Too Much to Qualify, Not Enough to Live

Imagine living with a chronic illness that requires constant medical attention, but not being able to afford it. This is the reality for millions of Americans who fall into the lower-middle-income class, a group that is often overlooked and under served by the healthcare system. They face unique challenges, teetering between disqualification for government assistance and the burden of managing substantial healthcare costs. As social workers, addressing their needs is vital in a society where such populations are often overlooked. To understand these challenges better, it is essential to understand the demographics of this group.

Social workers play a critical role in helping this financially strained population access government aid and healthcare, particularly in developing countries, where the World Bank classifies countries with a GNI per capita between $1,136-$4,465 as lower-middle-income countries (World Bank Country and Lending Groups, 2023). Mao et al. (2017) found that 5% of multi-chronic disease patients, mostly low-income patients, account for half of the healthcare costs. The significance of social workers' involvement in assisting these individuals is shown in this study, which focuses on the significant role they play in managing complex requirements, particularly in addressing the multifaceted financial difficulties that frequently hinder access to aid and medical care for this group.

Needs of Lower-Middle Income Chronically Ill Population

The authors of "Healthcare Needs and Difficulties of Low-Income People with Multiple Chronic Illnesses" (Lee, James, and Hunleth, 2020) draw attention to the significant healthcare challenges faced by those with multiple chronic illnesses who are low-income. They noted that these individuals often experience difficulties in accessing healthcare services and point to the need for timely and effective care. According to Mao et al. (2017), people with multiple chronic diseases, who are predominantly low-income, account for half of healthcare costs. These individuals often face additional challenges, such as poverty, mental health issues, homelessness, and social isolation, which can further complicate the delivery of care.

Those with chronic diseases who are ineligible for Medicaid due to their lower-middle income earning between $55,500 and $111,000 per year according to the U.S. The Census Bureau, 2023(Keisler-Starkey, 2023), can struggle to afford healthcare. Social workers can help guide these patients to programs such as Medicaid, PAPs, and SNAP, and promote affordable healthcare options to address the high cost of insurance. It is crucial to make healthcare more accessible and affordable for those who need it, particularly for those with lower incomes.

Chronic diseases can cause emotional distress, which must be managed. Social workers must provide counseling and support groups to help patients with depression and anxiety. They must also ensure their access to mental health resources. For instance, social workers can help COPD patients with anxiety about medication costs by connecting them to mental health services.

Chronic illnesses have a high mortality rate, and social workers working in hospice care can provide essential support to people in their care. According to the World Health Organization, chronic diseases account for 70% of the global deaths (Schmidt, 2016). The quality of life associated with the end-of-life process is affected by multiple factors including the patient's age and duration of illness (Callahan, 2017). The primary objective of hospice care is to maintain the quality of life of both patients and their caregivers. While it is impossible to fully understand the experience of dying, hospice social workers can gain valuable insights into the developmental challenges and needs of those dying. With this knowledge, hospice social workers can help patients grow as they confront mortality (Callahan, 2017).

Social Work Settings.

One of the main needs of the lower-middle-income chronically ill population is access to affordable healthcare. However, this group faces many barriers in obtaining quality care, such as high costs, eligibility criteria, and lack of insurance. Social workers can play a critical role in helping these patients navigate the complex healthcare system and find the best options for their needs.

Social workers play a crucial role in assisting lower-middle income individuals with chronic illnesses. These settings present unique challenges and opportunities for interventions. In hospitals and clinics, social workers guide patients through complex medical systems, especially those in the lower-middle-income bracket, who find healthcare costs burdensome. Lee et al. (2020) shows their role in managing healthcare intricacies, including waiting periods, as patients develop strategies to cope. Social workers also ensure that individuals with chronic illnesses receive home-based care, allowing access to necessary resources for the comfort of their homes. In today's digital age, community centers offer social connections complemented by online support groups and telehealth services.

Advocacy in workplaces is another vital role, as social workers promote accommodation and educate employers about the needs of individuals with chronic illnesses. They navigate the legal system in legal and advocacy offices, advocate for students with chronic illnesses in educational settings, and provide counseling and support groups in mental health agencies.

Nonprofit organizations rely on social workers to help lower-middle-income individuals with chronic illnesses access resources and navigate the healthcare systems. However, the eligibility criteria for social programs can be controversial, with debates about access and sustainability. Social workers play a crucial role in connecting people to resources and healthcare systems and addressing complex issues while aiding those in need. The debates surrounding social programs for chronically ill lower-middle-class individuals involve healthcare policies, finances, and values, including government involvement, fairness, and individual/collective responsibility.

Social Worker Roles

Social workers play a crucial role in assisting patients with lower-middle-income chronic illnesses. Zastrow and Hessenauer (2016) extensively discuss these roles in their textbook. Social workers can be advocates of and play a crucial role in aiding chronically ill individuals. They defend patients' rights, assist in accessing medical care, devise treatment strategies, and ensure patient rights. They guide clients through government support programs, such as Medicaid, Medicare, SNAP, and housing vouchers. Social workers aid in legal cases, such as SSDI and SSI, manage paperwork, and promote fairness in workplaces and schools. They help patients with chronic illnesses access healthcare, government schemes, legal aid, and education or employment. They help with disability benefits. In end-of-life settings, they work as advocates for hospice care.

Hospice social workers (Callahan 2017) are essential members of interdisciplinary teams that provide holistic care. They focus on psychosocial care, whereas certified hospice chaplains provide spiritual care. However, hospice social workers must also ensure that patients have access to the spiritual care that they desire. Hospice social workers can provide spiritual support by creating a spiritually sensitive therapeutic relationship and by referring to or delivering spiritual care. Addressing spiritual needs can be difficult, especially when they are unclear or change during death. Timely response is essential; therefore, hospice social workers must be spiritually sensitive and coordinate with the interdisciplinary team to ensure quality spiritual care (Callahan, 2017).

Betty, a patient of hematologist Dr. Smith, had her symptoms dismissed as anxiety by a previous doctor. Seeking answers, she turned to Elisha, a social worker advocate. Elisha presented research on Betty's symptoms to Dr. Smith, persuading him to conduct tests. These tests revealed a rare genetic mutation, enabling the prompt treatment and validation of Betty's concerns. Social workers play a crucial role in providing home-based care to individuals with chronic illnesses, ensuring that they have access to the necessary resources while enjoying the comfort of their own homes. Community centers also offer a sense of social connection to combat isolation, particularly in the digital age when online support groups and telehealth services are invaluable in reaching and assisting this population.

Social workers advocate workplace accommodations for individuals with chronic illnesses and educate employers about their needs, while also working in legal and advocacy offices to assist them in navigating the legal system. In educational settings, social workers support low- to middle-income students with chronic illnesses by advocating necessary accommodations, discussing resource allocation, and promoting fair educational opportunities. In mental health agencies, social workers provide essential support to individuals dealing with chronic mental and physical illnesses through counseling and support groups. However, financing and resource allocation debates may arise, particularly for lower-middle-income individuals with chronic illnesses who fall between government aid eligibility and the ability to afford these services.

Social workers are researchers with strong research skills and experience serving vulnerable populations. They evaluate programs, assess initiatives, and identify community needs. For example, they may conduct research support programs for lower-middle-income people with chronic illnesses. These studies sought to improve resource allocation, identify areas for improvement, and create new solutions to enhance end-of-life care and support.

Glenda is a renowned social work researcher who evaluates hospice program services and interventions. Her research has enabled the program to improve its approach by providing optimal care and support to patients and families. Glenda's research meets the needs of those who face end-of-life issues. The multifaceted nature of social work provides care and support to lower-middle-income individuals with chronic illnesses, ensuring that they live meaningful lives.

Knowledge and Skills

Social workers are crucial in assisting lower-middle-income individuals with chronic illnesses. Knowledge, skills, and empathy is also essential. They need a deep understanding of chronic diseases, healthcare systems, financial aid programs, and skills in case management, counseling, and leading support groups. They are skilled in evaluating client needs, creating customized intervention plans, and assisting clients in securing financial resources, such as Medicaid, Medicare, disability benefits, and charity aid. This expertise enables them to address financial issues related to chronic diseases. Their empathetic manner promotes trust and open dialogue, which are crucial for effective problem-solving. Lower-middle-income individuals face challenges in navigating the complex U.S. healthcare system, especially when dealing with chronic illnesses (Lee et al., 2020). Long waits, complex assessments, and bureaucratic hurdles worsened by funding cuts and strict work requirements make healthcare access crucial to streamline (Lee et al., 2020). Medicaid, CHIP, and pharmaceutical PAPs offer crucial financial aid.

“Generalist social work practice is a comprehensive approach to social work with individuals, groups, families, organizations, and communities. The CSWE requires bachelor's and master's programs to teach this practice. Generalist practitioners use a strength-based approach, engaging, assessing, brokering services, advocating, counselling, educating, and organizing to solve problems. Generalist social workers evaluate service outcomes to improve service quality and promote community and organizational development. The NASW Code of Ethics guides their practice, which seeks to improve the well-being of individuals, families, groups, communities, and organizations” (Zastrow & Hessenauer, 2016).

Strategies and Programs

Lower-middle-income individuals with chronic illnesses require diverse strategies and programs to address their multifaceted needs (Lee et al., 2020). Navigating the U.S. healthcare system often involves unavoidable waiting periods, especially for those without insurance or resources (Lee et al., 2020). The process entails state and federal evaluations, income assessments, work ability evaluations, consideration of illness severity, and citizenship verification, among others (Lee et al., 2020). Ongoing funding cuts and stricter work requirements have compounded the difficulties faced by this population (Lee et al., 2020).

Accessing healthcare through social welfare programs often involves long wait times, particularly in medicaid-accepting or sliding-fee facilities (Lee et al., 2020). This underscores the need for more efficient access to healthcare. Nevertheless, Medicaid and the Children's Health Insurance Program (CHIP) play essential roles in financially supporting lower-middle-income individuals with chronic illnesses (Lee et al., 2020). Pharmaceutical companies also contribute by implementing patient-assistance programs that bridge affordability gaps.

One notable example is the patient-centered medical home (PCMH) model, in which social workers collaborate closely with healthcare professionals. Research has confirmed the high effectiveness of PCMHs in managing chronic conditions (Hong et al., 2018). PCMH-certified practices excel in care coordination through case managers, quality care reports, and reminders for preventive and follow-up care. These findings demonstrate the promising potential of PCMH features, particularly in healthcare settings for chronic illnesses. Advocacy is vital for progress, aiming to secure more funding and healthcare access for at-risk, lower-middle-income individuals with chronic illnesses. Nonprofits, such as the National Alliance on Mental Illness (NAMI), advocate for improved mental health services, reduced care disparities, and policy changes. Programs such as the Supplemental Nutrition Assistance Program (SNAP) address nutritional needs, ensuring proper nourishment for lower-middle-income individuals with chronic illnesses (Center on Budget and Policy Priorities, 2022).

The combination of these strategies and programs aims to enhance healthcare access, reduce costs, improve care coordination, and provide culturally sensitive care, ultimately enhancing the quality of life of lower-middle-income individuals with chronic illnesses (Hong et al., 2018). This section summarizes the insights gained, paving the way for effective social work intervention. Financial aid, affordable care, emotional support, and mental health resources are crucial for patients with low-to middle-income chronic diseases. Social workers play a vital role in advocating for these resources, recognizing unique challenges and resilience, and equipping themselves with the skills necessary for effective support.

My experience drives me to champion resilient, often unnoticed, low-income, and chronically ill people. They require financial aid, accessible healthcare, emotional support, and mental health resources to prosper. Your support is crucial. My personal journey motivated me to champion this cause and urge everyone to support this vulnerable group. Their stories inspired us to redefine resilience and prosperity amid challenges. Social workers have the responsibility and the opportunity to make a difference in the lives of the lower-middle-income chronically ill population. By addressing their needs and advocating for their rights, they can help patients achieve better health outcomes and quality of life. As Nelson Mandela once said, ‘It always seems impossible until it’s done.

References

Callahan, A. M. (2017). Spiritual needs. Spirituality and Hospice Social Work, 55–71. https://doi.org/10.7312/columbia/9780231171731.003.0004

Center on Budget and Policy Priorities. (2022, June 9). Policy basics: The Supplemental Nutrition Assistance Program (SNAP). https://www.cbpp.org/research/food-assistance/the-supplemental-nutrition-assistance-program-snap

Hong, Y.-R., Huo, J., & Mainous, A. G. (2018). Care Coordination Management in patient-centered medical home: Analysis of the 2015 medical organizations survey. Journal of General Internal Medicine, 33(7), 1004–1006. https://doi.org/10.1007/s11606-018-4439-1

Keisler-Starkey, K. (2023, September 14). Health insurance coverage in the United States: 2022. Census.gov . https://www.census.gov/library/publications/2023/demo/p60-281.html

Lee, A. A., James, A. S., & Hunleth, J. M. (2020). Waiting for care: Chronic illness and health system uncertainties in the United States. Social Science & Medicine, 264, 113296. https://doi.org/10.1016/j.socscimed.2020.113296

Mao, A. Y., Willard-Grace, R., Dubbin, L., Aronson, L., Fernandez, A., Burke, N. J., Finch, J., & Davis, E. (2017). Perspectives of low-income chronically ill patients on complex care management. Families, Systems, & Health, 35(4), 399–408. https://doi.org/10.1037/fsh0000260

Schmidt, H. (2016, April 13). Chronic disease prevention and health promotion. National Center for Biotechnology Information. https://pubmed.ncbi.nlm.nih.gov/28590691/

World Bank Country and Lending Groups. (2023, June 24). World Bank Country and lending groups . World Bank Country and Lending Groups – World Bank Data Help Desk. https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups#:~:text=For%20the%20current%202024%20fiscal,those%20with%20a%20GNI%20per

Zastrow, C., & Hessenauer, S. (2016). An Introduction to the Profession of Social Work and Social Welfare (12th ed.). Cengage Learning.