Prevention worth more than the cure

By Dr. James A. Merchant

As health care and health insurance costs have risen sharply over the last 15 years – family health insurance premiums have increased 171 percent and single premiums 158 percent, as documented by our collaborator, – employees and employers increasingly struggle to maintain health insurance coverage and benefits.

In the 90 percent of Iowa workplaces considered to be “micro-enterprises” – those that employ nine or fewer workers, yet are the primary source of entrepreneurs and new jobs – nearly half of employees receive no health insurance.

While this percentage is now increasing with implementation of the Accountable Care Act (ACA), it is far too early to evaluate any impact of the ACA on this workforce segment. However, recent reports in the Annals of Internal Medicine and The Millbank Quarterly have documented decreases in all-cause mortality and improvements in health status, respectively, among Massachusetts residents after implementation the state’s health care reform law in 2006.

The evaluation metrics used in The Millbank Quarterly study were CDC-based, self-reported quality-of-life (QoL) and prevention behavior measurements – the same metrics we used in a 2010 statewide survey of 1271 Iowa voters, aged 18-65, which was just published in the Journal of Occupational and Environmental Medicine (

This survey provides statewide employment-sector estimates of health status, prevention behaviors and productivity measures by employment status (self-employed, employed by an organization or currently unemployed but seeking employment). Most importantly, it also assesses whether measures of QoL and prevention behaviors are linked with productivity measures – in this case, sickness absenteeism and presenteeism (self-rated job performance during the last four weeks).

Of particular interest, the self-employed reported better QoL than those employed by organizations – despite having less health insurance coverage, less often having a primary care doctor and more often working 50 or more hours per week (31.7 percent versus 16.6 percent). The self-employed also smoked less, drank less alcohol, exercised more, had a healthier diet and more often got 8 hours of sleep, but they less often received a flu vaccine or wore a seatbelt – both actions known to be positively influenced by primary care coverage.

These findings are consistent with other studies that show the self-employed work longer hours, exhibit higher job control, often experience more stress from job and financial insecurity, but generally cope well and consume less health care.

Indeed, an important incentive for the self-employed to remain healthy in 2010 was to qualify for health insurance, for which they paid higher premiums. As more of the self-employed obtain more affordable health insurance through the ACA, it is likely that this segment will grow and that QoL differences with the organizationally employed will narrow.

The picture for the sample of the unemployed (6.8 percent in Iowa at the time of the survey) was much different. Not surprisingly, the unemployed reported much poorer QoL measures across the board. While rates of depression (associated with poorer QoL) are well known to be higher among the jobless, this segment also reported much higher rates of smoking, much less weekly exercise, and much more obesity – but less alcohol consumption and higher seatbelt use – than the currently employed.

Evaluation of the multiple factors that may explain QoL differences among all employees found smoking and obesity to be the most consistently reported modifiable risk factors. These are important for employment and health insurance eligibility, as well as the causes of many chronic diseases. Smoking cessation and obesity prevention should be primary targets for employee and employer prevention and disease management programs.

The cost to employers of sickness absenteeism and presenteeism are estimated to be three times greater than health care costs. Therefore, we evaluated these two productivity measures in association with QoL and prevention behavior measures. The results were similar for the self-employed and organizationally employed. As QoL and prevention behaviors increased, self-reported absenteeism decreased and job performance increased – both in a step-wise fashion.

Workplace programs that emphasize worker satisfaction, promote healthy behaviors and provide prevention programs provide employers of all sizes the opportunity to influence far more than just their health care costs. Iowa employers, who pay all productivity costs and 70 percent of health care insurance costs, have every incentive to enhance their employees’ health and quality of life while improving also their bottom line.

James A. Merchant, M.D., DrPH, is a professor and director of the Healthier Workforce Center for Excellence in the College of Public Health at the University of Iowa.