By Kristin J. Cummings, MD, MPH and Kathleen Kreiss, MD
JAMA
January 30, 2008
Employment arrangements in which the worker has a nontraditional relationship with the work-site employer have come to be grouped together in recent years as “contingent” work. Throughout the 1970s and 1980s, as employers sought more flexibility, contingent employment arrangements became more common in the United States. From 1969 to 1993, the number of part-time workers nearly doubled, representing a quarter of all growth in the national workforce. From 1982 to 1990, employment in temporary agencies increased 10 times faster than did the workforce as a whole. During the 1980s, the use of independent contractors in coal mining and of contract company workers in agriculture doubled.
The use of contingent workers has not been limited to the private sector: by 2006, the federal government was spending an estimated $400 billion per year on contractors. Since national data were first collected by the Department of Labor in 1995, contingent workers have consistently represented nearly one-third of the total workforce, reaching 43 million in 2005. However, because only those with fixed addresses are surveyed, this is likely an underestimate. Thus, contingent work has taken hold in the United States, bringing with it concerning implications for health.
Contingent workers are a diverse group, ranging from well-compensated independent financial consultants to low-skilled construction workers. The majority of the contingent workforce is white and aged 25 years or older; however, compared with workers in traditional arrangements, contingent workers are more likely to be young, female, black or Hispanic, and to have lower incomes and fewer benefits. One analysis of 2005 federal data found that 16% of contingent workers have family incomes less than $20 000, a proportion twice as high as that of noncontingent workers. For some contingent workers, such as day laborers and agency temporary workers, the proportion surpassed 20%. Only 13% of contingent workers (and 9% of those with low family incomes) had health insurance provided by their employer, compared with 72% of noncontingent workers.
http://jama.ama-assn.org/cgi/content/full/299/4/448#AUTHINFO
Comment:
By Don McCanne, MD
“Only 13% of contingent workers had health insurance provided by their employer, compared with 72% of noncontingent workers.”
It is unrealistic to expect employers to provide long-term health benefits to these employees who move in and out of their workforce. Because of changes in income, residency, dependent status, and so forth, it is also very difficult to provide stable enrollment in public insurance programs.
A national health program in which enrollment is automatic and permanent would eliminate the problem of finding a way to finance health care for these individuals. Although that certainly would not eliminate all access problems, it would remove the financial barriers to care.
In the meantime, our Community Health Centers do provide some basic health services for these individuals, though access to specialized services, laboratory tests, imaging, pharmaceuticals, and other products and services, is still quite limited. If we had a health care financing system that covered everyone, just think of how much more effective these centers would be in providing appropriate health care services. As part of our health care delivery system, they also need assurances that they will have the funds to fulfill their mission.
