States' health care reform policies are likely to have major impacts on the work demands of state and local public health agencies in the United States. Recent research estimates that health insurance coverage expansion implemented as part of the implementation of the Patient Protection and Affordable Care Act (ACA) can reduce or eliminate health care disparities among Latinos and African Americans,1 underserved populations traditionally served by governmental public health agencies and safety-net clinics. In June 2012, the Supreme Court determined that the ACA's state Medicaid expansion for the working poor (up to 138% of federal poverty level) was optional for states. Since then, state responses to Medicaid expansion have been mixed, with some states expanding Medicaid coverage for low-income uninsured populations and/or implementing their own state-run health insurance exchange.2–4 Many states have elected not to expand Medicaid and are relying on the federal health insurance exchange to operate ACA-mandated insurance markets. It is estimated that these states and counties may forgo upward of $423.6 billion in federal Medicaid funds from 2013 to 2022.5 Other states are expanding Medicaid coverage but are not taking full operational responsibility for health insurance exchange operations. Instead, they are sharing responsibility with the federal government or health insurance companies to varying degrees.
The ability of states to operate their health insurance exchange can impact the work demands of community health professionals of local health departments (LHDs) and state health departments (SHDs). State involvement in running health insurance exchanges can influence insurance premium prices, the quality and consistency of oversight of providers' quality of care and financial reporting requirements, and the level of state enforcement of health plan regulations.6 Medicaid expansion states without a state-run health insurance exchange may be less able to enforce requirements of health plan contracts with local safety-net providers to ensure access to care for newly insured low-income patients. In this way, state control of health insurance exchange operations can aid in ensuring access to care for vulnerable populations and, ultimately, influence work demands of community health professionals in public health agencies.
Community health professionals, including public health nurses, community health workers (CHWs), and health educators employed by LHDs and SHDs play an important role in improving population health and reducing racial and ethnic disparities in health. Public health agency clients are more likely to be uninsured than have ACA-mandated private insurance. Community health professionals serve as bridges between their ethnic, cultural, or geographic communities and health care providers and public health agencies. They also engage their communities to prevent chronic conditions and complications of chronic conditions through education, lifestyle change, self-management, and social support.7
Both LHDs and SHDs face several challenges of scaling up of public health programs involving community health professionals, including limited funding and the highly variable training programs and requirements across the country. The ACA expands reimbursement for select health care services provided by community health professionals who work under physicians' standing orders to conduct patient education and screenings per practice-approved protocols without a clinician's examination.8 The ACA also incentivizes risk-based payment of providers, and this can incentivize the use of community health professionals by both public health agencies and health care delivery organizations.9 States' ACA implementation choices, however, will impact opportunities for expanding community health staff-delivered services to low-income patients. Low availability of reimbursement for community health professionals may negatively impact the use and experiences of community health professionals in states without Medicaid expansion and in states without a state-run health insurance exchange.
We analyzed community health professionals' responses to the 2014 Public Health Workforce Interests and Needs Survey (PH WINS)10 , 11 to compare the work satisfaction, quality of work experiences, experiences of leadership support, and perceptions of the ACA impact on their work. Public health nurses are generally the most educated of the community health professionals, have more latitude through their licensure and protocols to provide care to vulnerable patients, and work primarily in home-based or community-based settings.12 Health educator positions are often highly variable, but unlike CHW positions, most health educator positions require a bachelor's degree, and some require certification as a community health education specialist.13 In contrast, CHW positions generally do not have licensure requirements, as the education and training of CHWs are more highly variable and pay tends to be much lower.7 CHWs are a fast-growing profession14 and have potential to play a critical role in population health management. CHWs are peer educators whose goal is to promote health in their community through information distribution, assistance, social support, and organizing community networks.15 The existing literature shows a wide diversity of roles and responsibilities for CHWs,16 although CHWs of LHDs and SHDs tend to focus on disease screening, health education, outreach, and community organizing.17
Clarifying how public health nurses, CHWs, and health educators of LHDs and SHDs compare with other agency workers in their experiences and perceptions based on differences in state ACA implementation policies may inform policy recommendations to support the effective expansion and integration of community health professionals into the public health workforce in diverse policy environments. Moreover, understanding differences among community health occupations can inform targeted workforce policies to improve work experiences and retention.
PH WINS responses of community health professionals (public health nurses, CHWs, and health educators) and other agency employees (n = 16 696) were analyzed.18 Administrative data were used to define and select the state versus local public health agency worker samples included in PH WINS. Our analyses involve 2 separate samples from 37 states: (1) 10 246 SHD respondents from 35 states and (2) 6450 LHD respondents from 15 states. Community health professionals were 3.7% (n = 386) of SHD and 16.3% (n = 1047) of LHD respondents, respectively. We conducted all analyses separately for state and local public health agency workers, as different sampling procedures and analysis weights apply to state versus local worker respondents.11
PH WINS data included 4 questions assessing worker satisfaction with (1) their job, (2) the organization, (3) their pay, and (4) their job security. These questions used 5-point response scales ranging from “very satisfied” to “very dissatisfied.” Respondents reporting “very satisfied” or “somewhat satisfied” to the questions were categorized as “satisfied,” whereas all other respondents were categorized as “not satisfied” for each of the 4 dichotomous outcome measures.
PH WINS also included questions assessing the quality of worker experiences, experiences of leadership support, and the perceived impact of the ACA on the day-to-day operations of the health department, the skills needed to do their job, and the health department focus on clinical care and population-oriented services. We converted 5-point response scales for each item to a 0 to 100 scale, where the highest category is 100 and the lowest category is 0. We then calculated the unweighted average of responses to questions within each composite measure. These scoring methods are standard for staff experience composite measures.19 Three composite measures of public health worker experiences and perceptions were constructed: (1) quality of work experiences (5 items, α = .77); (2) leadership support (8 items, α = .79); and (3) perceived ACA impacts on work (4 items, α = .77).
State ACA policy implementation categories
We focused on 2 key features of state ACA policy implementation: (1) Medicaid expansion (vs not), and (2) state-run health insurance exchange (vs any other operational arrangement). We integrated 2014 state ACA Medicaid expansion and health insurance exchange design tracking data from the Commonwealth Fund with the 2014 PH WINS data. On the basis of variation in Medicaid expansion and health insurance exchange operations among states included in the PH WINS sample, we categorized each of the sampled states into 1 of 3 ACA policy implementation categories: (1) Medicaid expansion, state-run health insurance exchange (n = 9); (2) Medicaid expansion, no state-run health insurance exchange (n = 10); and (3) No Medicaid expansion, no state-run health insurance exchange (n = 18). The Figure depicts the geographic distribution of state ACA implementation policy categories across the United States.
We conducted all analyses separately for LHD and SHD samples, as the surveys were fielded as separate samples and the predictors of LHD and SHD worker experiences are likely different due to differences in the nature of community health work in state versus local agencies. First, we compared respondent characteristics of community health professionals and all other health department workers to examine the extent to which community health professionals differed in terms of their primary program area, tenure in their job and agency, employment status, supervisory status, union membership, salary, and personal characteristics, including self-reported gender, age, race/ethnicity, and highest professional/academic degree. We used χ2 statistics for categorical group comparisons of community health professionals and all other agency workers.
Next, we compared the dichotomous satisfaction measures for each community health professional group (public health nurses, CHWs, and health educators) with all other agency employees. Logistic regression models were estimated to compare the extent to which 3 community health professional groups differed in their satisfaction with their job, organization, pay, and job security compared with other health department workers. Similarly, these “unadjusted” linear regression analyses were used to examine differences in the 3 continuous outcome measures (quality of work experiences, leadership support, and perceived impacts of the ACA on work).
Finally, we estimated multivariate random-effects logistic and linear regression models to examine the extent to which community health professionals of LHDs (n = 1047) and SHDs (n = 386) in states forgoing Medicaid expansion and expansion states without a state-run insurance exchange have lower work satisfaction, lower-quality work experiences, perceive less leadership support, and perceive a greater impact of the ACA on their work than community health professionals in states with Medicaid expansion and state-run insurance exchanges (reference category), controlling for respondent occupation, age, gender, union membership, supervisory status, and salary. The models account for the clustering of respondents within states using state random effects, and they use robust standard errors for variance estimation.20 Analyses were weighted for clustered sampling and nonresponse separately for the LHD and SHD responses.
Respondent characteristics: Community health professionals versus other public health workers
Community health professionals were more likely to work in the primary program areas of chronic disease, communicable disease, and maternal and child health than were other workers (P < .001 for SHD and LHD workers). They were also less likely to be male and less likely to be supervisors or team leaders than were other public health workers in SHDs and LHDs (Table 1). In LHDs, community health professionals were less likely to be in the lower salary bracket (<$45 000/y) than were other employees and were less likely to be unionized (80.9 vs 84.3; P < .05).
Differences in job satisfaction and work experiences of community health professionals, by job title
Among SHDs, CHWs were significantly less likely to be satisfied with their job (68.3% vs 79.0%; P < .10), the organization (49.6% vs 64.9%; P < .10), and pay (30.4% vs 48.5%; P < .05), and also report lower-quality work environments (45.6 of 100 vs 55.1; P < .10) and less leadership support (49.6 of 100 vs 55.7; P < .05) (Table 2). In contrast, SHD public health nurses were more likely to be satisfied with pay (60.9% vs 48.5%; P < .05) and reported a higher-quality work environment (63.3 of 100 vs 55.1; P< 0.05) than did other SHD workers. Both SHD and LHD health educators had similar work satisfaction and quality work experiences to all other agency workers. LHD CHWs reported lower-quality work environments (43.7 of 100 vs 55.1; P < .01) but were more likely to be satisfied with the organization (79.9% vs 68.9%; P < .01) than were other LHD workers. LHD public health nurses were more likely to report job satisfaction (86.0% vs 82.9%; P < .10) and satisfaction with the organization (73.5% vs 68.6%; P < 0.05) than were other LHD workers. SHD public health nurses (48.9 of 100), CHWs (51.5), and health educators (41.9) perceived the ACA to impact their work to a greater degree than did other SHD employees (38.7).
The association of state ACA policy implementation and community health professional job satisfaction and work experiences
In unadjusted analyses (Table 3), there were no statistically significant differences in community health professional job satisfaction, satisfaction with the organization, or experiences of leadership support by state ACA implementation policy category. The work satisfaction and experiences of community health professionals in nonexpansion states differed for SHD and LHD worker populations. In nonexpansion states, LHD community health professionals were less satisfied with their pay but more satisfied with their job security than community health professionals in other states. In contrast, SHD workers of nonexpansion states were less satisfied with both their pay and job security. LHD workers in Medicaid expansion states with state-run health insurance exchange operations were more satisfied with their pay but less satisfied with their job security than were workers in other states. The quality of LHD worker experiences was lower for Medicaid expansion states without a state-run health insurance exchange than expansion states with a state-run health insurance exchange. Community health professionals in Medicaid expansion states with state-run health insurance exchanges perceived less impact of the ACA on their work than did workers in states with other ACA policy categories.
In multivariate regression analyses (Table 4) that controlled for respondent characteristics, there were no differences in work satisfaction (including pay and job security) by state ACA implementation policy category. In adjusted analyses, community health professionals in states without Medicaid expansion reported worse leadership support (β = −6.04; P < .05). The quality of work experiences and the perceived impact of the ACA, however, were no different between LHD and SHD workers in nonexpansion states and expansion states with state-run health insurance exchanges. Upon adjustment, the results related to quality of work experiences were slightly attenuated, whereas results related to leadership support shifted. In these adjusted analyses, LHD community health professionals in expansion states without a state-run health insurance exchange reported lower-quality work experiences (β = −13.06; P < .001) and less leadership support (β = −11.5; P < .05) than LHD community health professionals in expansion states with state-run health insurance exchanges.
Adjusted analyses also revealed important differences across community health professional occupations. Differences between occupational categories (public health nurse vs CHW vs health educator) were attenuated. The notable exception was the quality of worker experiences, where CHWs had lower-quality work experiences than public health nurses. LHD community health professionals in the lowest salary category (<$45 000/y) were less likely to be satisfied with their job (odds ratio [OR] = 0.43; P < .001) and pay (OR = 0.21; P < .001) than professionals making more than $65 000/y, although salary was unrelated to either satisfaction with the organization or job security. Unionized LHD community health professionals reported much more positive experiences of leadership support than nonunionized professionals (β = 12.8; P < .001) (Table 4).
Community health professionals both in states forgoing Medicaid expansion and in expansion states without a state-run health insurance exchange reported worse experiences of leadership support, possibly because state control of health insurance exchange operations may constrain a state's ability to enforce requirements of contracts with local safety-net providers to ensure access to care for low-income patients, potentially increasing demands on the community health professional workforce. Less state control of health insurance exchange operations, by extension, may negatively impact community health professionals' perceptions of leadership support, as leaders may be less able to remove barriers to access to care because they are more limited in their ability to enforce requirements of health plan contracts and to adjust health insurance policies based on local and state-specific needs. Given the potential greater demand for public health services in expansion states and local jurisdictions without a state-run health insurance exchange, public health agencies in these states may face more difficulty in retaining their community health professional workforce, due to financial constraints and unsustainable work demands for existing staff. In the future, it is possible that residents in states that deferred health insurance exchange operations to the federal government will be unable to receive tax subsidies to help individuals purchase insurance.21 This may exacerbate uninsured rate differences between Medicaid expansion states with and without state-run health insurance exchanges over time, thereby increasing work demands of community health professionals in expansion states without state-run exchanges.
Importantly, our analyses uncovered that CHWs of both LHDs and SHDs reported lower-quality work experiences than other workers, suggesting opportunities for agency leadership to further clarify, develop, and support their evolving roles in promoting and protecting the health of low-income and vulnerable populations. Given the highly variable training and diverse expectations and responsibilities of CHWs in conducting disease screening, health education, outreach, and community organizing, and their relatively lower pay for work that requires interpersonal, organizational, and clinical skills, it is not surprising that CHWs have worse experiences. Augmented policy efforts to formalize CHW professional competencies in public health practice22 , 23 and public health accreditation24 may aid in improving the quality of work environment and relatively worse experiences of leadership support.
Our study has some important limitations. We are unable to determine whether the association of state ACA implementation and the work experiences of SHD and LHD community health professionals is a causal relationship. Because there are only 37 states, there was insufficient statistical power to examine the association of state ACA implementation policies while controlling for many other state-level effects. As a result, we had to balance the need for model parsimony and improving causal inference through statistical adjustment. We opted to compare states by variation in 2 different ACA policy implementation decisions, controlling for important respondent characteristics, understanding that there are many factors that shape public health workforce experiences in states, and that the causal relationships cannot be assessed with the data we have. Also, with the small sample sizes for regression analyses focused on the subsample of community health professionals, we could only detect large effect sizes with statistical significance. Nevertheless, we found fairly strong relationships between state ACA implementation policies and community health professional work experiences, even when controlling for several important respondent characteristics. Finally, SHD community health professionals perceived the ACA to have a greater potential impact on their work than other SHD workers. Recent analyses of the SHD workforce indicate that SHDs had layoffs of public health nurses and health educators,25 potentially explaining greater perceived impact of the ACA on their work. Data on layoffs for each of the agencies could aid in disentangling the impact of layoffs on worker experiences. Future analyses, when data become available, should include the role of worker experience to the occurrence of layoffs during the state ACA implementation.
The potential for community health professionals to aid in population health management may be influenced by states' ACA policy implementation choices,22 including the expansion of Medicaid coverage and the management of health insurance exchange operations. To scale up public health programs involving public health nurses, CHWs, and health educators, reimbursement for their services by payers and promoting supportive work environments will be necessary for efforts to develop and retain community health professionals in LHDs, whose roles and responsibilities may be more likely to be adapted as state ACA implementation unfolds. Given differences in the budgetary and political constraints and opportunities among states, continued monitoring of community health professional work experiences and expectations by state and ACA implementation policy environments is warranted to ensure that agency leaders support community health professionals in their frontline work with American communities.
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Keywords:Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Patient Protection and Affordable Care Act (ACA); community health workers; health departments; public health nurses; public health workforce