All right, well, welcome, everybody. I'm going to get started. I'm sure people will trickle in, but I am so happy to have you here. My name is Andre Montoya Bartholomew. I'm a faculty with the University of New Mexico Preventive Medicine Program, but I am trained in occupational medicine at the Health Partners Program in Twin Cities. Also a recovering surgeon. I see some familiar faces here, but honestly, I'm just really happy to be giving a session. Once this is done, I'll be able to relax a little bit and enjoy the rest of the conference. This particular work has really been a passion of mine, but it is still a work in progress. For that reason, I really encourage you to think of any concerns, complaints, questions, requests for citation, anything that you have, write it down. I would be very interested because I really want to draw on the wisdom of this group. It's one of the best things I found about ACOM is that there's always somebody who has an opinion and somebody who's willing to share it with you, and it makes your work better. This is supposed to be a conversation about workplace policy and regulation. As occupational medicine docs, we really take pride in the fact that of all the medical specialties, we understand what it is to apply regulation to health. We understand the connection between work and health. How does work affect health? How does health affect work? How do we keep people productive and happy and healthy? From here derives all of our duties in medical surveillance, and DOT pilot exams, and work comp, medical legal causation, IMEs, everything. This is our jam. This is where we live, work, and health, and government regulation, and the employer. All of those things mixed into a soup and all trying to fight with each other. Speaking of regulation, we're going to start with someplace familiar. First of all, OSHA. First of all, you see the diagram, work, health. This one goes through workplace safety. This is OSHA, and I don't have to convince you that OSHA is good for health, but I'm going to try anyway. Since passage of OSHA in 1970, there's been decreased illnesses and exposures from regulated hazards. We know that. There's also been decreased fatal and non-fatal injuries by about two-thirds since it was passed. Inspections are associated with a decrease in injury rates and costs, and that effect seems to augment when there are citations issued, understandably. Finally, many authors have talked about a general deterrence effect in addition to the specific deterrence effect. That is, within a particular geographic area or a particular industry, if OSHA has a presence, then everybody ends up being safer and the injury rates go down, right? So OSHA, good for health. Next, this is the other place where we live, workers' comp. And workers' comp is, as you know, a no-fault system. It's for providing medical care for work-related conditions, disability, indemnity, vocational training, death benefits. And it's not really best understood as a primary or secondary prevention program, but rather it's like a tertiary program. Employers who retain workers' compensation are more likely to invest in a safe workplace. They are more likely to have decreased injuries, especially if the work comp insurer applies experience ratings to that particular company. But the real—oh, and, you know, provision of reduced-demand work through our restrictions really seems to speed return to work. It decreases eventual disability. But the biggest thing that work comp does is it really stabilizes that relationship between the employer and the employee. There's less litigation, fewer costs, less bad feelings, better psychosocial relationships. And ultimately, it's good for everybody, right? There's fewer lawsuits. So work comp, also good for health. I don't think I'm going to get any objections quite yet. So I'm going to make a quick note about this framework. If you'll notice, I've added a couple of orange bars here. The very top one, OSHA, of course, is a federal legislation that goes on the very top bar. As you move down the green arrow, we move through state regulations, and that would be where work comp generally lives. Below that is the employer policy. Now, the expectation is that federal law would set the floor, the TWA, if you will, right? That's the floor. This is what's required. States can augment that protection if they like, and employers can add additional protections if they like. And so, in general, we want to think of this as increasing protection as you go down the arrow. But I'll also make the point that as you go down that arrow, it really requires each of those levels to do their job and to do it to the best safety of the workers, right? And for example, at the federal level, you do have OSHA, but it requires the executive branch, while OSHA is the legislative product. It also requires the executive branch to enforce. That requires funding, it requires political will, so on and so forth. They write rules. As you go down, states can't drop below that floor, but they have some leeway in how well they enforce as well. And then employers can decide to increase those protections, but they can also decide to evade or defy those regulations. And so it can go either way. It adds some complexity, but I want to get this out of the way because this is how we're going to frame the rest of the conversation. So far, so these are the questions that you're going to help me tackle today. First of all, can we approach workplace policy and regulation as a work-related exposure, just as we would for lead or asbestos or silica, right? And in viewing the evidence so far, just with WorkComp and OSHA, I would say that we could, in principle, understand these protections as a work-related protection slash exposure to the greater extent that you're protected, you're going to have better health outcomes. Number two, what other policy regulations are work-related? There must be others, right, that affect health in the workplace. And by that, I mean that they are intrinsic to, they're essential to, they're inextricable from the workplace. Using this framework, number three, using this framework, can we identify populations who may be at greater risk? Can we identify populations who are covered but maybe don't need to be? Can we identify populations that should be covered but are not, and so therefore are not gaining the protections and will suffer worse health outcomes? So these last two questions, those are the things that we want to answer today. I'm going to put a yes on number one and then question marks. So we're going to tackle number two first. And in doing so, I'm really going to ask you to think bigger, you know, let's get really creative with this. Let's just start here. Health effects. First of all, you know, let's start with food. This is one of the most fundamental things that we need as humans. Some would call these a social determinant of health. And so it is important to health, but let's prove that. Adults who eat a healthy diet live longer, have lower risk of obesity, heart disease, certain cancers. This comes from the CDC. Healthy diet over the course of a working life, so that's over 20-year-olds, have a life expectancy, healthy diet, has a life expectancy that's 10 to 13 years longer than somebody who eats the typical Western diet. This is enormous. Food is incredibly important to health. Healthy food, access to healthy food. The Global Burden of Diseases Survey reported that 11 million deaths per year with 255 million dailies, that's disability-adjusted life years, lost due to poor diet and lack of access to healthy food. And, you know, by contrast, that is more than tobacco smoking. Diet is incredibly important. So I could go on and on. Good food, good for your health, okay, next step. Now according to the, so how do you access healthy food? Well, the first thing that you can say is it's dependent on income. This comes from the USDA. And availability. Generally, you have less availability when you live in a low income or a rural area. This is where, you know, we have conversations about food deserts and food swamps, but primarily it comes back to income, and that's why I added that right there. So hold that thought. Next, let's think of another social determinant of health. What else is incredibly important for human thriving? Let's talk about housing. So Office of Prevention and, Office of Disease Prevention and Health Promotion, it's part of Healthy People 2030, reviews both housing and housing quality in their framework. First of all, do you have housing? And second of all, what's the quality of that housing? And this can be anything from mold to lead exposure to availability of heat and cooling, fire hazard, overcrowding, infectious disease, you know, all the things that make a good immediate living space. And there's the environment outside of that. That would be neighborhood factors, crime, violence, environmental contamination, and so on. This is an independent determinant of chronic disease and injury is housing and housing quality. Now, on one extreme, you have none of that. Many of us live in houses that don't have lead exposure and don't have lack of access to heating and cooling and so on. On the other extreme is chronic homelessness, which leads to a multitude of adverse health outcomes and a life expectancy decrement of probably about 20 years. The average life expectancy is about 48 years with chronic homelessness. Obviously, housing, also incredibly important for health. Now, oh, and conversely, there's evidence that providing housing improves health, decreases medical costs, decreases medical costs, and so on. So providing housing is a good idea, and from this comes that housing first model, right? So how do you get housing? Well, according to the National Homelessness Law Center, they cite the U.S. Conference of Mayors, the top reasons for housing insecurity, follow me, lack of affordable housing, income, unemployment, again, income, poverty, income, and low wages, in that order. So income, income, income, income leads to your ability to find good housing and good quality housing. So two is a coincidence so far. Let's go for a trend. The next thing that we're going to talk about is education. So good healthy life needs education. Education level shows a strong positive association with health and lower rates of just about any kind of disease that you can think of, right? An individual with a graduate education, as compared to somebody with not a high school diploma, has an increased life expectancy of 10 to 15 years, again, enormous. Better health is generally explained by resultant, is usually explained because somebody will have higher income, they'll have better housing quality, healthier food, more access to health insurance, so on and so forth. There are many, many reasons, and some of these we've talked about already. How do you access education? Well, it really depends on the neighborhood that you live in, and remember that property tax determines the quality of the schooling system. Effects of poverty, discrimination, bullying, again, in that order, most of them having to do with income. So here we go again. Income relates to food, housing, and education. Now we have a trend. So is any of this surprising? Not really. Not really. And we have three things that generally define socioeconomic status, and of those three, let's see, I think it was higher education, income, and social class are three of the most common. But within those, the criteria that have the greatest effect on mortality are wealth and recent income. So obviously, this is an incredibly powerful social determinant of health, so powerful to the point that we control for it in most studies. We actually control it out of our results because, oh, I don't know, maybe we just assume that income is as immutable as age or sex or something like that. But we have to ask the question now, where does income come from? And if you look at the statistics, out of tax filers in the United States, make sure I'm on the right side, yep. Out of tax filers in the United States, 79% receive wages and salary. If you take retirement income out of that, that goes up to about 84%. So the vast majority of people receive their money, their income, through wages and salary. And just to be clear, the reason why I frame it this way is because those people who are earning wages and salary do so because they have work to gain skills, they spend time, they spend effort, the sweat of their brow, in order to earn money. That's the exchange, right? This is not somebody who earns income through passive means, through investments and dividends and that sort of thing. So income is work-related, certainly for those 84%. I would go as far as to say that it's absolutely inextricable from work is income. And we're talking about workers. I mean, honestly, let's be honest, the reason why I'm getting so deep into this is because we are the work doctors, right? We're not capital investment doctors, we're not passive income doctors, we're workers doctors. These are the people that we're talking about. Anyway, back to the through line. And then we have to ask the third question. First of all, good for health? Yes. Second, related to work? Yes. Number three, what is the regulation that dictates this? And in this case, the primary one is the Fair Labor Standards Act. You probably have heard of it. It was passed back in 1938, and it set a minimum wage and increased pay for overtime. Back when it was passed, this is just an oddity, the minimum wage is $0.25 an hour. Nowadays, strictly speaking, it's not that much higher. It was raised in 2009, and it's $7.25 an hour. So the question that we have to ask is, at a minimum floor, at the TWA, at the very top, is that enough to live on? Let's say that, you know, I was talking to my financial advisor, and she's like, oh, yeah, you know what? Rent should constitute about 30% of your income. And I was like, all right, well, 30% of the income, but if you do the math, somebody who is working minimum wage jobs in the most affordable cities in the nation would have to work three and a half full-time jobs in order to make rent for a two-bedroom apartment. Three and a half jobs, I promise, even when I was in surgery residency, I did not work that hard, right? That's just not enough. And by another measure, fully 60% of people in the country live paycheck to paycheck. About one in three, only one in three have cash on hand to cover a surprise or emergency $400 expense. And so that gives you an idea of where wealth is in this country. So once again, we return to the framework. Fair Labor Standards Act sets the floor, $7.25 an hour. States may increase that, right? Employers will increase that further, and that's why you and me earn doctor money. And that leads to our ability to buy food and housing and access education. The Fair Labor Standards Act also prohibited what they called oppressive child labor, and I hope we can get back to that in a moment. So let's continue. What other fundamental needs can we think of? What other social determinants of health? Well, how about health insurance? I said health care there. It's supposed to be health insurance. As described by the Healthy People 2030 and others, the most important determinant of health access is health insurance, and so that's really what we're talking about here. The other two factors are transportation and availability of health care services. Again, rural settings, low-income settings tend to have less health care access. But number one, health insurance. Number two, transportation. Number three, availability of services. So is it health-related? Well, disparities in health insurance coverage are definitely shown in the literature to be associated with disparities in health. Health coverage is associated with improved access and health monitoring. And so, yeah, I mean, health insurance, health access leads to better health. But is it work-related? Well, as it turns out, 54 percent of individuals receive their health insurance through an employer. It's a big proportion, a majority even. And I'm even going to go farther to say that the next largest proportion of people receive their care through Medicaid. As you know, the criteria for accessing Medicaid has to do with income, which has to do with work. So whether you're getting it through your employer or whether you're unable to get it through your employer, it still comes back to the workplace and the conditions of employment. I was dismayed and, you know, unfortunately surprised to hear that many of the MAs in one of my former clinics, they couldn't afford the health insurance that was provided by the employer. And so they had to access Medicaid. And so these aren't just individuals who are not employed. A vast majority of people who access Medicaid are working. They just don't make enough money to be able to get it through the employer, even when it's offered. All right? All right. So where are we going to go next? Oh, so it's associated with work. I'm going to add to that a little bit and say that access to health insurance, access to, access to wealth also affects your access to healthcare. Did you know that 62% of bankruptcies in the United States are due to medical bills, inability to cover medical bills? And finally, we mentioned that healthcare access is dependent on transportation, also related to income. Availability of resources depends on where you live, also related to income. And so health insurance is very closely related to health. It's very closely related to work. And we got to talk about regulations. So regulations, for the most part, healthcare is related, is, healthcare is regulated by various legislations including ERISA, the Employee Retirement Income Security Act, and the American, I'm sorry, the Affordable Care Act, COBRA, HIPAA, various other legislations. And that defines access. All right. I'm now working at UNM, and I have to say that I'm very, very happy with the benefits there. But that comes from my employment, right? And that comes from the fact that I've got doctor money, and I work in a doctor place. All right. Next, let's talk about retirement benefits. Are they good for health? Well, there's some evidence that retirement is good for your health, probably more for your mental health, maybe for your physical health. The evidence is conflicting. But we're not talking about the act of retirement. We're actually talking about retirement funds, retirement benefits. And so these are financial benefits. So after a lifetime of contribution to society in the companies that we oversee, people look forward to their golden years. You know, they want to have access to healthcare and food and housing and be able to visit their grandkids, go to Rolling Stone concerts. For me, it's not Rolling Stones. It's probably Red Hot Chili Peppers or something. But retirement is fundamentally income, and that's what allows you to do that. The people who have more retirement are the people that earned more income over the course of their career, not only through 401Ks or pensions or being able to set money aside in other investment vehicles. And so you have an ability to do that. Sorry. I'm going to get back to my notes. Okay. Good. So is it related to work? Well, yes. Yes, it is. And it really has to do with the fact that, you know, not only just by definition, retirement is the period of your life where you're done working and you've earned the ability to go visit your grandkids and start a garden and all of that, but also because the access to retirement funds as a financial benefit comes from the fact that you earned money and were employed throughout your life. So this is absolutely related to work as well. To complete the framework, retirement plans are related. Let's see. They are regulated by the school. Oh, no. That bar is over the thing. So it comes from ERISA as well. It also comes from the Social Security Act and an enormous body of tax law. That's really where retirement is regulated at the federal level. Of course, states add more employers. Our employers probably offer additional vehicles for retirement as a draw to come and work for them. And so there, you go down that arrow, same as before. So let's talk about one more thing. Just employment, access to work. I mean, that's a straight arrow all the way down from work down to health. And here I know that I'm preaching to the choir. I'm preaching to the clergy here. We all know that work is good for health. I make the residents every year read the first chapter of the AMA Guides to Workability, and it says work is good for health. Regaining work is bad for health. Regaining work is good for health. I mean, it's in the literature, and I don't have to convince you of that. But what determines employment or non-employment? Well, regarding the causes on a system level, most sources will refer to the market forces, right? The invisible hand. But I have to point out that it's really not that invisible. It lays within this framework. It depends on federal policy, state policy, whether it's for employers to hire people or lay them off and send those jobs over to a low-income country where they decrease labor costs, right? So this is not an invisible hand. It's all right here. As a couple of examples, remember that the Federal Reserve raised and raised interest rates over the last couple years. And with the knowledge, certainly, and maybe even the intention of decreasing employment, on access to work, which affects? So, laws at federal and state levels generally attempt to increase employment. Employers may lay off workers or they may hire. Every level makes its contribution. Now, I'm going to be very honest with you. I am not an economist. I'm a physician. But at the point where I can draw a straight arrow from work to health, and it's in the AMA guides, and I teach the residents every year, my assertion is that we really should be involved in this. At the point where people are unable to work because of policy changes at this level, we need to be able to know about it. We need to be able to comment on it, because it affects worker health. Relevant to this topic, unemployment benefits are regulated by the Federal Unemployment Tax Act, so otherwise known as FUTA. There it is. As well as the ADA and the Social Security Act. But there is evidence that unemployment is bad for health. But the evidence shows that greater unemployment benefits, even when you're not working, helps. It improves your health. So we've really filled out this chart. I'm not going to go to the next one quite yet. This is not for you. This is for me. Deep breath. I know that I've been giving you a lot of information. I've just been dumping it on you. I'm moving pretty quick, because I want to get to the question section. But ready? Okay. Let's go. So we really filled out this chart. What do we know now? Work? Good for health. Housing? Good for health. Food, education, health care, retirement, all good for health. Employment? Good for health. Also, all work-related. Some of them through this intermediary, well, most of them, through the intermediary of income. All of them, inextricable from work, definitely have an enormous effect on health. And I'm going to add one more. I'm going to add one more. Sorry about that. One more. But it's not an arrow. Oh, where did it go? Let's see the APHA. There it is. It's an orange bar. Unionization. Unionization is determined by the... I'm going to talk about that in a second. So I know before we get into unionization, because this can be a more controversial topic, you're going to be like, oh, there's going to be people who will say, no, we can't get involved in the relations between employers and employees. However, I'm going to make the point that unionization is good for health, and obviously it's related to the workplace. In fact, the health benefits are so large that the American Public Health Association has put out multiple position statements demonstrating basically a literature review of all the positive effects of unionization or access to unionization. They advocate strongly for the ability of employees to join unions. For the first part, unionization increases wages, income, right? It even increases wages for non-unionized workers in the same geographic area or in the same industry of a unionized employees. Furthermore, it leads to improved job security, autonomy, control over the workplace. It democratizes the workplace. And I don't know if you've ever tried to get your boss to do something, but your workplace is probably an autocracy, kind of like mine. My boss is right here. She's the king. She's the king right there. It democratizes the workplace to the point where workers have some control over it. And when it comes down to it, employee unions explicitly consider and address every one of these social determinants of health, whether it's income, work hours, access to health care, retirement, employment generally, unemployment benefits, control of workplace hazards, treatment for work-related conditions, unions address it. So it's good for health, and it's related to the workplace. So, oh, and sorry. I was going to say that the governing legislation is the National Labor Relations Act. This was passed back in 1935, and it really defines and regulates that relationship between employee unions and employers. Now, I think we're doing pretty well. I mean, so far we've answered question number one. So far we've answered question number one. Can we approach workplace policy and regulation as a work-related exposure? I would say yes. I mean, not only do we have OSHA and work comp, or I'm sorry, OSHA and, yeah, OSHA and work comp, but we have all of these other factors as well, and each one of them seems to have an effect on work, generally positive. Number two, can we, are there other policy regulations? Sorry, I already answered that. Yes, there are other policy and regulations that do the same thing. They are intrinsic to, they're essential to, they're inextricable from the workplace, and they do have an effect on health. Now, question number three, can we identify worker populations who may be at increased risk from lack of coverage? Generally lack of coverage, because we're assuming that these are generally a positive effect on health, right? So I'm going to put a provisional yes on each one of these. Yes, number two, wait, where's number two? Ah, there it is, and number three, yes. Yes, yes, and yes, but that one gets an asterisk, because we're going to talk about it now. So we're going to look at this from two perspectives. First of all, we're going to look at individual, remember which direction we're going. First of all, we're going to look at individual protections, usually dictated by the federal level legislation. Now, this might be ACA, or it might be the National Labor Relations Act, it might be the Federal Labor Standards Act, OSHA, so on and so forth, and we're going to give examples. Number two, we're going to look at individual worker populations and see how those individual worker populations may be covered or uncovered by a variety of different protections, and the implicit question is here, does it make sense? Obviously, I'm a doctor, I don't have to be protected from silica, because I'm not sawing concrete in my clinic. It doesn't make sense for me to have certain protections. Is that the case here? Are there worker populations, discreet, go back to your public health, right, discreet, identifiable, preventable exposures from lack of protection from these regulations and policies, who would benefit and should benefit from them? All right? Okay, so let's go. Number one, let's go back to the beginning, OSHA. Let's see if that pops up. There it is. Okay, so here's an example. As of 2023, construction workers in Texas are no longer entitled to water breaks. There are similar legislations here in Florida. I believe one of them was passed, which, as opposed to preventing it, says local jurisdictions can't pass protections for water breaks for construction workers. What? Have you, do you know how hot it is on top of a roof in Florida or Texas? Does it make sense that construction workers can't have water breaks? And what it essentially does, you see the red box, what it essentially does is OSHA does not protect, right? The state is not protecting or actively preventing protection, and the employer can decide to do whatever they want. They can still give water breaks, but they don't have to. And so, does it make sense? And what are the health effects? People die in fields in California because they haven't had water breaks. Over the last several years, they've actually gotten legislation to help push that along and provide water breaks, but it's still dependent on the employer to follow it. Another example. Black lung was nearly eradicated in the 1990s, but in 2018 they found a cluster, which came from, you know, the early 2010s, of black lung, hundreds of patients. And as you know, the latency between exposure and progressive, help me out, progressive pulmonary fibrosis is years, and so this hadn't been happening for a while. And so, where is the fault here? Because MSHA hasn't changed, obviously. The federal level hasn't changed. Maybe enforcement has changed. Maybe the legislation hasn't changed, but the executive enforcement hasn't changed. Maybe there are judicial opinions which weakened the ability of the Mine Safety Administration to apply these regulations, and then there's the possibility that employers were just not protecting their people the way that they should. I'm not here to answer that question. I'm just here to pose it based on this framework. Another example. All right. Next, let's move on to work comp. Thank you for the really dramatic picture here, but the fact is, in 2015, ProPublica released a report demonstrating that work comp insurers were paying out at the lowest rate for work-related conditions since the 1970s. Why? Well, across many states, remember this is a state-level protection. New laws cut medical and disability benefits, reduced coverage durations, limited employers who had to carry work comp, provided increasing control to insurers to decline or to, how do you say, dictate treatment. That's on the state level. And as you know, some employers, so that's at the state level, and as you know, some employers are really aggressive about keeping their work comp costs low, and granted, many of them do that by improving safety, awesome, or by evading regulation. We know who those companies are. Yeah, we know who those companies are. And, you know, some of them are more aggressive about it, but the fact is, that's at the employer level. So at multiple levels here, we end up with a worker population, perhaps discrete worker populations, who are less protected. And what does that do for health for this work-related exposure? Next. Fair Labor Standards Act. So who doesn't need a minimum wage? Well, apparently, when they passed it, they decided that certain discrete worker populations didn't need a minimum wage, or they didn't need overtime. And it's a really, it's kind of a random list. If you look at the original text, including many farm workers, seasonal and recreational establishments, somehow, dealership mechanics, federal criminal investigators, railroad employees, movie theater employees, tip your movie theater employee next time you get a chance, and other really oddly specific jobs. But they were specifically excluded at the federal level within the legislation. We also have to talk about wage theft. And this is an employer level effect. It takes many forms, unpaid hours, unpaid overtime, denied meal breaks, minimum wage violations. There's a whole host of ways that you can do this. In fact, some employers will promote somebody to a managerial position, so that they can place them on salary, and then they essentially work them just as hard, or even harder. And they end up earning less, maybe even less than minimum wage. So there's a lot of ways to do it. But the estimate is that as much as $15 billion a year is stolen from workers in this country annually. Mostly low-wage workers, and this won't surprise you. None of this should surprise you. Mostly low-wage workers, women, immigrants, people of color, young workers have their wages stolen. $15 billion. And I'm going to give you one more personal example. Medical residents. Medical residents do not receive overtime. How many hours a week did you work during residency? Lots. Lots and lots. Did you get overtime for it? No, you didn't get overtime for it, because there's a carve out within the federal level Fair Labor Standards Act for what's it called? Learned, learned, I think it's learned, professional exemption. And this is for people who study very hard to gain high-level skills they don't get overtime. Right? Oh, and by the way, medical residents and fellows, you may know, are beginning to form unions. And that can counteract the fact that they're uncovered at higher levels. So there's a protective factor there. All right. Next up. National Labor Relations Act. Despite the health benefits described in the APHA literature of unionization in the U.S. has plummeted since 1970 because of erosion, honestly erosion at all different levels. At the federal level, both within the executive, the legislative, the judiciary, at state level in the same way, employer suppression of unionization. You may have heard in the news that Amazon and Starbucks and other organizations have been judicially censured for illegal anti-union practices recently. It was described by one judge as egregious and widespread misconduct. Jeez, man. If my boss wrote me a letter saying that I was guilty of egregious and widespread misconduct, I would be embarrassed. Similar tactics seem to be used by Tesla, Trader Joe's, Apple, Chipotle, probably some of your other favorite brands. It's a business decision. It's written into their business model, maybe not explicitly. But there are entire consulting firms who show companies how to keep their workers from unionizing. They've got all kinds of tactics, right? And we have an indication as to how far they'll go to dealing with unions. At this very moment, Amazon, SpaceX, Trader Joe's are involved in a judicial fight at the Supreme Court level as to whether the National Labor Relations Act is unconstitutional. They're going straight for the core of this protection right now. And what does that do for health? Sorry, got to tie it all together. Next thing. Healthcare access. Health coverage. So the MMWR put out this report describing several different occupations. I love this stuff. I love it when they break it apart by occupation. So if you look at, say, architecture, engineering, community and social services, those kinds of occupations, the uninsurance rate, lack of insurance, is down around 3%. It's pretty good, right? But you look at farming, fishing, forestry, building and grounds maintenance, construction and extraction, food prep and serving related, you already know where this is going. It's up around 20, 30, 40% uninsurance within those occupational populations. Defined occupational populations. This is epidemiology at its finest. Employer-sponsored health plans have been known to variably refuse coverage for reproductive healthcare. That's not on here. But who does that affect? As an occupational population, birthing people, women, contraception and abortion restricted. It affects health and it's related to their workplace. The bottom one here is not healthcare specifically, but it was only last year. I think it was last year that railroad workers now have sick leave. They didn't have sick leave before this, right? And this was not a law that was passed. This was not a federal law that gave them sick leave all of a sudden. This was not a state law. This was the fact that the unions went on strike and they threatened not to work, that the companies promised to give sick leave. And so in some way, you can think of this as the National Labor Relations Act compensating for the Fair Labor Standards Act or some other legislation which would provide sick leave to workers. So those are several different protections, examples. Oh, obviously there are a absolute multitude of examples that we could talk about. But we're gonna shift gears here and we're gonna talk about specific occupational populations. Now, as we do this, think about what could have possibly gone on in history that would mean that these specific occupational populations just didn't get covered. Think about it that way. I'm not gonna answer it for you, but as we go through these populations, you might have some ideas. First one is farm workers. They're generally excluded from overtime pay. They lack various other benefits. They're paid, sometimes they're paid piecework. You've heard about piecework. You get $1.50 for a bushel of apples or something, but it's paid by the basket, by the work that's done, which sometimes lead to them being paid less the minimum wage. As a result, 30% of farm workers have family incomes below the federal poverty level. 30% of families are below the federal poverty level. They're prohibited from organizing under the National Labor Relations Act. They said, nah, you don't get to organize. They're poorly covered by OSHA. We all know that. I gotta ask the question, how does that make sense? Because agriculture, as we know, is one of the most dangerous occupations in the country. And so it doesn't make sense for them to be uncovered by OSHA. It also doesn't make sense for them to work as hard as they do and still be in poverty. Agriculture, and I'm gonna take a little sidetrack over to housing. Often, agricultural workers are provided on-site housing because they gotta be there, right? They gotta be at the farm. Occasionally, this is subsidized by the federal government, and that's only for H-2A workers, but only about 10% of agricultural workers are H-2A workers. The rest of them generally pay back to the farm housing costs. The rent is subtracted from their wages, and so you can see lots of examples of inflated housing prices, poor living conditions. It's very common, especially since they can't organize. Next one, domestic workers. Domestic workers are excluded from overtime pay under the Fair Labor Standards Act. They are also excluded from sexual harassment protections. What? How does that make sense? And occasionally for minimum wage, depending on where exactly they work. They're also prohibited from unionizing, so you can see a trend here. I'm gonna give you a little hint. Who works agriculture? Who worked agriculture when these laws were passed? Who works them now, right? So that's domestic workers. Next, ah, this is my favorite, incarcerated workers. If you know me, you know that I've done a little bit of work on this. Incarcerated workers are incarcerated. Let me put it a different way. There are lots and lots of people in prison and jails who do work in this country, and it's not just stamping license plates or mopping floors, they do that, but it's also other levels of manufacturing, telemarketing, they run dairy farms, they do agriculture, they do welding. There's one program in California that teaches them underwater welding, which is fantastic. It really helps the recidivism rates, and so that's one way that it's well done. The fact is they do a lot of, oh, they sewed Victoria's Secret underwear for years before Victoria's Secret got called out on it, and they were like, oh, we don't do incarcerated, we don't do slave labor, and they stopped. But it's all through the economy, and they do work, which means that they're exposed to all of the hazards of agriculture and construction and manufacturing and mopping floors and stamping license plates and making underwear. So what kind of protections do they have? I'm going to give you the punchline quick. Almost none of them, like almost completely uncovered by any of these protections. All of that, and the short answer is that a lot of these protections are given to the institution, to the carceral institution to provide workplace safety. They're probably doing it. Work comp, they're probably taking care of it, but there's very little oversight and there's very little regulation. And so in that sense, the top three bars go away. The employer bar, or yeah, the employer bar turns into a prison bar, and unionization is not technically outlawed, but the institution has wide leeway to decide whether they're going to allow their people to unionize. Do you think they are? No. They call it safety. Anyway, so that's incarcerated workers. Oh, and there's almost no medical or public health literature on that. So we have no idea what their injury and illness rates are. We have no idea what their exposures are. Gig workers, this one I want to spend a little bit more time with. The past decades has seen a rise in non-traditional work arrangements. Now you've probably heard it referred to as gig work or temporary work, contingent work, contract, freelance, on-demand work. There's a lot of words for it, but you have seen them in your clinic. The most common situation is probably where somebody comes in as a temp, and they're told that during that three months, six months, nine months, whatever the duration is, they prove themselves to the company, and maybe they'll get a full-time position. The reason is that employers figured out that restructuring work under these informal structures allowed them to avoid providing benefits. They would call them a contract worker, and they wouldn't have to provide health insurance, unemployment insurance, paid time off, work comp, and they save a lot of money through this. That's the point. It's also the same reason it's been referred to as precarious employment. Recognizing the increased risk, ad app-based ride share drivers have sued Uber and Lyft, asserting that they, essentially, that they're being exploited. And if you remember, most recently, there were the auto worker strikes. One of their major demands had to do with getting rid of that temp worker tier of workers because they would be standing next to this temp worker doing exactly the same type of work, and this person next to them is earning half of what they earn. And the fact is, when this person is earning half, it's gonna make me less likely to buck management because I don't wanna be a temp worker, and the temp worker doesn't wanna lose their job, and so you can see how this power dynamics play out in the workplace through the conditions of employment. Ah, here we go, child labor. So, I've often made the joke that if we're seeing children in our clinic, then something's wrong. It's not where I got into occupational medicine. I'm not good at dealing with kids, but it's getting less funny, honestly, nowadays, because in the past two years, even though the Fair Labor Standards Act prohibited what it called oppressive child labor, many states have introduced or passed legislation permitting children to work in more hazardous occupations for longer hours, sometimes for less than minimum wage, and providing legal immunity for employers. I think that's happened in Florida. In publicized cases, kids have died in hazardous occupations. Meat cutting, agriculture, construction, manufacturing, lumber yards. I mean, come on, what are kids doing in these situations? Exposed to these hazards. Roughly about 50 to 100 a year. The data is difficult to obtain, but child labor violations are also on the rise, and so companies are being called out for it more often. This is work. This is health. We are the work doctors. It seems that we should be involved in this. So, earlier, I had asked you to step way back and ask that question, right? We live, let me turn it up. We live way up there in that corner. OSHA, workers' compensation, but it turns out if we wanna call ourselves the work doctors, we need to understand all the ways that work affects health through these various mechanisms, and how to understand it. Essentially, what we're doing here is defining a map for the levers to pull. Where do these protections come from? Where are they taken away? Where do people fall through the cracks, and how does it affect the health of our worker patients? Honestly, it's, you know, the secondary question is, how is it that so many of our social determinants of health, we love talking about social determinants of health. There's whole departments at universities dedicated to studying the social determinants of health, but look how much of it flows through work, whether you're talking about food, or housing, or education, or healthcare, or retirement. It flows through work, and that's where we come in. I mean, frankly, it turns out that the politicians and the masters of industry have decided that so much of this is gonna flow through work, to the point where some people will say, you know what, if in this country, in the United States, if you don't work, you die, and it's not untrue. So I would love to see, I would love to see work doctors of AECOM step up, understand that this little corner that we've been inhabiting over here is not the whole picture. I would love us to step outside, look at the social determinants of health, look at everything that flows through work, and take power over that, to understand that we have been here the whole time. We are the ones who understand work, and health, and how they affect each other, and to use our powers to understand which levers to push, to make sure that health is better for our workers. And when we do, we expand our mandate, we expand our impact, our stature within the medical community, way, way, way past our numbers. So let those other docs take care of patients while they're not at work, but while they're at work, let's understand everything that flows through those patients, this is our turf right here, and this is where we should be commenting. Thank you. And we do have some time, I would love to hear any questions, any thoughts, what does this bring up for you? Did you write it down? Ashley, Ashley has a question. What you got? Thank you, Dr. Montoya, he was my residency director, and okay, I did have a question about the housekeepers, and when this OSHA protections were excluded, specifically, just because I thought that was interesting, and I didn't know about that, and the sexual harassment stuff. Okay, so domestic workers specifically, we talked about overtime pay, minimum wage, those things would have come from the Fair Labor Standards Act, that was 1935, sexual harassment protections came through the Americans, no, is that Americans with Disabilities Act, or is that Civil Rights Act? It's through the Civil Rights Act. I don't even know. It's Civil Rights Act? I don't know how strong that is, because... They were specifically excluded during those seminal legislations, and then the last one is unionizing, which would have been the National Labor Relations Act. And the majority of them were basically migrant workers who could not pretty much speak English right, and stand up for themselves. At the time that it was passed, in the early 1900s, largely black women. Okay, that's the start, and then it became more. And yeah, you could say that it hasn't changed, because the people who occupied those occupations now, still brown and black women. Yeah, okay, thank you. Thank you. And you don't have to get up to the microphone, Ed. Any other questions? Any other thoughts, objections? Yes. Yeah, great presentation on the very top. What do you think about 22 states that are under federal OSHA jurisdiction that have no protection for public sector workers? Now, I know New Mexico's a safe land state, but what can we do to get the same protection for these other 22 states? You are absolutely right. Yeah, that's one level of nuance that we can add to this framework, because that arrow doesn't always go through the state level. Where you go through OSHA, they're just depending on federal OSHA. You know, without having a deep knowledge of any particular state, you would have to assume that federal OSHA taking on something that the state OSHA could take on, perhaps you're losing people. Perhaps people are falling through the cracks. There are certainly not additional protections that state OSHA might provide. I know in Minnesota, New Mexico, they're places where I practiced. There are additional protections on top of what OSHA mandates, but in those cases, maybe a little bit less. And again, you bring up the point that this is us asking the question. I don't have an answer for you, certainly, but within this framework, yeah, absolutely. It'll be different for different occupational populations, in this case, defined by state. Excellent presentation. I wanted to take the framework of your presentation and apply it to a new framework, which I'm sure many of our colleagues here have experienced from COVID for the present, and that is the transition to virtual. Yeah. And then also, this hybrid that's developed as well, has there been any literature discussing the integration of these policies or interventions that you can discuss about this transition? Because I've seen a lot of these policies, and I'm scratching my head, I know my colleagues are just about the application, et cetera, you know, so I'm just wondering. Yeah, yeah, so I think what you're asking is, you know, specifically in the context of COVID, there have been legislations that may have provided or even prohibited or, you know, restricted, let's say, the ability to engage in remote work for appropriate industries or appropriate jobs. I haven't looked at that specifically, but you're right, it is relevant. What little I know is that the literature that tries to demonstrate a health benefit to remote work actually shows that mental health specifically suffers more for somebody who's engaged in remote work as opposed to going into the office, and that makes sense. I mean, you're disconnected from your community, you're alienated from your workplace and from the work that you do and your coworkers, but it may be good for your physical health just in the fact that you're not driving on the roads and getting in car accidents. You know, car accidents went way down during COVID because everybody was working at home, right? A conceptual question within this context, I would say that that first point of decreased mental health as a result of providing what we assume would be an extra protection may actually be bad for health, which is fine. Within this context, as at the beginning, remember, each of these protections flows through and has an effect. In general, these protections have a positive effect on health according to the literature, but they might not always. They might not always, and so it's incumbent on us to understand how the law, how the judicial decisions, how enforcement, and how each of these levels affects health. Yeah. Can I just comment on that specifically on musculoskeletal ergonomics and injuries? Typically in the workforce or workplace, there's a lot of regulations that are built in into patients' occupations on workplace ergonomics, but in some industries with this shift in virtual care, have you seen, you know, policies addressing this? I've seen many cases of issues with workplace ergonomics musculoskeletal and use of carbonic alcohol. Truthfully, I don't know. Truthfully, I don't know. I haven't looked into that specifically. Okay. Yeah. Anything else? All right. We have two minutes left. Welcome to take off. I'm gonna stick around for a little bit, but I'd love to chat with you. Come up and talk later. Thank you.

workplace policy

regulation

health outcomes

OSHA regulations

workers' compensation

fair labor standards

health insurance

retirement benefits

unionization