Changes in Health Care Workers' Economic Outcomes Following Medicaid Expansion.

Importance: The extent to which changes in health sector finances impact economic outcomes among health care workers, especially lower-income workers, is not well known. Objective: To assess the association between state adoption of the Affordable Care Act's Medicaid expansion-which led to substantial improvements in health care organization finances-and health care workers' annual incomes and benefits, and whether these associations varied across low- and high-wage occupations. Design, Setting, and Participants: Difference-in-differences analysis to assess differential changes in health care workers' economic outcomes before and after Medicaid expansion among workers in 30 states that expanded Medicaid relative to workers in 16 states that did not, by examining US individuals aged 18 through 65 years employed in the health care industry surveyed in the 2010-2019 American Community Surveys. Exposure: Time-varying state-level adoption of Medicaid expansion. Main Outcomes and Measures: Primary outcome was annual earned income; secondary outcomes included receipt of employer-sponsored health insurance, Medicaid, and Supplemental Nutrition Assistance Program benefits. Results: The sample included 1 322 263 health care workers from 2010-2019. Health care workers in expansion states were similar to those in nonexpansion states in age, sex, and educational attainment, but those in expansion states were less likely to identify as non-Hispanic Black. Medicaid expansion was associated with a 2.16% increase in annual incomes (95% CI, 0.66%-3.65%; P = .005). This effect was driven by significant increases in annual incomes among the top 2 highest-earning quintiles (ß coefficient, 2.91%-3.72%), which includes registered nurses, physicians, and executives. Health care workers in lower-earning quintiles did not experience any significant changes. Medicaid expansion was associated with a 3.15 percentage point increase in the likelihood that a health care worker received Medicaid benefits (95% CI, 2.46 to 3.84; P < .001), with the largest increases among the 2 lowest-earning quintiles, which includes health aides, orderlies, and sanitation workers. There were significant decreases in employer-sponsored health insurance and increases in SNAP following Medicaid expansion. Conclusion and Relevance: Medicaid expansion was associated with increases in compensation for health care workers, but only among the highest earners. These findings suggest that improvements in health care sector finances may increase economic inequality among health care workers, with implications for worker health and well-being.

Effects of government policies on the work of home care personnel and their occupational health and safety.

The health sector in Québec (Canada) is dealing with profound macro-economic and macro-organizational changes. This article is interested in the impact of these changes on the work of home health aides (HHAs) and home care nurses and their occupational health and safety (OHS). The study was carried out in the home care services (HCS) of four local community service centres (CLSC) with different organizational characteristics. It is based on an analysis by triangulation of 66 individual and group interviews, 22 observed workdays and 35 observed multidisciplinary or professional meetings, as well as on administrative documents. HHAs are experiencing an erosion of their job because the relational and affective aspects of their work are disappearing. This may be due to an increase in their physical workload, leading to an increase in musculoskeletal problems and, to a lesser extent, in psychological health problems. Nurses are seeing an increase in the volume of invisible work that they have to do, which also has the effect of decreasing the relational aspects of their activity. The increasingly numerous psychological health problems are the consequence of this change in their profession. This study also shows that managers' decisions at the local level can reduce or increase the work constraints of HHAs and nurses. Examples of good practices for HHAs are the stabilization of clienteles and the possibility of organizing their itinerary, while for nurses, it is in how clientele follow-up tools are implemented. This article discusses the effects of government policies and decisions on the work and OHS of home care personnel. To address this subject, we use a specific analysis of the workload of home health aides (HHAs) and nurses. We will show the relationships between managers' organizational choices to respond to governmental constraints and the resulting work changes. We will also look at their consequences on occupational health and safety (OHS) and on the work of different personnel.

How managed care growth affects where physicians locate their practices.

Managed care has had a profound effect on physician practice. It has altered patterns in the use of physician services, and consequently, the practice and employment options available to physicians. But managed care growth has not been uniform across the United States, and has spawned wide geographic disparities in earning opportunities for generalists and specialists. This Issue Brief summarizes new information on how managed care has affected physicians' labor market decisions and the impact of managed care on the number and distribution of physicians across the country.

How does provider supply and regulation influence health care markets? Evidence from nurse practitioners and physician assistants.

Nurse practitioners (NPs) and physician assistants (PAs) now outnumber family practice doctors in the United States and are the principal providers of primary care to many communities. Recent growth of these professions has occurred amidst considerable cross-state variation in their regulation, with some states permitting autonomous practice and others mandating extensive physician oversight. I find that expanded NP and PA supply has had minimal impact on the office-based healthcare market overall, but utilization has been modestly more responsive to supply increases in states permitting greater autonomy. Results suggest the importance of laws impacting the division of labor, not just its quantity.

Evolving trends in size and structure of group dental practices in the United States.

In this study, the authors examined recent trends in the growth of dental establishments and dental firms, including geographic location. In this article, they also present information about the demographic characteristics of dentists who work in a dental practice that is part of a larger company that delivers dental care in multiple locations. The number of dental establishments (single locations) and the average size of these establishments grew from 1992 to 2007. Large multi-unit dental firms grew in terms of number of establishments and the percentage of total receipts. Large multi-unit dental firms represent a small but growing segment of the dental market. Dentists less than thirty-five years old were most likely to work in a practice that was part of a larger company, and females were more likely than males to work in such a setting. The percentage of dentists working in these settings was also found to vary by region and state. The authors present a typology of dental group practice and suggest that future research should take into account the differences so that appropriate conclusions can be drawn and generalizations across categories are not made.

A report card on the physician work force: Israeli health care market--past experience and future prospects.

BACKGROUND: The worldwide shortage of physicians is due not only to the lack of physicians, but also to complex social and economic factors that vary from country to country. OBJECTIVE: To describe the results of physician workforce planning in a system with unintended policy, such as Israel, based on past experience and predicted future trends, between 1995 and 2020. METHODS: A descriptive study of past (1995-2009) and future (through 2020) physician workforce trends in Israel. An actuarial equation was developed to project physician supply until 2020. RESULTS: In Israel a physician shortage is expected in the very near future. This finding is the result of global as well as local changes affecting the supply of physicians: change in immigration pattern, gender effect, population growth, and transparency of data on demand for physicians. These are universal factors affecting manpower planning in most industrial countries all over the world. CONCLUSION: We describe a health care market with an unintended physician workforce policy. Sharing decision makers' experience in similar health care systems will enable the development of better indices to analyze, by comparison, effective physician manpower planning processes, worldwide.

Violência no trabalho em saúde: a experiência de servidores estaduais da saúde no Estado da Bahia, Brasil / Workplace violence in the healthcare sector: the experience of State health employees in Bahia State, Brazil / Violencia en el trabajo en el ámbito de salud: la experiencia de los empleados de salud del estado en Bahía, Brasil

Introdução: Existem poucas pesquisas e insuficientes informações sobre a violência do trabalho em saúde e sobre os efeitos negativos que o problema traz para o trabalhador do segmento. Objetivos: Este estudo teve por objetivo estimar a prevalência de violência autorreferida no trabalho em saúde. Material e métodos: Estudo transversal realizado com uma amostra de 679 servidores estaduais (Bahia, Brasil), por meio de entrevistas face a face e uso de questionário. Resultados: Dos entrevistados, 25,9% (IC95%: 22,6%-29,2%) referiram pelo menos uma das modalidades de violência investigadas, sendo a agressão verbal (19,4%) a mais frequente. As mulheres na faixa etária de 25 a 39 anos apresentaram um acréscimo de 80% na ocorrência de violência em relação às mais velhas (OR = 1,8; IC95%: 1,1-3,0), enquanto que as médicas também foram as mais atingidas (OR = 2,5; IC95%: 1,2-12,5). Entre os homens, ter de 25 a 39 anos (OR = 3,9; IC95%: 1,9-16,4) e trabalhar como auxiliar ou técnico em enfermagem (RP = 3,9; IC95%: 1,1-13,2) aumentou quase quatro vezes a ocorrência de violência no trabalho em saúde. Conclusão: Este estudo pode trazer contribuições importantes para a visibilidade da violência no setor saúde e fornecer subsídios para a formulação de políticas de atenção aos trabalhadores com repercussão na qualidade do atendimento prestado à população.

Introduction: There is little research and insufficient information about the violence of health work and about the negative effects that the problem brings to the worker in the segment. Objectives: This study aimed to estimate the prevalence of self-reported violence suffered by healthcare workers. Material and methods: using a cross-sectional design with a sample of 679 State health employees through face-to-face interviews and a questionnaire. Results: Of the respondents, 25.9% (95%CI: 22.6%-29.2%) reported having suffered at least one form of violence, with verbal aggression as the most frequent (19.4%). Women aged 25-39 suffered 80% more violence than older women (OR = 1.8; 95%CI: 1.1-3.0). Female physicians were the most frequently affected group (OR = 2.5; 95%CI: 1.2-12.5). Among men, a nearly fourfold increase in healthcare workplace violence was associated with age 25 to 39 years (OR = 3.9; 95%CI: 1.9-16.4) and nurse assistants or nurse technicians (PR = 3.9; 95%CI: 1.1-13.2). Conclusion: This study can help raise awareness concerning healthcare workplace violence and support policies for health workers; care, with repercussions on quality of care for health services users.

Introducción: Existen pocas investigaciones e insuficientes informaciones sobre la violencia del trabajo en salud y sobre los efectos negativos que el problema trae para el trabajador del segmento. Objetivos: Este estudio tuvo como objetivo estimar la prevalencia de la violencia entre los trabajadores de la salud. Materiales y métodos: Es un estudio transversal con una muestra de 679 trabajadores del estado de Bahía, Brasil, donde se usó un cuestionario mediante entrevistas. Resultados: De los encuestados, el 25,9% (IC95%: 22,6%-29,2%) informó al menos de una de las formas de violencia investigada, donde la agresión verbal (19,4%) era la más frecuente. A las mujeres de 25 a 39 años les afectó un aumento del 80% en la incidencia de la violencia (OR = 1,8; IC95%: 1,1-3,0), mientras que los médicos también fueron los más afectados (OR = 2,5; IC95%: 1.2-12.5). Entre los hombres, que tienen entre 25 y 39 años (OR = 3,9; IC95%: 1,9-16,4) y trabajan como asistentes de enfermería o técnicos (RP = 3,9; IC95%: 1,1-13,2) aumentó casi 4 veces la incidencia de violencia en el trabajo en salud. Conclusión: Este estudio puede contribuir de manera significativa a la visibilidad de la violencia en el sector de la salud y servir de apoyo para la formulación de la política de atención a los trabajadores que repercute en la calidad de la atención prestada.

An analysis of equity in Brazilian health system financing.

Health care in Brazil is financed from many sources--taxes on income, real property, sales of goods and services, and financial transactions; private insurance purchased by households and firms; and out-of-pocket payments by households. Data on household budgets and tax revenues allow the burden of each source except firms' insurance purchases for their employees to be allocated across deciles of adjusted per capita household income, indicating the progressivity or regressivity of each kind of payment. Overall, financing is approximately neutral, with progressive public finance offsetting regressive payments. This last form of finance pushes some households into poverty.

An analysis of equity in Brazilian health system financing

Health care in Brazil is financed from many sources-taxes on income, real property, sales of goods and services, and financial transactions; private insurance purchased by households and firms; and out-of-pocket payments by households. Data onhousehold budgets and tax revenues allow the burden of each source except firms’ insurance purchases for their employees to be allocated across deciles of adjusted per capita household income, indicating the progressivity or regressivity of each kind of payment.Overall, financing is approximately neutral, with progressive public finance offsetting regressive payments. This last form of finance pushes some households into poverty.