Expert Commentary

How work might worsen health

In light of debates over Medicaid work requirements, this review features studies that show how for healthy and unhealthy people alike, some forms of work might worsen health.

factory worker
(Library of Congress)

Debates over whether Medicaid recipients should have to work to qualify for the federal health insurance program for the poor often focus on the health effects of such a policy. Some supporters of the change suggest it might have beneficial health effects. The director of the federal Medicaid office, Brian Neale, and the administrator of the Centers for Medicare and Medicaid Services, Seema Verma, have espoused such views.

While research summarized in the first of these two roundups exists to support an association between employment and health, the specifics of this relationship require untangling. Though the employed tend to enjoy better health, it might be the case that the poorer health of some unemployed people explains precisely why they cannot work. In fact, part of this research review highlights a body of literature that supports this notion.

This review features studies that show that for healthy and unhealthy people alike, some forms of work might worsen health. For example, temporary, precarious and stressful work arrangements are each associated with poor health.

Health policy experts like Texas A&M professor Laura Dague suggest added work requirements will likely lead to decreased enrollment in Medicaid. Losing Medicaid could reduce people’s access to primary and preventive care, which in turn could have broader health effects. For a complementary perspective on this issue, this roundup features recent research on Medicaid expansions in individual states and the health effects of such changes in coverage.

Interrogating causality

“Influence of Poor Health on Exit from Paid Employment: A Systematic Review”
van Rijn, Rogier; et al. Occupational & Environmental Medicine, 2014. DOI: 10.1136/oemed-2013-101591.

Abstract: “This meta-analysis showed that poor health, particularly self-perceived health, is a risk factor for exit from paid employment through disability pension, unemployment and, to a lesser extent, early retirement. To increase sustained employability it should be considered to implement workplace interventions that promote good health.”

“Chronic Diseases as Predictors of Labor Market Attachment After Participation in Subsidised Reemployment Program: A 6-year Follow-up Study”
Nwaru, Chioma A.; et al. Journal of Epidemiology & Community Health, 2017. DOI: 10.1136/jech-2017-209271.

Conclusions: “Re-employed people appear to follow distinct labour market attachment trajectories over time. Having chronic diseases, especially mental disorders, appear to increase the risk for relatively poor labor market attachment.”

“Return to Work After Depression-Related Absence by Employees With and Without Other Health Conditions: A Cohort Study”
Ervasti, Jenni; et al. Psychosomatic Medicine, 2015. DOI: 10.1097/PSY.0000000000000138.

Conclusions: “Among employees with depression-related absence, return to work is delayed in the presence of other psychiatric and somatic conditions. These findings suggest that other diseases should be taken into account when evaluating the outcome of depression-related absence. Randomized controlled trials are needed to examine whether integrated treatment of mental and physical disorders improves successful return to work after depression.”

Is all work created equal?

“Is an Insecure Job Better for Health than Having No Job at All? A Systematic Review of Studies Investigating the Health-Related Risks of Both Job Insecurity and Unemployment”
Kim, Tae Jun; von dem Knesebeck, Olaf. BMC Public Health, 2015. DOI: 10.1186/s12889-015-2313-1.

Conclusions: “Though there were moderate differences across the health outcomes, overall, it was found that job insecurity can pose a comparable threat to health than unemployment. Policy interventions should therefore not only consider health risks posed by unemployment, but should also aim at the reduction of insecure employment.”

“Common Mental Disorders, Unemployment and Psychosocial Job Quality: Is a Poor Job Better than no Job at All?”
Butterworth, Peter; et al. Psychological Medicine, August 2013. DOI: 10.1017/S0033291712002577.

Conclusions: “Although employment is thought to promote mental health and well-being, work of poor psychosocial quality is not associated with any better mental health than unemployment. Policy efforts to improve community mental health should consider psychosocial job quality in conjunction with efforts to increase employment rates.”

“The Limitations of Employment as a Tool for Social Inclusion”
Leach, Liana S.; et al. BMC Public Health, 2010. DOI: 10.1186/1471-2458-10-621.

Results: “Those who were unemployed and those in poor quality jobs (characterised by insecurity, low marketability and job strain) were more likely to remain in these circumstances than to move to better working conditions. Poor quality jobs were associated with poorer physical and mental health status than better quality work, with the health of those in the poorest quality jobs comparable to that of the unemployed. For those who were unemployed at baseline, pre-existing health status predicted employment transition. Those respondents who moved from unemployment into poor quality work experienced an increase in depressive symptoms compared to those who moved into good quality work.”

“Perceived Job Insecurity as a Risk Factor for Incident Coronary Heart Disease: Systematic Review and Meta-Analysis”
Virtanen, Marianna; et al. British Medical Journal, August 2013. DOI: 10.1136/bmj.f4746.

Conclusions: “The modest association between perceived job insecurity and incident coronary heart disease is partly attributable to poorer socioeconomic circumstances and less favourable risk factor profiles among people with job insecurity.”

“The Lesser Evil: Bad Jobs or Unemployment? A Survey of Mid-aged Australians”
Broom, Dorothy H.; et al. Social Science & Medicine, 2006. DOI: 10.1016/j.socscimed.2006.02.003.

Findings: “We found that unemployed people reported worse health when compared to all employees. However, distinguishing in terms of employee’s job quality revealed a more complex pattern. Poor quality jobs (characterized by insecurity, low marketability and job strain) were associated with worse health when compared to jobs with fewer or no stressors. Furthermore, people in jobs with three or more of the psychosocial stressors report health that is no better than the unemployed.”

“Exposure to Temporary Employment and Job Insecurity: A Longitudinal Study of the Health Effects”
Virtanen, Pekka; Janlert, Urban; Hammarstӧm, Anne. Occupational & Environmental Medicine, 2011. DOI: 10.1136/oem.2010.054890.

Conclusions: “These findings suggest that perceived job insecurity can lead to adverse health effects in both permanent and temporary employees. Policies should aim to improve work-related well-being by reducing job insecurity. Efforts towards ‘flexicurity’ are important, but it is equally important to remember that a significant proportion of employees with a permanent contract experience job insecurity.”

“Working Without Commitments: Precarious Employment and Health”
Lewchuk, Wayne; Clarke, Marlea; de Wolff, Alice. Work, Employment and Society, September 2008. DOI: 10.1177/0950017008093477.

Abstract: “Using cross-sectional data from a Canadian population-based questionnaire, this article develops a new approach to understanding the impact of less permanent forms of employment on workers’ health. It concludes that employment relationships where future employment is uncertain, where individuals are actively searching for new employment and where support is limited are associated with poorer health indicators.”

“Is Temporary Employment Related to Health Status? Analysis of the Northern Swedish Cohort”
Waenerlund, Anna-Karin; Virtanen, Pekka; Hammarstrӧm, Anne. Scandinavian Journal of Public Health, 2011. DOI: 10.1177/1403494810395821.

Results: “Temporary employees had a higher risk of both non-optimal self-rated health and psychological distress. After adjustment for non-optimal self-rated health at age 30 and psychological distress at age 30 as well as for sociodemographic variables, the odds ratios decreased but remained significant. However, after adjustment for job insecurity, high job strain and low cash margin the odds ratio dropped for non-optimal self-rated health but remained significant for psychological distress.”

“Precarious Employment: Understanding an Emerging Social Determinant of Health”
Benach, Joan; et al. Annual Reviews of Public Health, 2014. DOI: 10.1146/annurev-publhealth-032013-182500.

Abstract: “This article identifies the historical, economic, and political factors that link precarious employment to health and health equity; reviews concepts, models, instruments, and findings on precarious employment and health inequalities; summarizes the strengths and weaknesses of this literature; and highlights substantive and methodological challenges that need to be addressed. We identify two crucial future aims: to provide a compelling research program that expands our understanding of employment precariousness and to develop and evaluate policy programs that effectively put an end to its health-related impacts.”

Unintended Consequences

“Effect of Medicaid Expansions of 2014 on Overall and Early-Stage Cancer Diagnoses”
Soni, Aparna; et al. American Journal of Public Health, February 2018. DOI: 10.2105/AJPH.2017.304166.

Results: “Among the 611 counties in this study, Medicaid expansion was associated with an increase in overall cancer diagnoses of 13.8 per 100 000 population (95 percent confidence interval [CI] = 0.7, 26.9), or 3.4 percent. Medicaid expansion was also associated with an increase in early-stage diagnoses of 15.4 per 100 000 population (95 percent CI = 5.4, 25.3), or 6.4 percent. There was no detectable impact on late-stage diagnoses.”

“The Impacts of Medicaid Expansion on Rural Low Income Adults: Lessons From the Oregon Health Insurance Experiment”
Allen, Heidi; Wright, Bill; Broffman, Lauren. Medical Care Research and Review, 2017. DOI: 10.1177/1077558716688793.

Results: “Given the many challenges of rural health care — distance, lack of access to specialists, and other factors — our experimental data suggest that Medicaid coverage resulted in considerable benefits for those living in rural Oregon, indistinguishable from those in urban areas. Despite concerns about inadequate provider networks or transportation issues, gaining coverage significantly increased the likelihood that rural individuals who reported health care needs felt those needs were addressed. Comparing urban and rural study participants, we found similar improvements in access to primary care, use of preventive screenings, and continuity of care. Rural participants also equally benefited from the financial protections afforded by coverage. Whether it was because of increased financial security or actual health improvements, rural individuals who gained coverage reported better overall health and happiness.”

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