The Future of Occupational Health Nursing in a Changing Health Care System

Abstract

Repealing the Affordable Care Act (ACA) has significant implications for the future of occupational health nursing practice. As changes are proposed and implemented, occupational health nurses must continue to prioritize preventive care, chronic disease management, healthy communities, environmental health, and sustainability. In particular, immigrant workers are a vulnerable population needing attention by occupational health nurses.

Prediction is difficult, especially if it’s about the future

—N. Bohr

The U.S. health care system seems headed for major changes in 2017. Most attention is focused on the repeal of the Affordable Care Act (ACA), but other broad changes could profoundly affect the practice of occupational health nurses and nurses in general. The per capita cost of health care in the United States is much higher than that of other developed countries. In 2015, U.S. health care costs increased 5.8% to reach US$3.2 trillion, or US$9,990 per person (U.S. Centers for Medicare & Medicaid Services, 2015) and was expected to exceed US$10,000 per person in 2016 (Keehan et al., 2016). The U.S. government spends approximately US$1.2 trillion a year on Medicare and Medicaid alone (Keehan et al., 2016). The ACA may have influenced health care costs, but the dynamic trends driving up these costs in the United States (e.g., skyrocketing costs of medications, a growing elderly population, and rising insurance premiums) preceded its enactment.

Critics of the ACA point to escalating insurance premiums, high deductibles, and an unsustainable burden for small businesses. Groups advocating for some form of ACA continuation point to the numbers of individuals who will lose their insurance coverage and the financial impact of repealing the ACA on the nation’s health care costs. State governments are concerned about their ability to assume responsibility for expanded Medicaid costs. Moreover, although the country is divided on these issues, other areas of changing government priorities (e.g., funding for health care workforce training, immigration laws, environmental health, and public health initiatives) are also being debated. This article will outline major areas of change ahead and potential implications for occupational health nursing practice.

Repeal and Replacement of the ACA

Since its inception, supporters of the ACA point to the achievement of providing insurance coverage to millions of individuals who could previously not afford coverage, and ending the practice of refusing insurance for those individuals with preexisting health conditions. These two elements have allowed some Americans to obtain coverage for the first time. Some supporters attribute slowing of the nation’s health care costs to the ACA; others point to the ACA’s role in rising premium costs, lack of choice in insurance companies, and unaffordable deductibles (Elwood, 2016). Regardless of whether one is for or against the repeal of the ACA, it is deeply embedded throughout the health care system and it is uncertain how repeal and replace will actually affect health care system drivers, including overall health care costs, quality, and accessibility (Singer, 2017).

It is likely that repeal of the ACA without simultaneous replacement policies will result in millions of young adults no longer covered by their parent’s policies, insurance policies that deny coverage to individuals with preexisting conditions, and millions of individuals no longer eligible for Medicaid. Two of the most unpopular aspects of the ACA have been the individual mandate for all Americans to have some type of health insurance coverage or pay a penalty, and the requirement that small businesses provide health insurance coverage for their employees. The costs of these two aspects have been highly criticized although a variety of bipartisan groups have agreed that the popular aspects of ACA (i.e., coverage for individuals with preexisting conditions and allowing young adults to remain on family policies) cannot be financed without requiring the individual mandate (Congressional Budget Office, 2017).

Employer-provided health care plans are the primary source of health insurance for U.S. workers and their families. The private business share of overall health care spending is approximately 20%, a proportion that has remained fairly steady since 2010 (U.S. Centers for Medicare & Medicaid Services, 2015). Employers can either purchase group insurance plans in which the cost is shared with employees or they can participate in a Health Reimbursement Arrangement (HRA) which offers a fixed monthly contribution to each employee who can then access the funds to cover health insurance premiums and qualified health care expenses. Under HRAs, employees can purchase any individual or family health insurance policy through the health insurance marketplace. The HRA has been the most popular option for employers with 50 or fewer full-time employees.

The repeal of the ACA leaves these options in doubt and creates uncertainty about whether small employers will continue to be required to provide coverage at all. Most employer-provided plans were relatively comprehensive before the ACA, but some employers offered plans that left employees with large health care bills or excluded services. The ACA requirement that all new health plans place a cap on the amount that individuals can be expected to pay out-of-pocket each year has protected individuals with catastrophic illnesses who previously would have faced crippling out-of-pocket costs. Previously, employer-provided plans could have an annual or lifetime dollar limit on benefits, creating extreme hardship for families with one or more members who needed costly chronic disease coverage. When families face extraordinary health-related financial crises, members’ abilities to be productive workers are challenged, given the extreme stress and hardships they face every day.

Regardless of support or opposition to the ACA, the issues are critically important to occupational health practice (Keifer, 2015). As the ACA is repealed and changes are proposed or implemented, occupational health nurses must monitor these changes and be cognizant of their potential impact on the workforce and individual workers for whom they provide programs and services.

Preventive Care

A major component of the ACA is evidence-based preventive and early detection services such as annual wellness visits and health screenings (e.g., cholesterol testing and colonoscopies) that are covered with no copayment. Accountable Care Organizations (ACOs) were incentivized to coordinate and improve care coordination across settings, including the workplace (Anderko et al., 2012). As a result, employees have become accustomed to receiving health screenings, immunizations, and annual examinations without deductible charges. Although some have criticized the costs of including free preventive and early detection measures for everyone, others have viewed preventive care as one of the more beneficial aspects of the ACA. Cessation of this benefit will not likely be popular among employees, especially women who found their contraceptive costs much more affordable and who might have received mammograms for the first time in their lives. The ACA directed the focus of health care beyond the health care system and toward the factors that keep populations healthy, including many components of occupational health nursing (Institute of Medicine, 2014; Shaw, Asomugha, Conway, & Rein, 2014). Population health became a term that all health care systems recognized, and the extent to which it will remain a priority after the ACA is repealed is unclear.

The National Prevention, Health Promotion, and Public Health Council (Council) has been one of the most controversial components of the ACA. The Council expanded the concept of interventions aimed at improving the health of populations beyond the care provided by health care organizations. This approach has included transforming the places where people work. The Prevention and Public Health Fund is the largest national commitment to investing in wellness and prevention and focused on three major prevention provisions: waiving costs for preventive services, providing new funding for community prevention services, and creating workplace wellness programs. This component of the ACA offered tremendous potential to enhance the practice of occupational health nursing and the provision of care to worker populations.

Repeal of the ACA is likely to result in the elimination of this initiative and to place more emphasis on the responsibility of individuals to determine the value of preventive health practices. Elimination of the national emphasis on prevention programs will turn the focus of occupational health nurses toward advocating for the inclusion of preventive services at the workplace.

Chronic Disease Management

Continued growth in the number of workers with chronic health conditions will have a profound effect on the practice of occupational health nursing (Sorensen et al., 2011). Adults aged 65 years and older comprise the fastest-growing segment of the U.S. population, increasing from 40.2 million in 2010 to a projected 88.5 million by 2050; this population shift will generate challenges for occupational health nurses providing care for ever increasing numbers of older workers (Delloiacono, 2015). Workers with chronic diseases have high rates of health care utilization resulting in high costs for employers. In addition, chronic conditions can adversely affect workers’ quality of life and their ability to continue to work. Worksites provide an ideal environment for reaching and coordinating the care of the employed segment of the chronically ill population (Sorensen et al., 2011). Furthermore, work conditions can also contribute to the development of chronic health problems associated with hazardous job exposures, increasing job demands, and inflexible work schedules.

The worksite can play a critical role in managing the care of individuals with chronic disease, promoting their health and preventing hospitalizations. Workplace wellness programs that were part of the ACA’s national public health strategy were designed to address the nation’s increasing incidence of chronic disease. Projections of chronic disease burden in the United States are alarming with close to a 50% increase from 2007 to 2023 and a total annual cost to the U.S. health care system estimated to reach US$4.2 trillion by 2023 (Bodenheimer, Chen, & Bennett, 2009). Occupational health nurses caring for employees who are managing chronic diseases need to be increasingly aware of the transition from fee-for-service to value-based care, a form of reimbursement that ties payments to quality of care, efficiency, and effectiveness.

Healthy Communities, Environmental Health, and Sustainability

Occupational health nursing practice is embedded in broad principles of public health with an overarching goal of preventing work-related injuries and illnesses. The profession has a long-standing commitment to providing safe and healthy environments in the workplace and beyond. Occupational health nurses define the environment as the totality of surrounding conditions including physical, sociocultural, organizational, economic, political, and interpersonal dimensions or properties that influence an individual or community (American Association of Occupational Health Nurses, 2013). The discipline’s practice has historically included the importance of environmental health policies to protect populations. Many of the workplace and environmental regulations that occupational health nurses observe every day are mandated at either the federal or state levels.

Funding for the Department of Labor, the Environmental Protection Agency, and the Centers for Disease Control and Prevention is critical in determining the extent to which occupational health nurses can protect and promote the health of the working population. It has been shown that the most effective health policies increase access to health care and social services, raise the quality of education, improve diet, provide affordable housing, and encourage physical activity (Fox & Grogan, 2017). Increasing the availability of jobs that pay a living wage and eliminating toxins from the environment are also critical to the health of this population (Thornton et al., 2016). This country has never been more divided on the need for policies to protect U.S. workers, the environment, and the planet (Fox & Grogan, 2017). Currently, the political climate threatens the rollback of policies designed to limit exposures of human populations to toxins in the air and water (Fox & Grogan, 2017). Occupational health nurses must continue to advocate for environmental health, legislation, and policies designed to protect the health of workers and their communities.

Immigrant Workers

The past two decades have seen shifting demographics in regard to diversity and immigration status of the U.S. workforce. The large majority of immigrant workers is in the United States legally and comprises 13% of the population and 17% of the workforce (The Pew Charitable Trusts, 2015). Immigrant workers may be U.S. citizens or hold green card status. Other authorized immigrant workers are here on temporary visas. The current U.S. system admits three major groups of temporary workers: highly skilled workers with university degrees, those who perform seasonal work in agriculture, and those who perform seasonal work in hospitality, recreation, or landscaping (Wilson, 2013). The three major temporary worker groups include the following:

• H-1B workers are those who have a bachelor’s degree or above and come to the United States to perform highly specialized work. This 3-year visa can be renewed once. With sponsorship from their employer, H-1B workers can apply for permanent legal status and remain in the United States if approved.

• H-2A workers are temporary agricultural workers from 59 approved countries. Their visas may be issued for up to 1 year and can be renewed 3 times.

• H-2B workers are temporary nonagricultural workers from 59 approved countries. Their visas may be issued for up to 1 year and can be renewed 3 times.

A third category of immigrant workers is unauthorized or undocumented immigrants. In 2014, it was estimated that approximately 8 million unauthorized immigrants in the United States were working or looking for work, comprising 5% of the civilian labor force (Passel & Cohn, 2016). This number has held relatively constant since 2009. It is highly likely in the current climate of immigration reform that the number of unauthorized immigrants will decrease and the number of legal temporary foreign workers will increase. The increase in temporary workers will occur in the context of significant changes in visa programs. Some of the areas that are being considered include the following:

• Increase the numbers of highly skilled H-1B workers, particularly in computer fields; allow workers to change jobs in the United States; and allow spouses of workers to be employed.

• Assure that no U.S. workers are displaced by H-1B visa workers and require employers to pay for transportation costs from workers’ countries to the United States and back.

• Consider a path to legal status for H-2A workers who have worked in U.S. agriculture for 5 or more years and require employers to be registered and provide transportation and housing.

The presence of immigrants in the workplace should be a concern of occupational health nurses; they should be aware of the demographic characteristics of the employees in their workplaces and the rights of guest workers on U.S. visas. Overall, immigrant workers, regardless of authorization or citizenship, are considered vulnerable workgroups susceptible to health disparities and health inequities. Evidence suggests several factors that contribute to disparities in health outcomes among immigrant workers, including type of work, education and training, culture, environment, access to health care, chronic infectious diseases, and discrimination (Flynn, 2014; McCauley, 2005; National Institute for Occupational Safety and Health [NIOSH], 2012). Although the temporary visa program does provide some worker protections, evidence demonstrates that these workers’ legal rights are not always observed and they experience more health and safety hazards than nonimmigrant workers (Farmworker Justice, 2011; Human Rights Watch, 2005).

Workforce Issues

Occupational health nurses assume a variety of responsibilities. These specialist nurses play a critical role on multidisciplinary teams that identify the safety and health needs of workers and prioritize, develop, and implement programs to meet worker needs. Advanced practice occupational health nurses provide primary care services in the workplace; other specialists manage the care of injured workers or workers with special health needs. Some nurses specialize in developing and evaluating evidence-based health promotion and disease prevention strategies. Occupational health nurses’ specialized education allows them to monitor and analyze workplace injury and illness trends and patterns and to develop strategies to assure that employers are aware of and observe issues of legal compliance. These nurses have advanced knowledge to evaluate the effectiveness of workplace interventions and overall health and safety programs. Other occupational health nurses have advanced education related to research training in occupational and environmental health (American Association of Occupational Health Nurses, 2013).

In 2011, NIOSH conducted a national survey to quantify the training needs of the occupational health and safety workforce (McAdams, Kerwin, Olivo, & Goksel, 2011). It was noted that the workforce was graying, particularly nurses. The number of occupational health nurses projected to retire in the next 5 years posed a particular concern because the projected need for occupational health nurses was higher than the number of students graduating with specialized training in the field. This shortage of occupational health nurses parallels the looming national shortage of nurses in all specialties. Current projections estimate a shortage of 1.2 million nurses in the United States between 2014 and 2022 (Grant, 2016). A shortage of this extreme has not been seen since the advent of Medicare and Medicaid in the mid-1960s. A 2012 Health Resources and Services Administration (HRSA) report predicted that the shortage of nurses may be decreasing and, in some parts of the country, the supply of registered nurses is exceeding current demand. However, this report did not look at the projected need according to specialization or advanced practice preparation (U.S. Department of Health and Human Services, HRSA, & National Center for Health Workforce Analysis, 2014).

The cost of education is one of the most prominent barriers to increasing the supply of nurses to meet workforce demand. Educational funding for all advanced practice nurses, including those in occupational health, is insufficient to meet the need, and, over the past decade, such support has been under constant threat. As a result, nursing students are experiencing levels of educational debt never before seen in this country. Other barriers to meeting the occupational health nurse workforce demand include a shortage of nursing faculty limiting the numbers of students that can be admitted to nursing education programs and insufficient occupational health nursing clinical training sites, although occupational health nurses are excellent role models for students enrolled in community placements (American Association of Colleges of Nursing, 2011).

Repeal of the ACA could impact workforce legislation and policy. The ACA highlighted the contributions of nurses with advanced skills (e.g., case management, informatics, and patient navigation); advanced practice nurses have increasingly been recognized as cost-effective providers who increase access to care. As health systems sought to fill vacancies for these specialized roles, wages and benefits increased. The questionable future of the ACA, however, makes it unclear to what extent nursing workforce training, including occupational health nursing programs, will be a national priority. If increasing specialization in nursing and selective support for the preparation of advanced practice nurses is driven solely by market forces and not balanced by national policy, Americans may see variations and increases in occupational health nursing shortages and employers unable to compete for highly specialized nurses.

Conclusion

Health policy often shifts with the election of new leaders (Obama, 2017). Major policy shifts appear certain following changes in both legislative and executive branches of government after the most recent election. New directions can bring improvements, but, unless undertaken cautiously and carefully, the impact on the complex health care system could be devastating. Proposed changes could shake many of the pillars on which the U.S. health care system has been built with definitive effects on the major areas outlined in this article. Occupational health nurses should pay close attention as the new health care agenda unfolds.

Applying Research to Practice

Shifts in health care policy and health care agenda are inevitable with the election of new governmental leaders. Challenges in the healthcare environment our country will face in the near future include: repeal and replacement of the Affordable Care Act, strategies for preventive care, management of chronic disease, improving community and environmental health, reducing health care disparities among immigrant workers, and workforce training needs. Occupational health nurses must monitor these changes and be cognizant of their potential impact on their workforce and individual workers for whom they provide programs and services. A unique opportunity exists for occupational health nurses to create meaningful changes in health care policy development by bringing important issues to the forefront of the healthcare agenda.