Journal of Agromedicine, 20:8–10, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 1059-924X print/1545-0813 online DOI: 10.1080/1059924X.2015.1000104
EDITORIAL
Obamacare and Immigration Reform: Is It Time to Promote Occupational and Agricultural Health and Safety?
Two articles in this issue address developing and maintaining a health workforce with the knowledge necessary to address the sometimes unique health challenges faced by farming populations. Work done at the University of Iowa as far back as the 1970s has concentrated on increasing the number and expertise, and improving the training, of health professionals in agricultural health and safety.1,2 Burnstein and Levy, along with others, have repeatedly noted the deficiencies of our medical education system in providing occupational health training. When most recently surveyed 20 years ago, only 68% of 115 responding medical schools provided occupational health education, and the median time devoted to the topic was six hours over four years.3 No more recent estimates are available, and there are no existing estimates for the frequency or depth of training in agricultural health and safety; however, it is certainly at best a small portion of the above time allotment. These new articles are timely in that changes are afoot that may create a demand for increasing the expertise of the US health care workforce with respect to occupational health in general and, in the case of the rural health care work force, agricultural health and safety specifically. Additionally, direct federal support for training the occupational health and safety workforce for both general occupational health and agricultural health has recently been in jeopardy. The budgetary provision to the National Institute for Occupational Safety and Health (NIOSH) for
the support of Educational Research Centers and Agricultural Safety and Health centers has been lined out in the President’s budget over the past four years. The recent increase in the Republican majority in the US House of Representative and the Republican takeover of the Senate leadership as a result of the 2014 midterm elections will no doubt have an impact on the content or function of the Patient Portability and Affordability Act (PPACA), also known as Obamacare. Republican intent to eliminate or modify the PPACA is clear.4 At the time of the writing of this editorial, the House had voted 50 times to repeal Obamacare. The legislation was never taken up in the Senate given the Democratic majority there. That majority is now gone. However, despite the major gains, Republicans did not achieve a filibuster-proof majority in the Senate, and President Obama is likely to veto any attempt at repeal of the law as a whole. Notwithstanding, some changes are likely to occur through budget reconciliation maneuvers, but which aspects of the law these maneuvers will affect is uncertain at present. As a result, the ACA is and is likely to remain the law of the land for the foreseeable future, although further legal challenges to the law are also possible. Certain provisions of the law may prove very important for the future of occupational health and safety professions in the US. Another influential event occurred on November 21, 2014, when President Obama
8
Keifer
announced an executive order that will give legal status to an estimated 5 million aliens living in the US. Although the President’s action will face resistance in the newly reconstituted House and Senate, some significant immigration reform seems likely to occur. NIOSH reports that in 2006, 6.3 million of the 15% of the US workforce who were foreign-born were undocumented.5 Many of these individuals work in dangerous industries. Evidence on workplace deaths among the working population in the US clearly indicates that immigrants tend to work more hazardous jobs than the general population. In addition, foreign-born workers have a higher risk of workplace death and injury than native-born workers. In fact, while death rates in the US are declining for the general worker population, rates for foreign-born workers are rising.6 The PPACA introduces two major changes to our present healthcare system that may have important repercussions for the occupational health and safety community, particularly for those in agricultural health and safety. Firstly, the individual mandate requires that all citizens and legal residents in the US show they have health insurance or face a penalty. All qualified individuals, which includes all citizens and legal residents, must be covered by their employers or spouses’ employers, or they must purchase health insurance. Secondly, the PPACA expands, under certain limitations, the opportunity for groups of practitioners to band together and enter into an accountable care organization (ACO) relationship in the process of caring for its Medicare fee-for-service population and for pediatric populations. ACOs capitate care for patients and reverse the standard fee-for-service payment model to a health maintenance model, wherein care is provided to a capitated population, and risk for poor outcomes is borne by the provider organization. This does not at present expand ACOs to non-federal insurance programs but some have appeared in the market place, and the change certainly opens the door for such a model to be adopted by more in the future. As Medicare and pediatric associated ACOs demonstrate success in terms of reducing costs, insurance companies will likely pursue such models with health care systems.
9
The effects of these legal changes may be profound for the health and safety community. The individual mandate implies that all legal US workers, including the self-employed, must carry health insurance. This would include workers in some of the most dangerous professions such as farmers, farm workers, and agricultural contract workers. These workers often are not covered by worker compensation and likely do not carry it on themselves. Because of this, when they are injured at work, the cost of their care is borne by society at-large. Costich pointed out that among farm injury-related hospital admissions in Kentucky, only 5% were covered by worker compensation, and 16% were covered by Medicaid or unreimbursed.7 In many states, agricultural workers are excluded from worker compensation coverage; in others coverage is optional for employers, or agricultural employers are not required to carry worker compensation insurance on their employees until a certain number of workers or a certain payroll threshold is reached.8 Also, owner-operators are generally not required to cover themselves with worker compensation, even if it is carried by the company they own. As a result, most individual farmers do not carry worker compensation on themselves, and many agricultural workers are not covered.9 Additionally, with the average age of farmers now 58 years, a significant portion of the farm owner-operator workforce is covered by Medicare. The PPACA will bring under insured care a substantial number of previously uninsured working class working people, many who do the most dangerous work in the nation such as construction or farm work. In the new insurance environment, the cost of care for the conditions they suffer due to work, if not covered by worker compensation, will fall to the insurance programs they purchase. If an ACO is involved the care provider network offering the ACO will be responsible. Occupational health professionals, specifically agricultural health and safety, may have an opportunity, due to the requirements of the PPACA, to open new conversations about prevention with entities responsible for providing coverage, such as insurance companies, or those providing care itself, such as ACOs.
10
EDITORIAL
It is time for us to engage both insurers and ACOs in conversations pointing out the importance of the work we do and how it is newly relevant to their interests. We must make it clear that in this new healthcare environment, all will benefit from support for research on prevention of occupational injuries and illness, expanded training of providers in the diagnosis and care of conditions resulting from exposures in the workplace, and expansion of the occupational health and safety workforce. We can now more than ever make a case for the value our professions hold in the new insurance environment. We must make it clear to insurers, providers, and legislators that what we do is an important, high value proposition for their businesses and for the nation.
REFERENCES 1. Rudolphi JM, Donham KJ. Toward a national core course in agricultural medicine and curriculum in agricultural safety and health: the building capacity consensus process. J Agromedicine. 2014;20:xx–xx. 2. Rudolphi JM, Donham KJ. Increasing the number of trained health and safety professionals in agricultural
medicine: evaluation of the building capacity program 2007-2013. J Agromedicine. 2014;20:xx–xx. 3. Burstein JM, Levy BS. The teaching of occupational health in US medical schools: little improvement in 9 years. Am J Public Health. 1994;84:846–849. 4. Pickert K. How a Republican majority could change Obamacare. Time. November 6, 2014. Available at: http://time.com/3563332/how-a-repulican-majority-couldchange-obamacare/. Accessed November 17, 2014. 5. Centers for Disease Control and Prevention. NIOSH Science Blog. Updated December 2014. Available at: http://blogs.cdc.gov/niosh-science-blog/2008/10/27/ immigrant/. Accessed November 24, 2014. 6. Orrenius PM, Zavodny M. Do immigrants work in riskier jobs? Demography. 2009;46:535–551. 7. Costich J. Who pays for agricultural injury care? J Agromedicine. 2010;15:54–57. 8. Migrant Clinicians Network. Criteria for Worker’s Compensation Insurance. Available at: http://www. migrantclinician.org/node/5388. Accessed November 24, 2014. 9. United States Department of Labor, Employment and Training Administartion. The National Agricultural Workers Survey. Updated January 2011. Available at: http://www.doleta.gov/agworker/report/ch1.cfm. Accessed November 24, 2014.
Matthew C. Keifer Editor in Chief, Journal of Agromedicine
Copyright of Journal of Agromedicine is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
EDITORIAL
Obamacare and Immigration Reform: Is It Time to Promote Occupational and Agricultural Health and Safety?
Two articles in this issue address developing and maintaining a health workforce with the knowledge necessary to address the sometimes unique health challenges faced by farming populations. Work done at the University of Iowa as far back as the 1970s has concentrated on increasing the number and expertise, and improving the training, of health professionals in agricultural health and safety.1,2 Burnstein and Levy, along with others, have repeatedly noted the deficiencies of our medical education system in providing occupational health training. When most recently surveyed 20 years ago, only 68% of 115 responding medical schools provided occupational health education, and the median time devoted to the topic was six hours over four years.3 No more recent estimates are available, and there are no existing estimates for the frequency or depth of training in agricultural health and safety; however, it is certainly at best a small portion of the above time allotment. These new articles are timely in that changes are afoot that may create a demand for increasing the expertise of the US health care workforce with respect to occupational health in general and, in the case of the rural health care work force, agricultural health and safety specifically. Additionally, direct federal support for training the occupational health and safety workforce for both general occupational health and agricultural health has recently been in jeopardy. The budgetary provision to the National Institute for Occupational Safety and Health (NIOSH) for
the support of Educational Research Centers and Agricultural Safety and Health centers has been lined out in the President’s budget over the past four years. The recent increase in the Republican majority in the US House of Representative and the Republican takeover of the Senate leadership as a result of the 2014 midterm elections will no doubt have an impact on the content or function of the Patient Portability and Affordability Act (PPACA), also known as Obamacare. Republican intent to eliminate or modify the PPACA is clear.4 At the time of the writing of this editorial, the House had voted 50 times to repeal Obamacare. The legislation was never taken up in the Senate given the Democratic majority there. That majority is now gone. However, despite the major gains, Republicans did not achieve a filibuster-proof majority in the Senate, and President Obama is likely to veto any attempt at repeal of the law as a whole. Notwithstanding, some changes are likely to occur through budget reconciliation maneuvers, but which aspects of the law these maneuvers will affect is uncertain at present. As a result, the ACA is and is likely to remain the law of the land for the foreseeable future, although further legal challenges to the law are also possible. Certain provisions of the law may prove very important for the future of occupational health and safety professions in the US. Another influential event occurred on November 21, 2014, when President Obama
8
Keifer
announced an executive order that will give legal status to an estimated 5 million aliens living in the US. Although the President’s action will face resistance in the newly reconstituted House and Senate, some significant immigration reform seems likely to occur. NIOSH reports that in 2006, 6.3 million of the 15% of the US workforce who were foreign-born were undocumented.5 Many of these individuals work in dangerous industries. Evidence on workplace deaths among the working population in the US clearly indicates that immigrants tend to work more hazardous jobs than the general population. In addition, foreign-born workers have a higher risk of workplace death and injury than native-born workers. In fact, while death rates in the US are declining for the general worker population, rates for foreign-born workers are rising.6 The PPACA introduces two major changes to our present healthcare system that may have important repercussions for the occupational health and safety community, particularly for those in agricultural health and safety. Firstly, the individual mandate requires that all citizens and legal residents in the US show they have health insurance or face a penalty. All qualified individuals, which includes all citizens and legal residents, must be covered by their employers or spouses’ employers, or they must purchase health insurance. Secondly, the PPACA expands, under certain limitations, the opportunity for groups of practitioners to band together and enter into an accountable care organization (ACO) relationship in the process of caring for its Medicare fee-for-service population and for pediatric populations. ACOs capitate care for patients and reverse the standard fee-for-service payment model to a health maintenance model, wherein care is provided to a capitated population, and risk for poor outcomes is borne by the provider organization. This does not at present expand ACOs to non-federal insurance programs but some have appeared in the market place, and the change certainly opens the door for such a model to be adopted by more in the future. As Medicare and pediatric associated ACOs demonstrate success in terms of reducing costs, insurance companies will likely pursue such models with health care systems.
9
The effects of these legal changes may be profound for the health and safety community. The individual mandate implies that all legal US workers, including the self-employed, must carry health insurance. This would include workers in some of the most dangerous professions such as farmers, farm workers, and agricultural contract workers. These workers often are not covered by worker compensation and likely do not carry it on themselves. Because of this, when they are injured at work, the cost of their care is borne by society at-large. Costich pointed out that among farm injury-related hospital admissions in Kentucky, only 5% were covered by worker compensation, and 16% were covered by Medicaid or unreimbursed.7 In many states, agricultural workers are excluded from worker compensation coverage; in others coverage is optional for employers, or agricultural employers are not required to carry worker compensation insurance on their employees until a certain number of workers or a certain payroll threshold is reached.8 Also, owner-operators are generally not required to cover themselves with worker compensation, even if it is carried by the company they own. As a result, most individual farmers do not carry worker compensation on themselves, and many agricultural workers are not covered.9 Additionally, with the average age of farmers now 58 years, a significant portion of the farm owner-operator workforce is covered by Medicare. The PPACA will bring under insured care a substantial number of previously uninsured working class working people, many who do the most dangerous work in the nation such as construction or farm work. In the new insurance environment, the cost of care for the conditions they suffer due to work, if not covered by worker compensation, will fall to the insurance programs they purchase. If an ACO is involved the care provider network offering the ACO will be responsible. Occupational health professionals, specifically agricultural health and safety, may have an opportunity, due to the requirements of the PPACA, to open new conversations about prevention with entities responsible for providing coverage, such as insurance companies, or those providing care itself, such as ACOs.
10
EDITORIAL
It is time for us to engage both insurers and ACOs in conversations pointing out the importance of the work we do and how it is newly relevant to their interests. We must make it clear that in this new healthcare environment, all will benefit from support for research on prevention of occupational injuries and illness, expanded training of providers in the diagnosis and care of conditions resulting from exposures in the workplace, and expansion of the occupational health and safety workforce. We can now more than ever make a case for the value our professions hold in the new insurance environment. We must make it clear to insurers, providers, and legislators that what we do is an important, high value proposition for their businesses and for the nation.
REFERENCES 1. Rudolphi JM, Donham KJ. Toward a national core course in agricultural medicine and curriculum in agricultural safety and health: the building capacity consensus process. J Agromedicine. 2014;20:xx–xx. 2. Rudolphi JM, Donham KJ. Increasing the number of trained health and safety professionals in agricultural
medicine: evaluation of the building capacity program 2007-2013. J Agromedicine. 2014;20:xx–xx. 3. Burstein JM, Levy BS. The teaching of occupational health in US medical schools: little improvement in 9 years. Am J Public Health. 1994;84:846–849. 4. Pickert K. How a Republican majority could change Obamacare. Time. November 6, 2014. Available at: http://time.com/3563332/how-a-repulican-majority-couldchange-obamacare/. Accessed November 17, 2014. 5. Centers for Disease Control and Prevention. NIOSH Science Blog. Updated December 2014. Available at: http://blogs.cdc.gov/niosh-science-blog/2008/10/27/ immigrant/. Accessed November 24, 2014. 6. Orrenius PM, Zavodny M. Do immigrants work in riskier jobs? Demography. 2009;46:535–551. 7. Costich J. Who pays for agricultural injury care? J Agromedicine. 2010;15:54–57. 8. Migrant Clinicians Network. Criteria for Worker’s Compensation Insurance. Available at: http://www. migrantclinician.org/node/5388. Accessed November 24, 2014. 9. United States Department of Labor, Employment and Training Administartion. The National Agricultural Workers Survey. Updated January 2011. Available at: http://www.doleta.gov/agworker/report/ch1.cfm. Accessed November 24, 2014.
Matthew C. Keifer Editor in Chief, Journal of Agromedicine
Copyright of Journal of Agromedicine is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
