Can EAPs help the working poor? The prevalence of uninsured and underinsured workers has put EAPs in a delicate and difficult position that threatens EA professionals' practices and the very survival of the industry.

The dual client system of employee assistance is inherently complex. EA practitioners must be dedicated to both the well-being of employees and the goals of business enterprise. The objectives and interests of the two clients, however, are often incompatible and irreconcilable.

Certainly, EAPs are agents of their corporate clients--senior-level executives approve their services and renew their contracts. Demands for efficiency, cost-containment, and surplus gains should not, however, take precedence over the interests of other members of the work organization at all times. Employees and managers also expect EAPs to produce certain outcomes, and their satisfaction and patronage are likely to have a considerable impact on program survival.

Since every member of the work organization--workers, managers, executives, and members of the board of directors--makes evaluations about the legitimacy of the EAP that affect the program's position within the organizational hierarchy, EA practitioners must be faithful in sustaining the balance between their dual obligations. Because management's and labor's interests frequently are incongruous, achieving favorable outcomes simultaneously can be impracticable. In recent years, however, many EAPs have been unsuccessful at achieving desired effects for either of their clients.

One factor hindering EAPs' ability to improve the quality of life of employees and the productivity and functioning of work organizations is the widespread inadequacy of healthcare coverage for the American workforce, particularly the working-class poor. The prevalence of uninsured and underinsured workers in this country has made EAPs dangerously insecure. This article examines the state of health care for the American workforce in relation to EA practice and outlines a plan and strategy for action.

THE CRISIS IN HEALTH CARE

According to Census Bureau (2004) statistics, 45 million people in the United States have no form of health insurance coverage. A great many of these uninsured people are lower-income workers (Strunk and Rechovsky 2002; U.S. Census Bureau 2004; Anderson and Keegan 2004) who do not receive employer-based coverage and are not eligible for government healthcare support.

While many work organizations provide coverage for their workers, rapidly rising health insurance premiums have prompted a growing number of employers to shift more of the costs of health care to their employees and/or reduce the scope of healthcare benefits they offer. These changes have resulted in decreased access to appropriate healthcare services for a multitude of workers. Many wage earners now forego health insurance because they are unable to pay their share of the premium, while others defer needed treatment because their healthcare benefits are insufficient.

The situation has worsened since the enactment of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, also known as the "welfare to work" law. An unintended consequence of this legislation has been an increase in the number of low-income working families without health insurance coverage (Garrett and Holahan 2000; National Bureau of Economic Research 2003). Generally, former welfare recipients acquire low-paying jobs that do not offer health insurance benefits and, in so doing, often lose eligibility for public health benefits (such as Medicaid) because their earnings exceed the federal poverty level.

Access to mental health care is further complicated by the lack of parity between medical and mental health insurance coverage. Employer-provided health plans commonly impose annual and/or lifetime dollar limits on mental health and substance abuse benefits that are less favorable than those offered for medical benefits under the same plan (Bazelon Center 2004).

Presumably, the disparity in mental health spending results from misconceptions about mental and emotional distress and a lack of sympathy for people with mental health and substance addiction problems. While employers fret over the possible abuse of mental health services, Britt (2003) estimates that work organizations suffer $44 billion in productivity losses each year due to depression alone. Yet the current standard within the healthcare marketplace is to stabilize, not cure, mental illness, particularly when it comes to managed care.

Incidentally, managed care has also played a decisive role in the current healthcare crisis. Managed care has a long history in the United States, beginning in the 1800s as pre-paid services designed to help meet the healthcare needs of select groups of people. This delivery system was expected to increase access to quality, comprehensive, coordinated health care, but over time managed care became a tool for reducing labor costs and ensuring surplus gains for employers and managed care organizations (Cohen 2003), which maintain the right to select service providers, monitor service utilization, and influence clinical and medical decisions pertaining to levels of care. This arrangement has the tendency to undermine access to appropriate healthcare service delivery.

Together, these developments--the shifting of healthcare costs from employers to employees, the dismantling of the public insurance safety net for low-wage workers, the persistent disparity between medical and mental health insurance coverage, and the profit focus of managed care organizations--have created a crisis for the American workforce, particularly the working-class poor. Besides raising serious social welfare concerns, including those related to the structure and quality of American production, this crisis also has given rise to dire implications for EAPs and the future of the EAP industry

WHAT IS AT STAKE?

EAPs justify their existence by demonstrating their ability to improve the productivity and functioning of the workforce. Assessment and referral are the core services used to achieve these ends.

These services, however, are only advantageous when employees can gain access to appropriate levels of care. Physical, mental, behavioral, cognitive, and other health-related problems generally persist or exacerbate in the absence of sufficient treatment. In such cases, EAPs do not provide a sufficient return on investment to corporate clients, help managers ameliorate performance problems exhibited by troubled employees, or improve the quality of life of people who work.

Because it is growing more difficult to link employees to needed resources and services that will help them attain normative standards of well-being, EAPs are losing their ability to produce desired employee and business outcomes. The resultant decline in EAPs' credibility is reducing their value and creating implications for program utilization, economic security, and professional stability. Each time EA practitioners are unable to help troubled employees secure access to adequate care, managers and employees grow more dissatisfied with EAP interventions and less likely to utilize program services in the future. As utilization rates fall, EAPs become less cost-effective and corporate clients begin to question their value.

The time has come for our industry to answer these challenges to our competency and reliability. If our field is to remain viable, EA professionals must earnestly plead for adequate healthcare coverage for workers, particularly the working-class poor. This is a formidable task; in a climate of retrenchment, work organizations tend to become less committed to the human relations side of their business. Moreover, because EAPs operate at the behest of their corporate clients, EA practitioners advocating on behalf of workers are likely to jeopardize their standing in the organization. Notwithstanding these very real challenges, there are workable solutions to the healthcare crisis that can help us deliver the desired outcomes for both our employee and employer clients.

A PLAN AND STRATEGY FOR ACTION

As "front-line" mental and behavioral health providers, EA practitioners are aware of both the needs of people as employees and the resources available to meet these needs. By playing a more active role in resolving the healthcare crisis for working people, EA practitioners can also increase the value of EAPs to work organizations. To these ends, we propose the following strategies:

Taking collective action and building coalitions. Lobbying state and federal lawmakers is likely to be the most effective course of action in solving the healthcare problem. Advocacy can increase public knowledge of this crisis and influence policymakers to support private health insurance reform and national healthcare benefits for the working poor.

The leading professional associations in our industry, EAPA and EASNA (the Employee Assistance Society of North America), should work together with healthcare providers and other interested organizations and individuals. As interested citizens and professionals and socially responsible organizations, it is our prerogative to uphold this cause and petition the government for legislative and regulatory remedies. Creating or joining an advocacy coalition that is united around the issue of health insurance reform is an effective way to promote affordable health care for the American workforce.

Assessing employees' needs and access to resources. EAPs should keep statistics that track employees' presenting issues, the corresponding referrals offered, and whether financial limitations hindered employees from obtaining healthcare services. This information could be used to help employers determine appropriate levels of healthcare coverage.

Developing linkages. EA practitioners must develop cooperative relationships with providers in the community who can help employees ameliorate or resolve health-related and behavioral disabilities. These linkages must be based not only upon the providers' professional abilities but also their commitment to providing services to the uninsured and underinsured. In the city of New York, for example, many practitioners in private practice agree to offer psychotherapy at low cost to a percentage of their caseload. Training institutes and mental health clinics operating on sliding scales are also affordable options for employees, many of whom may be able to use out-of-network coverage to supplement their assigned fee.

Keeping abreast of research studies taking place at local academic institutions or hospitals is also important. Many studies offer free health-related services if individuals agree to take part in their treatment protocols.

Expanding the EAP Core Technology. When referral services have little practical significance, ongoing mental and behavioral health treatment should be incorporated into the EAP model. EA practitioners have a professional responsibility to help people in need, so when appropriate referral options do not exist, practitioners themselves should help employees and family members resolve daily stressors or return to baseline functioning. Of course, this requires EAPs to employ individuals who are well trained in offering specialized and/or long-term treatment.

Conducting research. Research is key to developing a full understanding of the extent to which employees are underinsured and the implications that this has for the dual client system and the EAP industry as a whole. EAPs could generate descriptive information concerning health insurance policies and utilization, which could bolster their credibility in the lobbying arena and help employers better realize the value of investing in the health and well-being of their workforce. Moreover, EAPs can use research to identify the needs of dual client systems, establish the effectiveness of EA interventions, and test the feasibility of alternative service delivery programs. These actions would increase EAPs' value and legitimacy within host organizations.

It is important as well that EAPs become both consumers and producers of information. Collaborating in working research groups or on joint research projects is a cost-effective means of generating knowledge.

If EAPs are to remain viable as workplace service programs, it is necessary for those of us engaged in the field to take a more proactive stance on the healthcare issue. EA practitioners can play a major role in reforming the healthcare and insurance systems and influencing employers' perceptions of optimal productivity in the workplace as a function of employees' health and well-being. By way of these efforts, EAPs can act in their own best interests and serve their client systems more effectively.

References

Anderson, S.G. and M. Keegan. 2004. "Health coverage instability for mothers in working families." Social Work 49 (3): 395-404.

Bazelon Center for Mental Health Law. 2004. "Fast facts on insurance coverage and access to services for children with serious mental health needs." Retrieved September 14, 2004, from http://www.bazelon.org/ issues/insurance/factsheets/children.htm.

Britt, J. 2003. "Cutting mental health benefits may not be cost effective. HR Magazine. Retrieved October 19, 2004, from http://www.findarticles.com/p/ articles/mi_m3495/is_8_48/ai_107526591/print.

Census Bureau. 2004. "Income, poverty, and health insurance coverage in the United States, 2003." Washington, D.C.: U.S. Department of Labor.

Cohen, J.A. 2003. "Managed care and the evolving role of the clinical social worker in mental health." Social Work 48 (1): 34-43.

Garret, B. and J. Holahan. 2000. Welfare leavers, Medicaid coverage and private health insurance.

National Bureau of Economic Research. 2003. "The effects of welfare reform on the insurance status and health and low-income families."

Strunk, B. and J. Reschovsky. 2002. Working families' health insurance coverage, 1997-2001.

Raquel Warley is an EA professional in the Mount Sinai EAP and an adjunct lecturer at Hunter College's School of Social Work. Charlotte Elkin is a senior counselor at the Mount Sinai EAP and a psychotherapist in private practice in New York.