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Worker Health and Health Care Reform: The Patient Protection and Affordable Care Act at Work

Pronk, Nico Ph.D., FACSM, FAWHP

doi: 10.1249/FIT.0b013e3182a0611e
COLUMNS: Worksite Health Promotion

Nico Pronk, Ph.D., FACSM, FAWHP, is vice president for Health Management and health science officer at HealthPartners in Minneapolis, MN, where he also is a senior research investigatorat the HealthPartners Research Foundation. Dr. Pronk is an adjunct professor of Society, Human Development, and Health at the Harvard University School of Public Health, where he teaches and conducts research in worker health protection and promotion. He is past president of the International Association for Worksite Health Promotion (IAWHP), an ACSM Affiliate Society, coauthor of the IAWHP Online Certificate Course, editor of ACSM’s Worksite Health Handbook, 2nd Edition, and associate editor for ACSM’s Health & Fitness Journal®.

Disclosure: The author declares no conflicts of interest and does not have any financial disclosures.

With the passage of the Patient Protection and Affordable Care Act (ACA) (4) in March 2010, prevention and health promotion received a new level of attention. The looming concern of an aging workforce and the real threat of obesity, with its lagging problem of diabetes and other chronic conditions, pose major challenges for American business and industry; in particular, in dealing with the increasingcost of health care. The ACA presents major opportunities for prevention and health promotion. The ACA includes a focus on four specific areas of prevention: 1) clinical preventive services, 2) community prevention programs, 3) public health infrastructure and training, and 4) workplace wellness programs. Preventive care benefits such as vaccinations, counseling, mammograms, and colonoscopies must be covered in all new plans without charging the individual a copay, deductible, or coinsurance for these services. Prevention of disease and illness through a Prevention and Public Health Fund (PPHF) is another strategy outlined to improve health across the community.

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The new $15 billion PPHF, an integral part of the ACA, invests in proven prevention and public health programs. These programs would include smoking cessation, physical activity, and weight management, among others. The PPHF is focused on three areas in particular; these include 1) waiving cost sharing for preventive services, 2) funding for community prevention programs, and 3) the creation of workplace wellness programs. Unfortunately, new legislation passed by Congress in February 2012 reduces the PPHF’s spending by $5 billion (1,2), a major reduction in the PPHF’s funds available for preventive efforts. Little guidance has been made available to date related to a proposed $200 million grants program for small business wellness programs.

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The health of the American workforce is changing, along with its demographics. At once, the workforce is aging and chronic conditions are increasing, particularly among those workers aged 55 years or older. This sets up a concern for employers because chronic conditions (e.g., depression, diabetes, and cardiovascular disease) represent major drivers for increasing health care costs. Developments in the way that work is organized, designed, and managed, as well as the broader context of the work environment, result in new and emerging risks for workers. This relates in particular to psychosocial risks. Psychosocial risks may be defined as interactions among job content, work organization and management, and other environmental and organizational conditions and the employees’ competencies and needs that prove to have a hazardous effect on employee health and safety through their perceptions and experiences. The World Health Organization estimates that psychosocial risks, such as depression, anxiety, and stress, will be the main source of disability during the next decade (5). Of course, these psychosocial work dimensions also are related to potential benefits. So, whereas companies and organizations should manage these risks, as they manage risks in all areas of their business, they also should recognize that these risks encompass potential opportunities. As such, risk management efforts may be a powerful tool in achieving organizational outcomes and the creation of healthy workplaces. Table 1 provides an overview of psychosocial dimensions and potential risks and opportunities associated with them.

The ACA affords an opportunity for workplace programs to address the physical, psychosocial, and socioeconomic environments. Through this avenue, substantial potential exists to create health via the workplace and reach deeper into the community. Principally, this may be achieved by influencing four dimensions across the populations served: the worker, the workplace, the family, and the broader community.

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The Worker

Health and wellness programs designed to improve worker wellness are identified as one of the major prevention objectives in the PPHF (1). Implementing worksite health and wellness programs and services that meet a “reasonable design” standard, as per the ACA (4), holds promise for improvement of worker health. The term “reasonabledesign” likely needs more delineation and may benefit from a closer connection to evidence of effectiveness. However, when programs follow principles of design linked to successful outcomes, a major benefit for employers and employees may be gained. As noted above, however, 33% of the initial funding set aside for the PPHF has been cut in 2012 (2).

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The Workplace

When it comes to improving the health of the public, the worksite plays an important role. Most working adults spend a substantial portion of their time at the workplace. In addition, employers tend to have a longer term relationship with their employees and have structures in place that connect to them as individuals (such as benefits, communications, supervisor relationships, etc.) during an extended period. As such, implementing prevention through the workplace setting is an important strategy to reach a large segment of society.

The ACA mostly adopted the requirements of the Health Insurance Portability and Accountability Act (HIPAA) nondiscrimination regulations, although some changes apply. For example, some changes apply to the use of financial incentives to help generate employee engagement in health and wellness programs. Because incentives may be integrated into health care benefits design (i.e., health insurance products), it is important for worksite health practitioners to be familiar with the use of these and to best leverage them. Properly designed incentive programs should improve health outcomes, be relevant, not be coercive, and be in alignment with the culture of the organization. In terms of total value, the allowable value of incentives has been raised from 20% to 30% of the cost of coverage in 2014 as part of the ACA. Furthermore, the incentive may be increased to 50% if such an increase is determined by the secretaries of Labor, Health and Human Services, and the Treasury to be appropriate. This may affect the overall use of incentives in the marketplace. The regulatory constraints already in place for the use of incentives remain.

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The Family

The workplace is linked inextricably to the family. Workers do not leave their family life at home once they arrive at the office. Similarly, when they go home at the end of their shift, they do not leave the workplace behind either. Work-family balance is an important opportunity to leverage when considering improvementin health via employer-based strategies. As noted in Table 1, appropriateuse of organizational “life balance” policies and providing flexibility in work schedules can make the difference between considering this a risk as opposed to a potential benefit.

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The Community

Access to healthy employees is a key consideration for employers. As a result, employers should pay attention and be engaged in the health of the communities in which they reside. In this community context, employers are linked to other stakeholders, including health plans, care delivery provider groups, and people of these communities including their own employees (3). The ACA provides several examples that allow for leverage and synchronization of approaches that benefit community health as well as the improvement of health for the company and its workers. For example, participation in community health education initiatives, the promotion of best practices, the support and implementationof [social] policy approaches to increase the adoption and maintenance of health behaviors (e.g., bike paths, vending machine criteria, smoke-free zones/buildings, etc.), and the alignment of incentives.

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It may seem a daunting task to figure out how best to leverage the ACA for the promotion of health and well-being of workers as part of your program. Clearly, staying current on the topic is important. A reasonable approach to consider is to first be aware of how the ACA affects your day-to-day work. Health care reform is in full swing, but not every step of the multiyear plan has been delineated yet. Staying up-to-date and being part of an ongoing dialog among colleagues can be a good way to figure out the most relevant pieces for your situation. Also, consider your relationships with health plan partners or broker firms when it comes to the impact of the changing health care benefits landscape and how that may affect your program. To provide some ready-access resources related to the ACA, Table 2 outlines several Web sites that may be of interest.

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1. Haberkorn J. Health policy brief: The Prevention and Public Health Fund. [cited 2013 May 5]. Available from:
2. HR 3630, the Middle Class Tax Relief and Job Creation Act.
3. Pronk NP, Kottke TE. Health promotion in health systems. In: Rippe JM, editor. Lifestyle Medicine. 2nd ed. Boca Raton (FL): CRC Press; 2013.
4. Pub. L. No. 111–148, 124 Stat. 119, to be codified as amended at scattered sections of the Internal Revenue Code and in 42 U.S.C. (March 23, 2010).
5. World Health Organization. Health impact of psychosocial hazards at work: An overview. [cited 2013 May 6]. Available from:
© 2013 American College of Sports Medicine.