Standing in her wedding gown, Courtney Davis held this sign:
“Message2Congress: If you had banned asbestos, maybe my dad would have been here to give me away.”
Her father, Larry W. Davis, 66, died in July 2012 of pleural mesothelioma—a cancer caused by asbestos exposure.
Stephanie Harper was a daddy’s girl. She told reporter David McCumber, her father was a jack of all trades–repairing vehicles, fixing HVAC–and when he came home at night, “I’d sit on his feet and grab his pants leg.” The 37 year-old mother from Texas now suffers from mesothelioma and agonizing pain that goes along with it. Stephanie was most likely exposed to the asbestos fibers from her dad’s work clothes.
Paul Zygielbaum, 64, is a retired technology executive from Santa Rosa, California. He was exposed to asbestos at home and during his early career as an engineer. Zygielbaum was diagnosed with mesothelioma in 2003. His treatment included ghastly surgery in which is abdomen was opened and filled with chemotherapy chemicals. Paul was on the legislative front lines in 2007 when the US Senate nearly passed a bill to ban asbestos.
The politics of that effort and the stories of Courtney, Stephanie and Paul are profiled by Hearst Newspapers’ reporter David McCumber. The three articles have been published over the last several weeks in the Connecticut Post, the San Antonio Express News, and the San Francisco Chronicle, respectively (here, here, and here.) McCumber does a public service reminding us that the scourge of asbestos—and the companies that profited from it—continues to cause disease and death.
Nearly 60 countries have banned asbestos, but the US is not one of them. Companies still import it into the US—more than 1,000 tons of it annually. We also have the deadly legacy of 13 million tons of the deadly mineral that was used in our country since 1900.
Then I read this from a news release issued by OSHA last month:
“OSHA cites 6 Chicago-area companies for worker exposure to asbestos”
Really?? Workers still getting exposed to asbestos?
It makes me angry to learn how some companies gamble with people’s lives. Asbestos exposure in US workplaces is just setting up individuals and their families to be the next ones suffering from asbestos-related diseases. Even more maddening is that these companies won’t be held accountable when the exposed develop disease years from now. Something is seriously wrong with a company that allows its employees and others to be exposed to a known human carcinogen. Take away their business licenses and permits to operate.
OSHA’s news release indicates that last summer, the six firms were involved in a renovation project at Chute Middle School in Evanston, Illinois. The project involved removing 60 feet of pipe that contained asbestos insulation. OSHA responded to a complaint and found more than a dozen violations of safety standards designed to protect workers from exposure to asbestos. In this day and age—and more than 40 years after OSHA issued its first asbestos regulation—it’s inexcusable for any firm to be so ignorant about asbestos.
OSHA proposed two willful violations related to asbestos and a $55,000 penalty to Environmental Services Firm Ltd. of Evanston, Illinois. This firm was supposedly the onsite asbestos consultant. F.E. Moran received citations for 10 serious violations related to asbestos and a proposed penalty of $47,500. The other firms that also received citations for violations of OSHA’s asbestos standard are Nicholas & Associates, ASAP Environmental, and B.B. Construction Enterprise, Inc.
I asked Paul Zygielbaum to read OSHA’s news release. He remarked:
“This is an unfortunate reminder of an ongoing American tragedy of which most citizens are unaware. I’m glad to see OSHA enforcing the law when companies carelessly or malevolently disregard the well-being of their workers. I only wish that the penalties were harsh enough to be a more effective deterrent.”
I agree. It’s been 25 years since Congress updated OSHA’s penalty amounts. It’s to be a LOT more expensive for companies that violate worker safety laws, including giving senior officials jail time.
And what about the Evanston/Skokie School District that hired these firms? What steps had the school district’s leadership taken to ensure they were contracting with responsible firms—not those that don’t understand or comply with OSHA regulations. I hope the school district is getting some bad publicity, and that all the firms involved are now on some sort of “no bid allowed” list.
Courtney Davis, Stephanie Harper and Paul Zygielbaum are three of the millions across the globe touched by asbestos-related disease. Without a global ban on asbestos use and strong regulations to prevent exposure, sadly, they’ll continue to have company.
A new analysis of data from the world’s largest and longest-running study of women’s health finds that rotating night shift work is associated with higher mortality rates. The new findings add to a growing awareness that long-term night shift work comes with serious occupational health risks.
Published this month in the American Journal of Preventive Medicine, the study found that all-cause and cardiovascular disease-related mortality were significantly increased among women who worked more than five years of rotating night shifts when compared to those who never worked the night shift. In addition, the study found that working 15 or more years of rotating night shifts was associated with a modest increase in lung cancer mortality. Previous research has also found a link between working the night shift and serious health risks. In fact, in 2007, the World Health Organization designated night shift work as a probable carcinogen, as it disrupts the physical, mental and behavioral changes that follow a daily cycle — otherwise known as circadian rhythms. Study authors Fangyi Gu, Jiali Han, Francine Laden, An Pan, Neil Caporaso, Meir Stampfer, Ichiro Kawachi, Kathryn Rexrode, Walter Willett, Susan Hankinson, Frank Speizer and Eva Schernhammer write:
The circadian system and its prime marker, melatonin, are considered to have anti-tumor effects through multiple pathways, including antioxidant activity, anti-inflammatory effects, and immune enhancement. They also exhibit beneficial actions on cardiovascular health by enhancing endothelial function, maintaining metabolic homeostasis, and reducing inflammation. Direct nocturnal light exposure suppresses melatonin production and resets the timing of the circadian clock. In addition, sleep disruption may also accentuate the negative effects of night work on health. Taken together, substantial biological evidence supports the role of night shift work in the development of poor health conditions, including cancer, (cardiovascular disease), and ultimately, mortality.
To conduct the study, researchers analyzed data from the Nurses’ Health Study, which was established in 1976 and involved nearly 122,000 nurses. The night shift analysis was based on 22 years of health and behavioral data follow-up among nearly 75,000 of the participating nurses. In a press release about the findings, study co-author Schernhammer, an associate professor at Harvard Medical School and associate epidemiologist at Brigham and Women’s Hospital, described the study as “one of the largest prospective cohort studies worldwide with a high proportion of rotating night shift workers and long follow-up time. A single occupation (in this case, nursing) provides more internal validity than a range of different occupational groups, where the association between shift work and disease outcomes could be confounded by occupational differences.”
In analyzing the decades of data, Schernhammer and her colleagues found that all-cause mortality appeared to be 11 percent higher for nurses who worked six to 14 years of rotating night shifts, which was defined as working nights at least three times per month. In addition, cardiovascular disease-related mortality appeared to be 19 percent higher for those working rotating night shifts for six to 14 years as well as 23 percent higher for those working such shifts for 15 years or more. No association was found between rotating night shifts and cancer mortality, except in the case of lung cancer — nurses who worked rotating night shifts for 15 years or more appeared to experience a 25 percent higher risk of lung cancer mortality. The researchers noted that while the impact of rotating night shifts appeared to be stronger among current smokers in regard to all-cause mortality, the effect of night shift work was still “statistically significant” among nurses who never smoked.
The researchers noted that while the study helped confirm previous findings on the adverse effects of night shift work, more research is needed to inform and shape feasible interventions for such workers.
“To derive practical implications for shift workers and their health, the role of duration and intensity of rotating night shift work and the interplay of shift schedules with individual traits…warrant further exploration,” the study concluded.
To read a full copy of the study, visit the American Journal of Preventive Medicine.
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.
Elbert C. Woods’ work-related death could have been prevented. That’s how I see the findings of Federal OSHA in the agency’s citations against his employer, Cleveland Track Material. The 45-year-old was working in August 2014 at the company’s Cleveland plant when he was pulled into machinery. I wrote about the incident shortly after it was reported by local press.
Inspectors with OSHA conducted an inspection at Cleveland Track following Woods’ death. The agency recently issued citations to the firm for six serious violations and proposed a $49,000 penalty. The violations all involved gross failures in the company’s lockout/tagout system. Cleveland Track settled with OSHA and agreed to pay a $35,000 penalty.
Just a few weeks prior to the work-related death of Elbert C. Woods, another Cleveland Track worker, Michael John Rettew, 41, died from injuries he suffered in April 2014 at the firm’s facility in Reading, PA. The company received citations from OSHA for serious violations and agreed to pay a $9,750 penalty
When some local press initially reported Elbert C. Woods’ death, they called it an accident. An “accident” suggests the circumstances were unforeseen or could not have been avoided. OSHA’s findings tell a different story. Call it cutting corners, call it poor management, call it breaking the law. Whatever you want to call it, Elbert C. Woods’ work-related death—and that of Michael John Rettew—could have been prevented, it was no accident.
Fatal work injury that killed Stanley Thomas Wright was preventable, Nevada OSHA cites Rebel Oil Co.
Stanley Thomas Wright’s work-related death could have been prevented. That’s how I see the findings of Nevada OSHA in the agency’s citations against his employer, Rebel Oil Company. The 47-year-old was working in August 2014 at a railyard in North Las Vegas, NV. Wright was asphyxiated while working inside a tank car. I wrote about the incident shortly after it was reported by local press.
Inspectors with Nevada OSHA conducted an inspection at the railyard following Wright’s death. The agency recently issued citations to Rebel Oil for three serious violations and proposed a $11,475 penalty. The violations involved failing to evaluate the hazards of a confined space, failing to inform workers of the danger posed by confined space, and failing to take prevention measures related to entering the confined space. Rebel Oil is contesting the citations.
When some local press initially reported Stanley Thomas Wright’s death, they called it an accident. An “accident” suggests the circumstances were unforeseen or could not have been avoided. Nevada OSHA’s findings tell a different story. Call it cutting corners, call it poor management, call it breaking the law. Whatever you want to call it, Stanley Thomas Wright’s work-related death could have been prevented, it was no accident.
Individuals with chronic occupational exposure to lead have an 80 percent higher odds of developing Amyotrophic Lateral Sclerosis (ALS) than individuals who do not have the exposure. Those are the findings of a recently published meta-analysis of 13 studies of individuals with “Lou Gehrig’s disease” (ALS). The authors, funded by the Public Health Agency of Canada for its National Population Health Study of Neurological Disease in Canada, note:
“Epidemiological studies investigating the association between prior exposure to lead and ALS began about five decades ago, after a series of ALS cases with antecedent exposure to lead were reported as early as 100 years ago.”
The authors used nine case-control studies, all of which specifically examined work-related lead exposure as a risk factor for ALS, in their meta-analysis. The studies included one based on data from the National Registry of US Veterans with ALS, and community-based studies of ALS patients in New England and from three counties in western Washington State.
Based on their meta-analysis, the authors reported a 1.81 higher odds of developing ALS for those with a history of work-related lead exposure (using a random-effects model: 95% CI 1.39 to 2.35; using a fixed-effects model 95% CI 1.42 to 2.29.) They also conducted sensitivity analyses using four additional high-quality cohort studies which examined the relationship between ALS and occupational exposure to “heavy metals.” The authors concluded:
“The available data suggest that about 5% of all sporadic ALS cases may be attributable to occupational exposure to lead, although the actual attributable fraction could be somewhat lower because of the assumptions in this calculation.”
An estimated 5,600 individuals in the US are diagnosed with ALS each year. For a disease for which little is known about its causes, it’s refreshing to read a paper (even a meta-analysis) that examined environmental risk factors. Whether the attributable fraction is 5% or half that, more than 100 new cases of ALS each year might be associated with work-related lead exposure. All the more reason to eliminate or control lead exposure in workplaces.
The CDC defines an elevated blood lead level (BLL) for an adult as a BLL ≥ 10 ug/dL. In 2010 (most recent data available) 31,459 adults were identified through laboratory reporting to have blood lead levels (BLL) ≥ 10 ug/dL. Nearly 1,400 of them had BLLs four times higher. From 2002-2011, more than 11,500 adults had BLLs ≥ 40 ug/dL. It’s not as if lead poisoning is a thing of the past. OSHA continues to find employers who violate worker protection regulations for lead (e.g., here, here, here.)
Preventing lead poisoning will take some work. Even when worker exposure to lead is found, OSHA’s 1978 lead standard hasn’t kept up with the science. It certainly doesn’t help matters that it only requires medical removal protection for workers with a BLL ≥ 50 ug/dL for construction workers (and ≥ 60 ug/dL for workers in other industries.) Nor does it help that CDC funding for state-based surveillance of adult lead poisoning was eliminated in 2013. TPH’s Kim Krisberg reported on the discontinuation of the National Institute for Occupational Safety and Health’s Adult Blood Lead Epidemiology and Surveillance program. The 20-year old program provided a modest, combined $812,500 annually to 40 state health departments to analyze and conduct follow-up on laboratory reports of adult lead poisoning.
“A Meta-Analysis of Observational Studies of the Association Between Chronic Occupational Exposure to Lead and Amyotrophic Lateral Sclerosis” stems from the Canadian government’s $15 million effort to better understand neurological health conditions. The National Population Health Study of Neurological Conditions in Canada involves three national surveys and 13 research project, conducted by 125 researchers at 30 institutions across Canada.
With the new year just around the corner, it’s the perfect time to celebrate worker victories of 2014. At In These Times, reporter Amien Essif gathered a list of the nine most important victories of 2014, writing:
Much has been made of the incredibly hostile climate for labor over the past few decades. Yet this past year, workers still organized on shop floors, went out on strike, marched in the street and shuffled into courthouses to hold their employers accountable, and campaigned hard for those who earned (or, often enough, didn’t earn) their vote. Legislators, meanwhile, tarried on with their anti-worker “right-to-work” laws, and union busters busted up unions. But if state legislatures and the U.S. Supreme Court were harsh on workers, the National Labor Relations Board (NLRB) was refreshingly helpful, passing down several rulings that made organizing easier and wage-theft harder.
Among Essif’s top nine were the nationwide protests organized by fast food workers, which “have brought international attention to the plight of low-wage workers in this country and around the world.” Other victories highlighted include the more than 18,000 workers with American, Virgin and JetBlue airlines who voted to join unions; the passage of San Francisco’s Retail Workers Bill of Rights; court rulings that found that FedEx misclassified employees as independent contractors; and the historic union drive among college athletes at Northwestern University in Illinois.
To read the full list and get inspired to kick off a new year of worker victories, visit In These Times.
In other news:
Charleston Gazette: The nation’s coal mines are on track to report record lows in work-related deaths, writes reporter Dylan Lovan. According to Lovan, federal mine safety officials attribute the good news to changes made in the wake of the 2010 Upper Big Branch disaster in West Virginia, in which 29 miners were killed in an explosion. (Don Blankenship, former CEO of Massey Energy, which owned the mine, was recently indicted on charges that he conspired to violate safety and health standards.) As of about a week ago, 15 coal mining-related deaths happened in 2014; the previous low mark was 18 deaths in 2009. However, Lovan writes that the “improved record has coincided with a plummet in coal production in Appalachia, leaving far fewer mines operating in a region where many of the worst violators have historically been found. Eight of the coal deaths this year have been in Appalachian mines.”
Los Angeles Times: Reporter Amy Hubbard writes that police deaths surged in 2014, with 126 officers killed nationwide while on duty. The number represents a 24 percent increase over 2013. California leads the country in law enforcement deaths, with Texas coming in second, Hubbard writes. However, the article notes that the 2014 toll is less than the average for the last decade, which comes to about 151 deaths per year.
Huffington Post: Fast food company Shake Shack released financial numbers showing that the industry can make money even while paying employees livable wages. Reporter Jillian Berman writes that the company is going public and recently filed the necessary paperwork with the Securities and Exchange Commission showing that Shake Shack is experiencing “blockbuster growth in recent years, even as it pledged to keep paying its workers better than the industry standard.” Shake Shack employees start off at $10 an hour, which is nearly $3 more than the federal minimum wage of $7.25. However, the company is still reporting a mighty profit, Berman reports, with sales growing from $21 million in 2010 to $140 million in 2013. In related Huffington Post news, minimum wage workers in 20 states will get raises in the new year.
Miami Herald: Publix, a major grocery store chain throughout the South, has announced that same-sex couples who are legally married will be eligible for spousal insurance benefits regardless of whether they work in a state where gay marriage has yet to be legalized. Reporter Steve Rothaus writes that the “grocer said that there will be a special 30-day enrollment period for same-sex married employees beginning Jan. 1. Thirty days later, same-sex spouses will receive the same insurance benefits as opposite-sex spouses.” The Florida-based grocery chain owns nearly 2,000 stores in Alabama, Florida, Georgia, North Carolina and Tennessee.
The Atlantic: The publication’s business editors break down the 17 top lessons Americans learned about income inequality in 2014. Among the list: High income inequality is associated with stunted overall economic growth; the middle class is shrinking, with American households becoming more concentrated at the top and bottom of the earnings spectrum; and while service sector jobs are leading the recession recovery, low pay and erratic scheduling practices mean workers are still struggling to meet their most basic needs.
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.
While we take a breather during this holiday season, we’re re-posting content from earlier in the year. This post was originally published on January 6, 2014.
by Liz Borkowski, MPH
Now that it’s 2014, millions more people in the US have health insurance coverage (either Medicaid or private insurance), thanks to the Affordable Care Act. In the weeks ahead, many of the newly insured will be visiting healthcare providers to address ongoing health concerns. The Washington Post’s Sandhya Somashekhar and Karen Tumulty highlighted one person with a pent-up demand for healthcare, Sharon Kelly of Louisville, Kentucky:
Kelly said that having Medicaid coverage on Jan. 1 “is a huge relief,” adding, “I’m a redhead and I used to live in California. I have things on my skin that are probably cancer. I just sit here watching these things change color, waiting for January 1st, so I can get an appointment with a dermatologist.”
As the newly insured try to schedule appointments and address ongoing health problems, we’ll start getting answers to two important questions: Will health insurance translate into access to healthcare? And will those gaining coverage enjoy better health?
Having an insurance card doesn’t necessarily mean you’ll be able to get an appointment to see your doctor when you need to. Some parts of the country don’t have enough healthcare providers to deliver the recommended primary or secondary care to all residents. In some cases, providers have appointment slots available, but patients can’t get the time off work or the transportation to visit those providers. Others could make it in for an appointment but can’t afford the co-payment or deductible they’d need to pay in order to be seen. Language barriers and facilities inaccessible to those with disabilities can also complicate access to healthcare.
And whether or not an insured person can see a doctor, insurance and healthcare services don’t automatically equal better health outcomes. For instance, a diabetic patient might have health insurance and visit a healthcare provider regularly, but still find it difficult to monitor his blood sugar, take his medications, and follow diet and exercise guidelines. (Community characteristics like the availability of safe places to exercise can influence exercise patterns, and researchers have documented the physical, psychosocial, and workplace factors that make it challenging for many low-wage workers to eat healthily and get recommended exercise.)
As states are deciding whether to expand their Medicaid programs under the Affordable Care Act, two experiments in Oregon are helping to answer questions about the healthcare and health outcomes of previously uninsured individuals who gain Medicaid coverage.
A limited expansion and a new Medicaid model
Years before the ACA was passed, Oregon determined that it could offer Medicaid coverage to a limited number of low-income adults. The state couldn’t afford to provide coverage to all who wanted it, so in 2008, it used a lottery to determine who would get the coverage. That created the conditions for a randomized trial to evaluate the effects of extending Medicaid to the previously uninsured. The Oregon Health Study group has been following a group of Oregon adults and comparing the experiences of those who received new Medicaid coverage to those who did not.
The group’s latest study, just published in Science, used data from 2007 and 2009 (one year before and one year after the expansion), and focused on Portland-area hospitals. The researchers, Taubman et al, found that those who gained Medicaid coverage significantly increased their emergency-department use, compared to those who did not gain coverage.
That’s not an encouraging result, but there’s better news from more recent activities. Since the limited 2008 Medicaid expansion took place, Oregon has launched a prevention-focused effort to improve health while slowing the growth of healthcare costs. The plan involves major changes to the state’s Medicaid program starting in 2011, including offering patient-centered primary care to Medicaid recipients. As Wonkblog’s Sarah Kliff explained last year, the state hopes that by better coordinating healthcare and other assistance, they can prevent the kinds of costly complications that land patients in hospitals and nursing homes. (This is especially important because Oregon has accepted the ACA’s Medicaid expansion and is seeing enrollment grow.) Kliff gave an example of what such coordinated care can look like:
At the Mosaic Medical clinic in Prineville, a tiny Central Oregon logging town of 9,192, Juana Martinez and Michelle Ortiz are practicing the type of medicine that [Governor John] Kitzhaber thinks could fix the system. They are community health workers, the ones who make sure that patients do not slip through the cracks.
“Back there, you just get patients’ vitals,” said Martinez, motioning toward the exam rooms. “Here, it’s more knowing about them and making sure you can help them.”
That’s what she and Ortiz have done with Rebecca Whitaker. The 53-year-old Medicaid patient moved to Prineville last year, after shuffling through three Arizona nursing homes in six years, while recovering from a stroke.
Doctors had prescribed her 28 medications. Her social anxiety would get so bad that, sometimes, she rubbed her hands raw. By the time Whitaker got to Prineville to live with her cousin, she had given up on the health-care system.
… At Mosaic Medical, Whitaker received care for her diabetes and blood pressure. She also began seeing the clinic’s behavioral health specialist every week, who helped tend to her anxiety and depression.
Community health workers aided in other ways. They helped to ease her social anxiety by attending bingo night together. When Whitaker expressed an interest in moving out of her cousin’s house, Martinez helped her find an apartment.
“They have been the most moral support I’ve ever had in my life,” Whitaker said. “They cared, and that made me want to care. Little by little, when things got too frustrating in life, I’d see one of them. They changed my whole life.”
Ideally, everyone could get this kind of high-quality, coordinated care. Given limited state and federal dollars, though (states’ Medicaid programs rely on a combination of federal and state funding to provide coverage to low-income residents), states have to prioritize the most cost-effective interventions.
Healthcare use and outcomes
The researchers studying Oregon’s 2008 Medicaid expansion have used surveys, hospital data, and credit reports to assess Medicaid’s impacts at one year post-expansion and two years post-expansion. The results from the study measuring experiences one year after Medicaid enrollment (Finkelstein et al, The Quarterly Journal of Economics, 2012) were striking: the Medicaid enrollees had used more healthcare, including primary and preventive care as well as hospitalizations; had less medical debt; and reported having better physical and mental health compared to non-Medicaid subjects.
In the study of outcomes two years following enrollment (Baicker et al, NEJM 2013), the researchers collected blood-pressure measurements and blood spots from subjects as well as administering questionnaires, which included screening questions for depression. As before, they found that the Medicaid group used more healthcare, had less financial strain, and reported better health. This time, though, they also had data to measure clinical – as opposed to self-reported – outcomes, and the results were not so encouraging.
The researchers focused on four conditions that are important contributors to US health problems and might be expected to show improvement after two years of insurance coverage: hypertension, high cholesterol levels, diabetes, and depression. They reported, “Medicaid coverage did not have a significant effect on measures of blood pressure, cholesterol, or glycated hemoglobin.” (Glycated hemoglobin, or HbA1c, tests are used to diagnose diabetes and see how well the disease is controlled.) They did find that “Medicaid coverage led to a substantial reduction in the risk of a positive screening result for depression,” and that the Medicaid group had less financial strain from medical costs.
From the Oregon Health Study Group’s research, we can see that low-income Oregonians who received Medicaid coverage in the 2008 expansion benefited from it. Their patterns of healthcare utilization suggest that they were able to access healthcare, and they feel better mentally and physically. They also had less financial hardship, and that could be contributing to a sense of better health.
On most objective measures, though, the results of this experiment are disappointing. We hope that expanding insurance will make it easier for people to address conditions like high blood pressure and diabetes, and that better control of such chronic conditions will translate to fewer emergency-department visits and hospitalizations. The results from Oregon’s 2008 Medicaid expansion show that providing coverage doesn’t necessarily translate into improving health outcomes, at least not in a two-year time period for low-income adults.
Oregon Medicaid today
Wonkblog’s Sarah Kliff talked to Oregon officials who make an important point about the just-published study showing greater emergency-department use by Oregon’s new Medicaid recipients: It’s measuring the effects of the state’s 2008 Medicaid system, not the one that the new 2014 enrollees will find. The Oregon Health Authority now has data from the first half of 2013 (as opposed to the 2009 data behind the new study), and Kliff points out that rates of emergency-department visits by Medicaid beneficiaries have fallen, from 61 per 1,000 member-months in 2011 to 55 in early 2013.
The Oregon Health Authority’s latest metrics report also gives rates of Medicaid adult hospital admissions for complications from a few key chronic diseases. Admissions for diabetes complications rose slightly from 2011 to early 2013, but fell substantially for COPD or asthma and for congestive heart failure.
It appears that Oregon is seeing some initial encouraging results from efforts to improve the quality of care Medicaid recipients (and all Oregonians) receive. And it’s not the only state working to expand access to preventive and primary care for those who might otherwise end up in the emergency department. NPR’s Julie Rovner reported:
[The Oregon Medicaid emergency department] study doesn’t come as much of a surprise to those people who actually run Medicaid programs around the country.
“This is not something that is unexpected and not something that we’re not prepared for,” says Kathleen Nolan. She’s director of state policy and programs for the National Association of Medicaid Directors.
Nolan says most states are already working to help Medicaid recipients get care in more appropriate settings. “Things like nurse-advice lines, trying to work with the community clinics and community providers to expand hours and make sure that people who are working two and three jobs can get access to primary care after hours and on the weekends,” she said.
The Affordable Care Act is an important first step toward improving US health outcomes. It does include investments in prevention, primary care, and changing payment systems to reward quality rather than just quantity of services provided, but its main effect will be on health insurance coverage. Efforts like Oregon’s ongoing one will be essential for finding cost-effective ways to assure that the newly insured have access to high-quality healthcare that improves health.
by Anthony Robbins, MD, MPH
When my colleagues here at The Pump Handle asked me if I would like to comment on the recent demise of “Single Payer” health insurance in Vermont, I hesitated because my Vermont hands-on experience is so dated. I moved on from being Vermont State Health Commissioner almost 40 years ago. But on second thought, I may have learned some things during my time in Vermont (and from 1970 to 1972 in Quebec) that can contribute to understanding health insurance in Vermont and in the US more generally.
How did I happen to move to Montreal? Canada had just authorized provincial health insurance programs, more aptly named in French–l’assurance maladie (sickness insurance). The plans were tax-financed programs to pay for medical services. I thought national health insurance was just around the corner in the United States, so I went to Montreal to get some practical experience. A foolish optimist I was.
In the early 1970’s, under the leadership of Alan Gittelsohn and Jack Wennberg, Vermont had created a universal hospital services database. (Hospital care was then, and is now, the most expensive part of the medical services sector.) Every Vermonter who was discharged from a Vermont hospital, also from big hospitals in surrounding states and Quebec, became part of the database. Hospitals provided information including the town of residence, age and sex, plus the discharge diagnoses, procedures, and length of stay.
US Census data helped complete the picture of hospital services for Vermonters. Both hospital data and census data recorded the town of residence. Vermont has 251 towns and two “gores”. No longer just counting numbers of discharges, by the early ‘70s, Vermont could consider rates of use. Population denominators made it possible to generate per capita rates of hospital use, town by town. In maps that displayed the rates, the towns clustered around the medical center in Burlington had far higher hospitalization rates than distant and rural towns.
Almost everyone in Vermont was insured, and Blue Cross, chartered under state law, provided most of the hospital insurance to Vermonters. Blue Cross priced coverage using “community rating” where everyone in the state paid the same premiums, irrespective of where he or she lived. It was easy to see that people away from Burlington were subsidizing hospital care for people living in the metropolitan area. I was reminded of what my teacher, Rashi Fein , had taught me: Look at the income transfers in the medical care system. He meant that that medical expenditures were such a large a part of the US economy that they were capable of moving huge amounts of money among parts of the population.
If private insurance companies captured a greater share of the market in Vermont, they might have introduced competition and shifted prices to reflect “experience rating”. Discrimination, such as refusing coverage for pre-existing conditions, would surely have become more common. But, because insurance company earnings are a percentage of their throughput (the claims they pay), there was never any reason to think that health insurance companies, even when competing, were eager to reduce total expenditures.
In Vermont, many of us began to think of health insurance as another tax. And a big one! It ranked after federal and state income taxes and real estate taxes, and ahead of the state sales tax. Health insurance transferred income from poorer residents in rural parts of the state to residents of wealthier towns nearer hospitals and particularly to those near the medical center in Burlington.
It is not surprising that Vermont became one of the first states to consider a tax-financed health insurance system. Such a program might have been able to reduce hospital expenditures and eliminate unfair income transfers.
(A few years later, when I directed the Colorado Department of Public Health, I explored a state takeover of the troubled Colorado Blue Cross plan to create a state insurance program. Community rating was losing out to commercial insurers with experience-rated prices. Employers wanted to take advantage of the fact that their workers were healthier than other people who did not work. Colleagues at Blue Cross of America sensed movement toward national health insurance. They wanted to test in Colorado whether the creation of a state health insurance authority using an existing Blue Cross plan could be the national model.)
By the time that Dr. Howard Dean, a primary care doctor by training, became governor in 1991, Vermonters had learned far more about medical care than citizens of most states. The idea of state health insurance was increasingly popular and Governor Dean explored how to create such a plan.
But what looked attractive to well informed Vermonters did not look as good when perceived as baggage to carry into a national campaign for President. The powerful insurance industry hated national health insurance. Governor Dean abandoned state health insurance for Vermont and ran for President in 2004.
Why, ten years later, has another Democrat, Vermont Governor Peter Shumlin, followed a course not unlike Howard Dean? Shumlin has recently announced that he will no longer pursue a state health insurance program that has been given the awkward appellation, “single payer.”
My own view is that for a state health insurance program to work will require that its advocates recognize two truths, that:
- It will eliminate private health insurers that now make a tidy profit on every dollar spent on medical services. A public authority will pay bills, just as Medicare does. (Many people will surely find employment working for the public authority.)
- Health insurance is a tax that causes large income transfers. It will need the same kind of analysis to which we subject taxes: how progressive or regressive do we want it to be. From whom does it take income and wealth and to whom does it provide services they could not otherwise afford?
President Obama was not up to recognizing these truths and the Affordable Care Act, as enacted, leaves the insurance industry in the drivers seat. ACA’s principal accomplishment, and not an insignificant one, is to make health insurance available to more Americans.
Governor Shumlin looked at his prospects in Vermont and evinced no more courage than our President. He no longer had a dominant Blue Cross plan and taxes had become an even dirtier word. Although the cost to Vermonters would have been no higher, expenditures would have appeared in one place, more or less “on-budget”. Shumlin came to see tax-funded medical care, like Medicare, as an evil rather than, as the rest of the world knows, an important step forward.
Anthony Robbins, MD, MPA is co-Editor of the Journal of Public Health Policy. (Facebook page here.) He directed the Vermont Department of Health, the Colorado Department of Health, the U.S. National Institute for Occupational Safety and Health, and the U.S. National Vaccine Program.
While we take a breather during this holiday season, we’re re-posting content from earlier in the year. This post was originally published on May 6, 2014.
by Kim Krisberg
Two years ago, domestic workers in Houston, Texas, took part in the first national survey documenting the conditions they face on the job. The experience — a process of shedding light on the often isolating and invisible world of domestic work — was so moving that Houston workers decided they didn’t want to stop there. Instead, they decided it was time to put their personal stories to paper.
The result is “We Women, One Woman!: A view of the lived experience of domestic workers,” which was officially released last month. The anthology features the stories of 15 nannies, house cleaners and caregivers — all are members of La Colmena (The Beehive), a domestic worker group that’s part of Houston’s Fe y Justicia Worker Center and that works to organize domestic workers and educate them on their rights. The anthology’s release follows two years of domestic workers meeting regularly to share their stories, participate in writing workshops and ultimately, use their own words to illustrate the experience of working in the largely unregulated, oversight-free workplaces that are people’s homes.
“We always talk about how there’s no statistic that can accurately capture what it’s really like,” Laura Perez-Boston, executive director of Fe y Justicia, told me. “Statistics can’t tell stories.”
The anthology’s stories, published in both English and Spanish, cover a range of topics, often exposing issues such as wage theft as well as unsafe and unfair working conditions. The women also write about their personal lives — single motherhood, poverty, immigration, leaving their native countries and families behind — and why they felt it was so important to speak out about their workplace experience. For example, Consuelo Martinez, an elder care provider, wrote in the anthology: “I’d like to express what we have to go through because for many people being a domestic worker is a job that doesn’t mean anything. …I want everyone who hears me to remember this warrior woman who helped her children get ahead in life with an honorable job and a lot of pride.” Other La Colmena members, such as Lucy Quintanar, were less personal in their narratives, instead using the opportunity to call for better working conditions and collective power.
“We need to get a union to get our rights, to make people conscious of the situation and the circumstances of this employment,” Quintanar told me. “I hope everybody reads it…I would like to let (other domestic workers) know that there’s a place called La Colmena where they can get help to learn their rights. Don’t be afraid to speak out.”
Quintanar originally sought out Fe y Justicia after an employer refused to pay her wages she had earned — more commonly known as wage theft. (The National Domestic Workers Alliance survey that originally inspired the anthology found that 23 percent of domestic workers are already paid below state minimum wage.) At the time, Quintanar was working as a live-in domestic worker, taking care of children, cleaning the house and doing typical household chores. One day, her employer asked her to clean the swimming pool, which Quintanar refused to do as it wasn’t among the job duties to which she’d agreed. The employer fired her on the spot and never paid Quintanar the $450 she was owed. It was the second time an employer refused to pay her hundreds of dollars in wages that she had earned, Quintanar said.
Quintanar told me that the women of La Colmena have become like family for her.
“When you’re working, you don’t have the opportunity to have friends,” she said. “La Colmena is very important to me…I like belonging to a group. Now I can organize with other women to improve our labor conditions.”
It’s easy to see how much effort and emotion was poured into the anthology, as the women who wrote its stories also handcrafted the covers of each book. One La Colmena member fashioned tiny fabric aprons that tie around the book, while another woman used Guatemalan weaving fabric to create original covers. One worker used a picture that her daughter drew of a woman with long, dark braids hugging the Earth. All of the book covers are wrapped in a scrapbooking material printed with the shape of a honeycomb.
Mitzi Ordoñez, domestic worker organizer at Fe y Justicia, said she and the members of La Colmena hope the anthology will reach both employers as well as other domestic workers. Ordoñez said plans are in the works for a second anthology, which would focus on success stories and how domestic workers are empowering each other to fight for better conditions.
“We want to make employers aware of the true value of this work,” she told me. “Nannies and caregivers — these are jobs that make other jobs possible. For domestic workers, we want to let them know that there’s a place where they can come and they’re not alone.”
The anthology experience has put the power of storytelling front and center, Perez-Boston said. Narrative can be a strong tool for organizing and building a common identity, she noted, especially for domestic workers, who often work alone in isolated environments.
“Storytelling can help us move toward social transformation,” she told me.
The anthology’s initial publishing run of 500 copies is nearly sold out; however, more copies are expected to come out soon. To inquire about purchasing a copy, email Ordoñez at email@example.com. Click here to learn more about La Colmena and the Fe y Justicia Worker Center, and click here and here to learn more about the domestic worker survey that originally inspired the Houston anthology.
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.
While we take a breather during this holiday season, we’re re-posting content from earlier in the year. This post was originally published on June 30, 2014.
by Liz Borkowski, MPH
Last week’s White House Summit on Working Families – hosted by the White House Council on Women and Girls, the Department of Labor, and the Center for American Progress – served both as a pitch to employers to adopt more family-friendly policies, and as a push for policies that require all employers to evolve for 21st-century realities. Wages, paid leave, flexibility, and caregiving were major topics in the day-long event, and speaker after speaker returned to the same themes. I was honored to attend the event, and left it feeling hopeful that we’ll keep seeing improvements in workplace policies – perhaps first at the level of individual employers, cities and states (where we’ve already seen progress), and eventually at the federal level.
“No one in this country should work a full-time job and have to live in poverty,” said Secretary of Labor Thomas E. Perez, who has been pushing for an increase in the federal minimum wage. As for why more workers need access to paid sick, medical, and family leave, he told the crowd, “No one should have to choose between the job they need and the family they love.”
Neera Tanden, President of the Center for American Progress, described the way her boss’s flexibility helped her to balance work and family when her children were young – but, she noted, many US workers don’t have access to paid leave or flexible schedules. “I won the boss lottery, but you shouldn’t have to,” she told the audience.
Vice President Joe Biden picked up on that theme. He described how he struggled to balance his job as a US Senator with raising his sons after his wife and daughter were killed in a car crash. He told the crowd that he made 8,000 round trips between Washington, DC and Delaware so he could be home before his children went to bed, and that he skipped procedural votes to make it to parent-teacher conferences and his kids’ games and debates. It was hard for him and challenging for others like him – but, he noted “we’re the lucky ones,” with good salaries and some schedule flexibility. It’s even harder for those whose struggle to make their paychecks cover expenses and don’t have flexible schedules or paid leave.
Another theme that speakers echoed was the idea that the US economy has changed, but workplace policies have failed to keep up with the changes. Where it used to be the norm for households to have one breadwinner and one parent who stayed home and cared for children, that’s not a workable option for most US households today. (And, I’d add, many low-income households didn’t have that option even in the Leave it To Beaver days.) As the average lifespan increases, many households are also faced with responsibilities to care for aging parents and young children simultaneously.
In his remarks, President Obama also shared his family’s story of challenges in balancing jobs and family, and repeated that they still found it hard even though they were among the more fortunate workers. And then he said this, to cheers and thunderous applause:
And every day, I hear from parents all across the country. They are doing everything right — they are working hard, they are living responsibly, they are taking care of their children, they’re participating in their community — and these letters can be heartbreaking, because at the end of the day it doesn’t feel like they’re getting ahead. And all too often, it feels like they’re slipping behind. And a lot of the time, they end up blaming themselves thinking, if I just work a little harder — if I plan a little better, if I sleep a little bit less, if I stretch every dollar a little bit farther — maybe I can do it. And that thought may have crossed the minds of some of the folks here from time to time.
Part of the purpose of this summit is to make clear you’re not alone. Because here’s the thing: These problems are not typically the result of poor planning or too little diligence on the parts of moms or dads, and they cannot just be fixed by working harder or being an even better parent. All too often, they are the results of outdated policies and old ways of thinking. Family leave, childcare, workplace flexibility, a decent wage — these are not frills, they are basic needs. They shouldn’t be bonuses. They should be part of our bottom line as a society. That’s what we’re striving for.
The President noted that there are countries that have figured out how to do childcare well and affordably, suggesting we could follow their lead and make it so decent childcare doesn’t cost more than in-state college tuition (something that’s currently the case in 31 states). And, he noted, “Many women can’t even get a paid day off to give birth. Now, that’s a pretty low bar. You would think [that’s something] that we should be able to take care of.”
In her speech, Jill Biden – who is a community-college professor as well as wife of Vice President Biden – pointed out that employees can be more productive if they’re not worried about childcare or their aging parents. Several small-business owners or members of upper management at large corporations, described the productivity and loyalty they experienced from employees as a result of offering higher wages, paid leave, and flexible scheduling.
I was also delighted that Makini Howell, owner of Seattle’s Plum Bistro described the public-health motivation behind her decision to support the city’s paid-sick-leave law: “I don’t want to serve you a cheap contagious flu with your sweet potato fries.” She and other business representatives also noted that demonstrating trust in employees not to abuse sick-leave policies tends to inspire trustworthy behavior.
Speakers also addressed the ways that family-unfriendly workplaces can hurt the economy as a whole, as well as individual businesses. Senator Amy Klobuchar (D-MN) pointed out that 70% of the US economy is consumer-driven, and low wages hurt consumer spending. Betsey Stevenson, a member of President Obama’s Council of Economic Advisors, noted that when trained, educated workers drop out of the workforce because they can’t meet their families needs otherwise, that’s a big loss to our economy.
The workers who drop out of the workforce for caregiving purposes are most often women, but several speakers stressed that family-friendly policies help men, too, and that this is not a zero-sum game. Earlier in the month, a White House Summit on Working Fathers addressed this sometimes-overlooked topic; Scott Behson collected some of the memorable quotes from the event at his Fathers, Work and Family blog.
The event showcased large and small employers that have chosen to go above and beyond what the law requires (which, in the case of federal law, isn’t much), and offer their workers higher wages, paid leave, and the flexibility they need to balance job and family responsibilities. They spoke about “the business case” for family-friendly policies –or, what I imagine much of the rest of the world considers to be commonsense policies. Another route to higher wages and better leave policies is unionization; House Minority Leader Nancy Pelosi (D-CA) said in her panel discussion that no one has done more for equal pay than organized labor.
Even as speakers encouraged other businesses to adopt these high-road practices, there was also a recognition that we can’t just wait for all employers to follow suit, or for workplaces to become unionized – this is an urgent problem that needs policy solutions. Workers should have access to livable wages, paid leave, and flexibility even if they don’t “win the boss lottery.”
In addition to Secretary Perez’s call for a higher minimum wage, President Obama urged Congress to pass the Pregnant Workers Fairness Act, which would require employers to make reasonable accommodations for women with pregnancy-related medical needs, and the Paycheck Fairness Act, aimed at reducing the gender wage gap. In a session on caregiving, Nancy Duff Campbell of the National Women’s Law Center added a call for the Strong Start for America’s Children Act to increase access to affordable, high-quality childcare, preschool, and pre-kindergarten.
Two bills that I was surprised not to hear mentioned (although it’s possible they came up in breakout sessions) were the Healthy Families Act and the Family and Medical Leave Insurance Act (FAMILY Act). The Healthy Families Act would allow workers in businesses with 15 or more employees to earn up to seven days a year of paid sick time, while the FAMILY Act would set up a social-insurance system to enable workers, regardless of employer size or job tenure, to get a portion of their pay while taking medical or family leave for serious health conditions.
The Washington Post’s Zachary Goldfarb suggests a disturbing reason why President Obama isn’t endorsing the FAMILY Act: The proposed social-insurance system relies on an additional payroll tax of 0.2 percent to fund replacements of a portion of workers’ salaries when they’re taking medical or family leave. According to the National Partnership for Women and Families, a worker earning the US median wage would pay an extra $65 per year into the system; the figure would be higher for higher-income workers, but in any case it would be a very modest contribution in exchange for access to benefits that could mean the difference between paying the rent and getting evicted for those who need to take time off to address a serious health condition or care for a new child.
Goldfarb notes, though, that President Obama made a 2008 campaign pledge to not raise taxes on families earning less than $250,000, and the FAMILY Acy would entail a tax increase on all workers. It seems that it would be worth violating a campaign promise in order to pass a law that would do so much good for so many people – especially those living paycheck to paycheck. Maybe President Obama would have more to say on the subject if the law were to pick up more support in Congress.
With Congressional gridlock as the current norm, the real hope for change seems to be at the state and local levels – and perhaps national action will eventually follow. Cities and states across the country are considering, or have already passed, laws and ballot measure to raise wages and require employers to offer paid sick leave; Rhode Island recently became the third state (following California and New Jersey) to establish a social-insurance system for paid caregiver leave. A Center for American Progress poll conducted earlier this month found that 71% of respondents, including 62% of Republican respondents, support paid family leave for workers with a sick child or immediate family member.
In a conversation with Robin Roberts, First Lady Michelle Obama told the summit audience, “The numbers are on our side – more and more people are realizing that this is an issue for everybody.” Later, she said, “We have to help elected officials understand just how important these issues are.”
Chandler Warren’s work-related death could have been prevented. That’s how I see the findings of Tennessee OSHA in the agency’s citations against his employer Federal Express. The 19-year-old was working in July 2014 on the night shift at the company’s World Hub in Memphis, TN. News reports indicated that the equipment used to load containers onto an aircraft crashed down on him.
Inspectors with Tennessee OSHA conducted an inspection at FedEx’s Memphis World Hub following Warren’s death. The agency recently issued citations to the firm including for one serious violation with a proposed $4,000 penalty. The violation involved the company’s failure to provide a safe workplace (Tenn. Code Ann. § 50-3-105). Based on FedEx’s second quarter earnings, the company’s profit from just one minute of operations exceeded the TN-OSHA penalty.
When some local press initially reported Chandler Warren’s death, they called it an accident. An “accident” suggests the circumstances were unforeseen or could not have been avoided. Tennessee OSHA’s findings tell a different story. Call it cutting corners, call it poor management, call it breaking the law. Whatever you want to call it, Chandler Warren’s work-related death could have been prevented, it was no accident.
ACA predicted to have positive impact on insurance disparities; Medicaid expansion key to widening access for black Americans
With the second round of open enrollment now underway, the Affordable Care Act is expected to help narrow racial and ethnic disparities in insurance coverage, a new report finds. However, not all communities are predicted to benefit equally. Because nearly half of the country’s legislatures decided against expanding Medicaid eligibility, black Americans may continue to face difficulties finding quality, affordable health coverage.
This month, the Urban Institute’s Health Policy Center released a new report detailing racial and ethnic differences in insurance rates under the ACA. Using data from the American Community Survey, report authors used a simulation model to estimate rates of uninsurance in 2016 among five racial and ethnic groups: whites, Hispanics, Asians, blacks and American Indians/Alaska Natives. Estimates were then calculated for three different insurance scenarios: coverage without the ACA; coverage with the ACA and under current Medicaid expansions; and coverage under the ACA with all states expanding Medicaid eligibility. (At the time of the ACA’s passage, the law set a nationwide standard for Medicaid eligibility, expanding the program’s criteria to cover adults with family income up to 138 percent of the poverty level. Unfortunately, in 2012, the Supreme Court ruled that states could decide against expanding Medicaid. Today, 27 states and Washington, D.C., have either expanded Medicaid eligibility or plan to do so.)
The Urban Institute report predicts large reductions in uninsured rates for all racial and ethnic groups under the current Medicaid expansion map and predicted even larger reductions if every state expanded Medicaid. The gains narrow insurance coverage disparities between whites and each of the minority groups, except for blacks, as large numbers of black Americans live in states where policymakers oppose Medicaid expansion. However, under a scenario in which all states expand Medicaid, blacks are predicted to experience a “marked reduction” in uninsurance rates, and the coverage disparity between blacks and whites would significantly narrow. (Because some states haven’t expanded Medicaid, many Americans fall into a new coverage gap, in which they don’t qualify for Medicaid and they don’t quality for subsidies in the new health insurance marketplace.) Report authors Lisa Clemans-Cope, Matthew Buettgens and Hannah Recht write:
For uninsured individuals, where you live matters. The ACA, through Medicaid expansion, is likely to reduce longstanding racial/ethnic differences in health insurance coverage between whites and minorities. But for those living in nonexpansion states, health insurance coverage remains out of reach.
Specifically, under the ACA with current Medicaid expansions, American Indians and Alaska Natives are predicted to experience a decrease in uninsurance rates from 25.7 percent to 13 percent (a nearly 50 percent reduction with 600,000 people gaining insurance coverage). Hispanics are projected to experience a decrease in uninsurance rates from 31.2 percent to 19 percent (a more than 39 percent reduction with 6.6 million people gaining coverage). In addition, uninsurance among whites would decrease more than 51 percent, from just more than 13 percent without the ACA to 6.3 percent under the ACA and current Medicaid expansions — overall, 11.1 million whites would gain coverage. Not surprisingly, if legislatures in all states decided to expand Medicaid eligibility, gains in coverage as well as declines in insurance disparities between whites and blacks are predicted.
The report predicts that if all states were to expand Medicaid, uninsurance rates among blacks would decline from 11.3 percent (the rate under the current Medicaid map) to 7.2 percent (the rate under a fully expanded Medicaid map). Today, 1.4 million blacks fall into the ACA coverage gap, which translates into just more than 23 percent of the nation’s uninsured black adult population, the report stated. In addition, if all states expanded Medicaid under the ACA, nearly 14 million whites would gain coverage (a nearly 65 percent reduction in the uninsured rate); 7.8 million Hispanics would gain coverage (a nearly 47 percent reduction); 4.3 million blacks would gain coverage (a more than 63 percent reduction); 1.4 million Asians and Pacific Islanders would get insurance (a more than 53 percent reduction); and 787,000 Americans Indians and Alaska Natives would gain coverage (a more than 61 percent reduction).
But like the authors said above, place matters when it comes to insurance coverage. For example, the authors wrote in a blog article that in St. Louis, just more than 20 percent of black residents are predicted to go without insurance without the ACA — a rate that falls to 14.8 percent under the ACA with current Medicaid expansion and to 7.5 percent if Missouri lawmakers expanded Medicaid eligibility. In comparison, in the St. Louis area that falls within the Illinois state line, only 5.3 percent of black residents are predicted to remain without health insurance under ACA and the state’s decision to expand Medicaid.
To download a full copy of the Urban Institute report and access an interactive map that illustrates insurance coverage under the different scenarios, click here.