摘要：Objectives. We examined rates of uninsurance among workers in the US health care workforce by health care industry subtype and workforce category. Methods. We used 2004 to 2006 National Health Interview Survey data to assess health insurance coverage rates. Multivariate logistic regression analyses were conducted to estimate the odds of uninsurance among health care workers by industry subtype. Results. Overall, 11% of the US health care workforce is uninsured. Ambulatory care workers were 3.1 times as likely as hospital workers (95% confidence interval [CI] = 2.3, 4.3) to be uninsured, and residential care workers were 4.3 times as likely to be uninsured (95% CI = 3.0, 6.1). Health service workers had 50% greater odds of being uninsured relative to workers in health diagnosing and treating occupations (odds ratio [OR] = 1.5; 95% CI = 1.0, 2.4). Conclusions. Because uninsurance leads to delays in seeking care, fewer prevention visits, and poorer health status, the fact that nearly 1 in 8 health care workers lacks insurance coverage is cause for concern. For complex socioeconomic reasons, private health insurance, typically provided by an employer, is “the dominant mechanism for paying for health services” in the United States. 1 (p79) According to the Kaiser Commission on Medicaid and the Uninsured and the Urban Institute, analyses of data from the Current Population Survey (CPS) show that, in 2006, 54% of the US civilian, noninstitutionalized population had employer-sponsored health insurance; 5% had private, nongroup health insurance; and 26% had public health insurance coverage. Approximately 46 million US residents (16% of the population) are currently uninsured. 2 Numerous studies have shown that, relative to people with health insurance, uninsured people receive less preventive care, are diagnosed at more advanced disease stages, and, once diagnosed, tend to receive less therapeutic care and have higher mortality rates. 3 – 8 Although national uninsurance trends are well-documented, the rate of uninsurance within the health care workforce has received scant attention. Given that health care employment rates are increasing at a more rapid pace than overall employment rates, this lack of attention is especially worrisome. According to the Bureau of Labor Statistics, nearly half of the 30 occupations in which employment opportunities are growing fastest are health care occupations. For example, whereas the Bureau of Labor Statistics projects that overall employment will increase about 10% from 2006 to 2016, employment opportunities for personal and home care aides are projected to increase nearly 51%, and opportunities for physical therapist assistants are expected to increase by a third. The Bureau of Labor Statistics also projects that, by 2016, new job opportunities for registered nurses will increase by approximately 24% (approximately 587 000 new jobs). 9 Although the overall employment outlook for health care workers is promising, what is less clear is to what degree employment in health care is associated with health insurance coverage. A 2001 General Accounting Office report suggested that one fourth of nursing home aides and one third of home health care aides were uninsured. 10 The Kaiser Family Foundation reported that the uninsured rate among workers in the health and social services industry was 23% in 2007. 11 On the basis of a review of the literature in the health and human services occupations, Ebenstein concluded that the health insurance plans offered to direct care workers in the developmental disabilities field are “inferior … with less coverage and more out-of-pocket expenses” and that fewer direct care workers “are able to afford health coverage even if they are eligible.” 12 (p132) Taking a more comprehensive look at the US health care workforce, Himmelstein and Woolhandler 13 used 1991 CPS data to estimate uninsurance rates among physicians and other health care personnel. They reported that, overall, 9% of health care workers were uninsured, along with more than 20% of nursing home workers. Examining CPS data from 1988 to 1998, Case et al. found that uninsurance rates among all health care workers rose from 8% to 12%, that rates increased more for health care workers than for workers in other industries, and that rates differed according to occupation and place of employment. 14 For example, occupation-specific uninsurance rates were 23.8% among health aides, 14.5% among licensed practical nurses, and 5% among registered nurses, whereas place-specific rates were 20% among nursing home workers, 8.7% among medical office workers, and 8.2% among hospital workers. 15 In their studies, Himmelstein and Woolhandler 13 and Case et al. 14 used national-level data to estimate uninsurance trends among health care workers. However, these trends were not adjusted for health care workers' social, demographic, or economic characteristics, which would have helped explain variation across categories or over time. Moreover, with the growth of the health care workforce, estimates from these older studies probably do not reflect the current situation. As a result, the picture of uninsurance as it pertains to the health care workforce lacks the precision and currentness necessary for sound policy decisions. In an effort to expand knowledge in this area, produce more up-to-date estimates, and provide support for possible policy decisions, we used data from the National Health Interview Survey (NHIS) to examine uninsurance among workers in the health care industry.
