Duke 2008 | ASHE | Equity and Efficiency in Health and Healthcare

Motivation: In 2006, 2.7 million workers in the United States worked in the direct care occupations, the majority of them providing nursing and personal care to America's elderly in long-term care settings. As the baby boom cohort ages, demand for long-term care is expected to increase, and yet the market for direct care workers is already characterized by high rates of turnover and reports of shortages in some geographic areas. Direct care is also an occupational group with high levels of occupational injury. In 2005, nursing aides had the third-highest level of on-the-job injury among all occupations nationwide, with the majority of complaints being musculoskeletal injuries to the back.

Objectives: The first goal of this paper is to document the incidence of work-limiting injuries in the direct care workforce and to examine the impact of injury on the rate at which direct care workers leave jobs. The second goal is to examine the factors correlated with (but not necessary causally related to) work-ending injuries, including demographic characteristics, earnings and hours histories and place of employment. The third goal is to assess the impact of state-level policies, particularly minimum training requirements for Certified Nursing Aides (C.N.A.s), nursing home staffing regulations and worker's compensation systems, on injury rates.

Methodology: This study is a panel analysis using pooled data from the 1996 and 2001 waves of the Survey of Income and Program Participation (SIPP). This dataset provides information on 3,612 spells of employment for women working as nursing, home health and personal care aides. Detailed month-level estimates of spell length and transitions into and out of these occupations are constructed using a set of unique employer identification numbers for each employer of each worker in the survey. Injuries are measured by questions asked each month about whether survey participants have any: (1) work-limiting conditions or (2) work-preventing conditions.

Results: Direct care workers are not significantly more likely than workers in occupations with comparable wages and skill requirements (i.e., sales, cleaning and household service, child care) to report a work-limiting condition while they are still employed. However, a greater fraction of direct care workers (5.38 percent) report a work-preventing condition immediately after leaving a job relative to any of the comparison groups except cleaning (6.5 percent). Among direct care workers who stop working after leaving a job, almost 1 in 5 report a work-preventing condition ? a greater fraction than in any comparison occupation. Workers who end a direct care work spell in disability are significantly older, less likely to be non-white and more likely to be employed in the home health sector compared to other workers transitioning out of direct care work jobs. While employed, these workers also earned an average of $400 per month less than workers who transition directly to another job, suggesting human capital differences between these two groups that may be related to past injuries. The second part of the analysis (ongoing) examines on the causal impact of state-level policy on disability rates using panel regression models.