
productive and rewarding lives, which reflects on the assumption that people on
welfare are irresponsible and need guidance to change their behavior.
Clients’ advocates question the assumption that substance abuse is widespread among
welfare recipients. Estimates from National Household Survey range from 15-25% of
welfare clients being addicted vs. 6% of the general public.
Legal experts argue that drug testing is an invasion of privacy.
The stakeholders: social workers, psychologists, and other professionals are critical
of mandated drug testing have had limited impact while attorneys for ACLU have
greater potential. Govt. officials tap into the distrust of welfare programs and their
clients and win support for policies. But drug testing is expensive and that is what
limits its use.
Separation of Treatment for Those with Mental Health and Substance Abuse Problems—
 Intervention policy: the decision to treat people with substance abuse and mental
health problems with 2 different programs at 2 different times or treat only 1
condition and ignore the other.
 Comorbidity (substance abuse and mental health problems), about 56% of those with
any alcohol, drug, or mental disorder will have 2 or more of these in their lifetime.
50% of people with mental illness have substance abuse problems and 35% of
alcoholics and 50% of drug addicts have mental disorders.
 Stakeholders: psychiatrists have negative attitudes toward substance abusers and
psychoanalysis did not work. AA members have developed a critical attitude towards
psychiatry. These negative feelings have reinforced organizational and economic
arrangements with NIAAA splitting off from National Institute for Mental Health in
1973. In the 1990s on the federal level, substance abuse and mental health services
were combined under Substance Abuse and Mental Health Services Administration
(SAMHSA) and programs have developed programs to focus on mental health and
substance abuse issues.
Conclusion

Policy responses to substance abuse: (1) sort out political, moral, and legal aspects of
substance abuse policy; (2) reach a consensus about the levels of seriousness of
abuse; and (3) develop the most effective and humane ways of dealing with the
phenomenon.
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Ch11--Popple & Leighninger—Child Welfare: Family Preservation Policy
The system to report child abuse with laws in every state mandating reporting has increased
from 9,563 reports in 1967 to nearly 3 million in 1992. Family preservation is the approach
to reduce kids placed in foster care and the goals are: 1) allow kids to remain safely in their
homes; 2) maintain and strengthen family bonds; 3) stabilize the crisis situation that
precipitated the need for the placement; 4) increase the family’s coping skills and
competencies; and 5) facilitate the family’s use of formal and informal helping resources.
Look at pg. 280 (Fig. 11.1) for service delivery contrasts between traditional and family
preservation services. Family preservation uses several models: short and intense services in
Homebuilders (cognitive-behavioral), structural family therapy (uses family systems theory
and emphasizes the relationship between family and other systems), and psychodynamic and
behavioral approaches.
Historical Analysis
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
Protection for kids in the 19th century as they became economically worthless, but
emotionally priceless—decline of useful tasks they could do in industrial economy.
Equal rights for women and kids emerged in the second half of the 19th century and
the recognition that kids were important for the future of society.
The Child Rescue Movement—New York in 1875 (society to prevent cruelty of kids). These
societies did not view themselves as social welfare agencies. They were law enforcement
agencies that would remove kids to placement agency or children’s homes and prosecute
parents.
Social Work Takes Over—The child rescue movement did not give recognition that kids love
their families and would want to stay with them in many cases. Social work was emerging as
a profession and began to move the responsibility of child welfare from private to public
auspices.
Child Abuse Becomes the Dominant Theme—The discovery of child abuse by medical
profession, and public knowledge and interest in the problem led to developing child abuse
reporting laws. The increase in reports by 8,663% vs. 128% of staff illustrates how the pace
of staff increases is not adequate to provide services.
Foster Care—From Solution to Problem—Loring Brace took kids from New York and
placed them in rural settings. No attempts were made to work with parents to return kids
home. There was little follow-up or supervision after placements were made. By 20th
century, foster care placements replaced institutional placements in many cities. In 1950s
and 1960s, studies of foster care showed that kids stayed in the system about 3 years and
75% grew up in foster care. Parents had no relationship with their kids in the system. Many
kids went from home to home in foster care. In late’70s and 1980s, permanency planning
movement was based on the child’s home being the best place and removal should happen
only in extreme circumstances; when kids are removed, a plan should be developed,
monitored, and revised as needed; the focus of the plan was to return kids home or adoption
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and if not possible, then long-term foster care. While kids in foster care decreased from
520,000 in 1977 to 275,000 in 1984, crack cocaine, AIDS, rise in births by teens increased
foster care placements to 429,000 by 1991. Number of foster families decreased from
137,000 homes to 100,000 from ’84 to ’89 as a result of increase number of women working,
low payments made to foster parents, and inadequate support services and training for foster
parents.
The Emergence of Family Preservation—The Adoption Assistance and Child Welfare Act
(P.L. 96-272) of 1980 required that child welfare agencies provide services to prevent the
necessity for placement and courts were to determine if the agencies made reasonable efforts.
The second reason was the increase of kids in foster care that needed to contain costs and
bring in family preservation to help. By 1991, over 400 preservation programs were funded
by federal govt. and foundations; and by ’93, it became federal policy (P.L. 103-66, the
Family Preservation and Support Program).
Social Analysis

Problem Description—child dependency as a problem has 3 levels: child poverty,
child maltreatment derived from poverty, derived from the first 2 levels is high foster
care population.
o Descriptive Data—incidence of child maltreatment is estimated to be between
1.4-1.9 million kids per year; summary reports of the problem has increased
due to reporting systems; number of confirmed reports substantiated by
investigators is 1 out of 3; and the number of increased confirmed reports
leading to child placement.
o Relevant Research—Kids separated from parents suffer psychological distress
and separation has consequences for child’s development (Bowlby) and this
confirms similar findings of primate studies by Harlow of cloth surrogate
mother raising monkeys. Kids raised below the poverty line are 10 times
more likely to be abused and neglected than middle-class kids.
o Is Family Preservation Policy in Accord with Research Findings?—Research
in foster care lends support to permanency planning (providing a
psychological parent) or to family preservation (support biological parents to
be psychological parents). But child poverty is the bigger issue of child
maltreatment.
o Major Social Values Related to Family Preservation—Kids, family, and govt.
rights sometimes can conflict since kids need protection, but in a way to
maximize the rights of parents to rear their own kids. Time-limited family
preservation program is a way for govt. to intervene as quickly as possible and
get out of family life to balance the rights of all concerned.
o Family Preservation Goals—Manifest (stated) goals: prevent placement of
kids in families in crisis; protect kids and prevent child maltreatment; improve
family functioning with daily-living and problem-solving skills; and prevent
child abuse and neglect. Between manifest and latent (unstated) goal is that
family preservation is perceived as cost-efficient way to deal with child
maltreatment. Not proven is the notion that a latent goal is to preserve existing
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patriarchal family structures and power relationships in society, but families
are female-headed, single-parent households and changing to nuclear families
is not mentioned in the family preservation policy.
o Hypotheses—(1) If intensive, time-limited, social work services are provided
to families with kids at risk of placement, and these services are provided in a
timely fashion, then placement of kids can be permanently avoided. (2) If
child placement is avoided via provision of intensive family preservation
services, then reduction in foster home placement will save more money than
the family preservation services cost.
Political Analysis
Family preservation appeals to many liberals and conservatives. For liberals, it does not
blame the victim, proceeds from strengths perspective, emphasizes cultural sensitivity,
emphasizes a belief that people have capacity and desire to change, defines family as a
unique system and respects the dignity and privacy of family members. For conservatives,
shortens the time govt. is involved, emphasizes that people are responsible to solve their
problems, emphasizes independence and weaning people from social services, resonates with
emphasis on family values, and is viewed as cost-effective ways to protect kids. Some
groups do oppose family preservation policy because it removes accountability, or is cutting
into their market of adoptions, or some groups in our profession think the policy puts kids at
risk.
Economic Analysis
Cost savings of $3,000 per family per year with family preservation, $10,000 for foster care
and $40,000 for institutional care but foster placements must decrease or the rate of increase
slow down for policymakers not to lose their enthusiasm and critics gain credibility.
Policy/Program Evaluation
Studies have found lower placement rates in groups receiving preservation services than
control group from 14% in New Jersey, 28% in California, and 22% in Minnesota. If family
preservation policy does not reduce the population in placement and the cost of services
regardless of how successful it is politicians seeking cost containment in child protection will
abandon it.
Current Proposals for Policy Reform
As family preservation has not reduced foster care rates, there is a strong movement for
kinship care (extended family for placements), mostly African-Americans! Kids are less
likely to return to their parents than kids in foster homes, but they are still with families and it
is cheaper than foster care. Many states will only give public assistance payment for kinship
care as compared to $10K of costs for foster care. However, states are being pressured to
provide the same level of support for kids in kinship care as foster care, which then would
not turn out to be a cost saver.
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Conclusion
1) Family preservation is a philosophy behind child welfare policy and as a specific
programmatic response to the problem of child maltreatment. But programs have not shown
to be cost-effective per se.
2) Family preservation will involve many types of interventions and benefits. Poverty must
be addressed, employment, housing, medical care, and decriminalization of substance abuse
to remove economic incentives for drug dealing, day care, parenting education, and mental
health services.
3) Family preservation might do better if they were evaluated as one of the interventions to
reduce placements.
4) Child maltreatment results from many variables of psychology to macrosocial and
macroeconomic issues that are interrelated with one another.
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