Our study provides a national-level description of uninsurance among the US health care workforce by health care industry subtype and workforce category. Our results show that disparities in uninsurance rates exist in the health care workforce and that these disparities differ significantly according to industry subtype and workforce category. For example, people working in ambulatory care and residential care settings were more likely to be uninsured than were those working in hospital settings. Our findings are consistent with those of earlier studies documenting higher uninsurance rates among health care workers employed in practitioners’ offices and nursing homes than among those employed in hospitals.13,14
One reason for this disparity may be that in many cases companies in the ambulatory care and residential care industries are smaller than hospitals.20
Previous studies have indicated that a firm’s size is related to the likelihood of an employee being insured, with employees in small firms less likely than employees in large firms to be covered by employer-based health insurance.21–24
In addition, health care workers in nursing homes and residential settings earn lower wages, a factor associated with higher rates of uninsurance.25,26
According to the BLS, mean hourly wages in 2007 were $10.03 for home health aides and $11.14 for nurse aides, orderlies, and attendants; mean hourly wages for registered nurses in hospital and residential settings were $30.69 and $27.12, respectively.27–29
By contrast, the mean hourly wage in 2007 for physicians was more than $70 per hour.30
Most low-income workers cannot afford health insurance premiums and copayments, even when coverage is offered by their employer.12,31,32
On the basis of a review of studies on characteristics of direct care workers and the wages and health insurance benefits available, Stone reported that most home care workers earning low incomes cannot afford health insurance.31
Our analyses also demonstrate that uninsured health care workers are more likely to be part-time employees, young, unmarried, Black, or Hispanic; to have less than a college education; and to have lower incomes. These findings are consistent with those of other studies investigating the characteristics of people most likely to be uninsured.6,21,33,34
There is also evidence supporting concerns that the health and well-being of uninsured workers in the health care industry may be at risk. According to Hadley and Reschovsky,21
uninsured individuals are less likely to receive preventive and therapeutic care, thereby increasing their risk of poor health. Moreover, Chou and Johnson, in a study examining health status and obesity prevalence in various health care worker categories, found that individuals employed as health technicians or health service workers were more likely to report poor health and to be obese than were those employed in health diagnosing occupations.35
Because poor health and obesity are often linked to a lack of health insurance coverage or inadequate coverage, and because our results demonstrate that the rate of uninsurance among health care service workers is relatively high, the natural question to ask is whether these factors are causally linked. Does the relatively high rate of uninsurance cause the high rates of obesity and poor health among some classes of health care workers? Although we did not directly address this question, our findings suggest that additional research on health insurance coverage, health care use, and health outcomes among health care workers is warranted.
Several limitations of this study should be noted. First, our measure of uninsurance was a point-in-time measure representing individuals’ self-reported lack of insurance coverage at the time of their interview. Among those lacking health insurance coverage, we had no additional information regarding whether employer-sponsored insurance was offered but declined or simply was not offered. Similarly, employment-related information was ascertained relative to respondents’ employment in the week preceding the interview. Thus, our estimates represent only a snapshot of uninsurance in the health care workforce.
Second, the health care industry subtypes and workforce categories in our analyses were broadly defined. We were limited to the 3 health care industry subtypes identified in the NHIS data. Moreover, the NHIS does not release detailed occupation categories and has combined physicians and nurses in the same group since 2005. Thus, our use of these coarsened health care workforce categories may have masked important disparities in uninsurance within each category. Third, the public use data of the NHIS lack state-level identifiers, prohibiting us from analyzing or controlling for state-level health care infrastructure and health policy differences.
Our study raises some important and perhaps alarming issues about the health care workforce in the United States. In some settings, specifically residential care and nursing homes, almost one third of all workers providing hands-on care to vulnerable adults are uninsured. There are several implications of these findings, including concerns about workers transmitting undetected infectious disease because they delay seeking care and transmitting the flu because they do not receive a flu shot; moreover, poor health status and obesity among these workers could result in an increased number of lost workdays caused by illness, contributing to high turnover rates in nursing homes.
Hospitals fare better in providing their workforce with insurance coverage, possibly because they pay higher wages and because they need to attract a highly skilled workforce. Even in hospitals, however, an average of 10% of service workers lack health insurance coverage.
There are currently no regulations stipulating that health care providers offer health insurance coverage to their workers or requirements that they do so. Health care providers are considered similar to other employers and are treated as such by federal and state regulations. Yet, the type of service they provide and the dependency of patients on their care providers for appropriate and safe care do make them distinct.
Some states have pursued policies to address the high rates of uninsurance among health service workers, primarily through the Medicaid program, which currently pays almost half of the wages and benefits of caretakers. For example, Minnesota passed legislation requiring that a certain amount of each increase in the Medicaid payment rate be directed toward health insurance coverage of health service workers.36
In addition, Michigan passed legislation requiring that nursing homes devote a specific amount of existing state funds to wage increases and benefit improvements.36
States might also consider other financial incentives in their nursing home payments that are directly targeted to health insurance coverage. Given concerns about infectious diseases, new resistant bacterial strains, and the quality and safety of our health care institutions, it is essential that the people working directly in these settings receive needed health care services, including recommended immunizations and primary and preventive care.
Our analyses demonstrate that disparities in uninsurance exist in the US health care workforce and that these disparities differ significantly according to health care industry subtype and workforce category. Because the future of US health care depends on the support and development of a quality health care workforce, the fact that nearly 1 in 8 people in the US health care workforce lacks insurance coverage is a cause for concern.
Creating policies specifically aimed at ensuring that health care workers are adequately insured will not only help workers themselves but also promote the health of those they serve. Of course, knowing that a problem exists is not the same as knowing why the problem exists, and effective health policies require both kinds of information. For this reason, further research, building on the results described here, is needed to understand the determinants of the disparities in uninsurance that exist in the US health care workforce.