Keeping the Momentum of Change Going Once the Energy of the Crisis Has Passed
As social workers, we are central in recognizing health disparities and social justice work. Many social workers are on the front lines with direct contact to clients and the ability to address disparities and advocate with them. As the energy of the pandemic passes, I would like to explore how to keep the momentum going from the context of a social worker in a dialysis health care setting ... Given their extensive training in engagement, assessment, intervention, and evaluation skills for individuals, families, groups, organizations, and communities, social workers-who are required in dialysis facilities by federal regulation-are well-positioned to help address the area of supportive care for patients, families, and staff' (Anderson et al., 2019). I would also like to challenge social workers to consider our personal bias toward health disparities and social justice work.
As a professional mental health and health care social worker, I will address three specific areas: racial disparities, ageism, and immigration status. "A number of studies have found that daily experiences with bias and discrimination contribute to chronic stress among racial and ethnic minorities, which may contribute to higher rates of chronic illness" (Benjamin, 2015). Racial disparities exist within institutions and organizations that still inflict racial trauma and retain vestiges of racial bias. "Individuals with kidney disease should receive timely referrals for specialty care. Those from underserved communities are less likely to see a nephrologist prior to starting dialysis and are therefore also more likely to have poorer outcomes on dialysis" (Tucker, 2021). Poverty, health care inequities, education level, occupation, income, and difficulty obtaining insurance coverage are well-documented areas of concern. People in metropolitan, suburban, and rural communities also experience differences in health access. These disparities are further complicated when age and immigration are also factored in. Ageism health disparities exist as well. "Another study published in the Journal of General Internal Medicine ound that experiences of discrimination within health care settings were associated with new or worsening disabilities among older1 patients" (Benjamin, 2015). A dialysis patient can struggle with obtaining insurance, services, and transportation. Patients who have worked all their lives, have paid into the Social Security system, and depend on Social Security as their monthly income can find themselves choosing between health and living needs. Their income may fall above poverty guidelines for state programs, including Medicaid, yet not be enough to cover their annual deductible, co-pays, out-of-pocket expenses, and transportation needs. Patients may experience coverage gaps or be unable to afford medication. Patients who are using a wheelchair and are not Medicaid eligible can incur a cost of $180 to $300 per week to be transported by an ambulette to their dialysis treatment. Another ageist consideration is the age at which one can obtain a kidney transplant. Most kidney transplant centers will not give a kidney to a person over 75 years old due to age and not necessarily health status.
Immigration barriers are another area to address disparities. In some cases, patients have been brought to this country as children and are now adults still without legal status in need of dialysis treatment. Another immigration barrier is those patients who entered this country as adults due to fleeing a health care system with no option for safe dialysis treatment. These patients without legal status requiring dialysis also do not have insurance coverage for preventative care. Preventative procedures may not be covered, such as a kidney biopsy or treatment for autoimmune disorders such as lupus. "Many undocumented patients with advanced CKD (Chronic Kidney Disease) are young, and their kidney disease may not be attributable to diabetes. This is important, as some of these other diseases, if treated, can prevent these patients from requiring dialysis" (Suarez, 2019).
As a social worker, I have intervened with patients expressing anger toward other patients who do not have legal status. The patients are angry because the person without legal status has Medicaid. I work in New York state, where there is a health insurance program for those without legal status, but some states do not have a similar program. Patients of legal status do not understand that the program is limited to paying for dialysis treatments, emergency medical care, and transportation to and from dialysis. Patients do not realize that the person without legal status cannot obtain medications for blood pressure or diabetes, will not be
eligible for a kidney transplant or in-home care such as home care aides, and will have a higher death rate. Patients without legal status cannot obtain a vascular access, partly due to lack of insurance and lack of providers willing to accept state-
funded insurance. They will be dependent on a chest catheter, which creates a higher risk of potential for infection. Patients without legal status will die younger and unhealthier due ro their inability to obtain certain medications and transplant, which would prolong their life expectancy. A transplant would be a viable i option if permitted. "Undocumented immigrants with End-Stage Renal Disease, (ESRD)) are normally younger, have fewer comorbidities, and have a potential living donor. These characteristics make them ideal transplant candidates who are likely to have good outcomes. Unfortunately, most of chem are unable co get a transplant due to lack of insurance" (Suarez, 2019). There are many areas of health disparities social justice social workers continue to need to address. "Health is also of special importance for society because a nation's
prosperity depends on the entire population's health" (Braveman et al., 2019). Access to health care for all individuals means appropriate medical treatment for all, including medically necessary medications, tream1ent, or management of health conditions; access to kidney transplant; and legal status advocacy for all
individuals regardless of race, age, or legal status. As social workers, we recognize resource availability, limitations of systems, and the struggle to allocate needed resources.
Jennifer L. Rowe, LCSW, is a social worker with over 25 years of field experience. She has a strong interest in caregivers, multiple sclerosis, end-stage renal disease, and persons diagnosed with Alzheimer's disease. She is a nationally certified dementia practitioner. Ms. Rowe can be . reached at jennilerrowelcsw@gmail.com