Barriers to occupational health services tolow wage workers in CA

The California Commission on Health and Safety and Workers Compensation, a highly visible state agency, has released its study of “Barriers to occupational health services for low-wage workers in California.” This is the largest scope and best investigated study of its kind. I have previously posted on numerous other more limited studies about garment, hotel and meat processing workers, and day laborers. I have copied below the entire Executive Summary.
This study says several important things either explicitly or by omission. First, work safety and access to workers compensation protections are pervasive problems among low wage workers — in particular, immigrant workers. The authors are effectively confirming other studies, in this broad and deep examination.
Second, the authors say by their silence that the California state agency with the greatest practical influence over correcting these problems is, well, useless. The authors appeared to have never even interviewed executives at the massive state run State Compensation Insurance Fund. SCIF is by far the largest workers comp insurer in the state, in fact the largest in the world, and whose seven person board includes three union representatives.
I queried the Commission last summer about why SCIF is not even mentioned. I did not receive a direct answer. I am left with the feeling that one state agency, CHSWC, decided that SCIF was useless as either a source of information or as a agency of work safety and workers comp system improvements.
Who are these low wage workers? The authors write, “Officially, over 3.7 million Californians are employed in occupations whose median wage is less than $10 an hour, the definition used in this report to classify workers as “low-wage.” Perhaps as many as two million more may be employed in California’s expanding underground economy. The majority of low-wage workers are nonwhite and immigrants. Typical low-wage occupations in California include restaurant and food service employees, health aides, cashiers, janitors, hotel cleaners, assemblers, security guards, farm laborers, retail clerks and sewing machine operators, among others.
“Overall, nearly two-thirds of the 25 leading occupations reporting non-fatal work-related injuries and illnesses are low-wage occupations. Heavy physical exertion, exposure to toxic substances and blood borne pathogens, repetitive motions performed bent over or in awkward postures for hours and slips, falls and other accidents are some of the common risk factors.”
The Executive Summary:

Frequently absent from debates on workers’ compensation is a discussion of prevention efforts by industry and the critical role prevention could play in reducing workers’ compensation expenditures and, most importantly, worker pain and disability. Also overlooked has been the dilemma of low-wage, mostly immigrant, workers who do some of the most hazardous jobs in our society and who face substantial, often systemic barriers in their attempts to obtain medical treatment and workers’ compensation benefits when they are injured.
Exclusion of low-wage workers from the workers’ compensation system often means that the burden of medical care and disability is shifted to their families and to the taxpayers who fund the public and community-based health care services these workers use. This form of cost-shifting also presents serious problems for legitimate businesses in California that must compete against firms that can easily underbid them because they provide no employee benefits, invest little or nothing in injury prevention, and often violate basic labor laws and health and safety regulations.
Scope of the Report. Many businesses that employ low-wage workers do not participate in the abuses described in this report and are often themselves victims of such practices because they struggle to compete against firms that do not abide by the law. This report looks at those businesses that do not abide by the law. It covers three interrelated topics: (1) low-wage workers and the issues they face in accessing the workers’ compensation system, (2) prevention efforts in a typical industry that employs low-wage workers; and, (3) the involvement of community health clinics in providing care to injured workers. Recommendations for introducing systemic changes through prevention efforts and increasing access to medical treatment and workers’ compensation benefits for low-wage workers are presented.
Methodology. Findings are based on a series of seven focus groups with workers, extensive interviews with community-based organizations that serve the low-wage worker populations, site visits and interviews with industry representatives and business owners in the building maintenance industry and a survey of community clinics. An extensive review of the literature and existing data was also completed.
Limitations. Accurate quantitative data do not exist on this topic. Consequently, this report is a qualitative exploration aimed at identifying the key issues and providing insight into the employment and socio-cultural dynamics that contribute to the health and safety access problems of low-wage workers. As such, this report focuses on identifying problem areas. While there was surprisingly strong consensus about the nature of these problems, it should be noted that this report is not an assessment of prevalence; as stated above, not all businesses that employ low-wage workers participate in the abuses described in this report. An additional caveat is that Senate Bill (SB) 899 was passed during the course of this study and the bill’s provisions were not yet in effect when the research was conducted.
Officially, over 3.7 million Californians are employed in occupations whose median wage is less than $10 an hour, the definition used in this report to classify workers as “low-wage.” Perhaps as many as two million more may be employed in California’s expanding underground economy. The majority of low-wage workers are nonwhite and immigrants. Typical low-wage occupations in California include restaurant and food service employees, health aides, cashiers, janitors, hotel cleaners, assemblers, security guards, farm laborers, retail clerks and sewing machine operators, among others.
Overall, nearly two-thirds of the 25 leading occupations reporting non-fatal work-related injuries and illnesses are low-wage occupations. Heavy physical exertion, exposure to toxic substances and blood borne pathogens, repetitive motions performed bent over or in awkward postures for hours and slips, falls and other accidents are some of the common risk factors.
Underreporting. A recent U.C. Davis study concluded that the Bureau of Labor Statistics reporting system overlooked between 33% and 69% of all injuries. Various studies in other states have found that from 9% to 45% of workers do not report injuries or file legitimate claims for workers’ compensation. Based on the interviews and research for this report, underreporting is endemic among certain groups of low-wage workers. Major risk factors include:
• Employment in the informal or “underground” economy. Over 2 million workers may be employed by illegally operated businesses in California. The underground economy, its growth spurred in part by the popularity of subcontracting, produces between $60 billion and $140 billion in goods and services annually. Wage and hour violations, hazardous conditions and worker intimidation are common. Limited enforcement, lack of workers’ compensation coverage, payment by piece rate, take-home work and, occasionally, human trafficking are problems which contribute to injuries and underreporting in this sector.
• Employment in small businesses. Small businesses employ the majority of low-wage workers. Compliance with complex and sometimes costly training, prevention and legal requirements can be exceptionally difficult for small-scale enterprises with limited resources. New businesses and immigrant-owned businesses may be particularly at risk.
• Immigrant status (especially undocumented immigrant). More than 26% of California residents are immigrants, a percentage over two times higher than the rest of the United States. An estimated 2.7 million residents, approximately 6.5% of the state’s population, are undocumented. Limited English language and literacy skills (coupled with low acculturation levels) are major barriers for many immigrants.
• Lack of health insurance, sick leave and other employment benefits. No health insurance, lack of access to health care services and the inability to take time off work to seek care or recover from illnesses and injuries were repeatedly cited as reasons why workers did not seek care for chronic—and sometimes even acute—occupational injuries and illnesses. Nationally, 76% of low-wage workers have no paid sick leave. Based on a recent UCLA study, California workers employed in the smallest firms (42.5%), low-income workers (48.9%), and undocumented workers (50.4%) were the least likely groups to work in firms that offered health insurance.
• Lack of unionization. Union representation is far less frequent among foreign-born and low-wage workers in California. The great majority of workers interviewed in this study were non-union.
Low-wage workers face multiple barriers to filing workers’ compensation claims when they are injured on the job. The findings from the focus groups and interviews are presented in the respondents own words since this best conveys the nature and scope of the problem. Common themes mentioned in the interviews and focus groups with workers included:
• Fear of Retaliation. Fear of job loss and other retaliation for filing workers’ compensation claims or for complaining about unsafe conditions were the most frequent concerns mentioned by workers. Actual physical abuse of workers in order to push them to work harder or because they had complained, while less common, was also reported.
• Blacklisting. Fears of blacklisting or of ostracism by their fellow workers for potentially jeopardizing jobs are other variations of the often overt pressure on workers not to report injuries or speak up in the workplace. While we were unable to ascertain how much blacklisting actually occurs, the belief that it does exist is widespread and contributes to the atmosphere of intimidation.
• Firing. While in some cases these fears may be misguided or exaggerated, all too often they were a realistic appraisal of the workplace situation. Several supervisors reported that firing employees who complained or filed workers’ compensation claims was company policy.
• Underreporting of Chronic and Non-acute Injuries. Most claims that ultimately do get filed are from workers who have already been fired or who have acute injuries that require emergency care. Chronic pain and non-acute injuries were only infrequently reported to employers. In some cases, this was due to lack of understanding that these conditions are work-related and serious enough to report.
• Normalization of Pain and Injury. For many low-wage workers, sub-acute injury and pain are so common that they are considered a normal part of the job.
• Working Despite Injuries. Lack of insurance or sick leave means loss of much needed pay. Interviewees described continuing to work despite nearly unendurable pain because they believed they had no alternatives. Others reported constant worry about health problems and chemical exposure.
• Perceived Employer Indifference to Worker Injury. The widespread belief that employers did not care about injuries created an atmosphere that contributed not only to underreporting, but to worker unwillingness to notify employers of health and safety problems at the job site. Many believed that employers would consider them ‘complainers’ or worse if they raised such concerns.
Treatment of Injured Workers. Workers who had been injured on the job reported numerous problems in getting adequate care or compensation benefits for their injuries and illnesses. These included being sent to company doctors who trivialized their injuries, being dropped at emergency room or left without care, given only token medical treatment and being forced to work despite injuries. Some reported attempts to dissuade them from filing for workers’ compensation Referring workers to primary care providers or attempting to make them pay for their own medical care when they were injured were also reported.
Treatment of Workers Who Filed Claims. When workers actually tried to file workers’ compensation claims, they often faced overwhelming barriers in the workplace. Some accused employers of deceptive practices including claiming that they were not actually their employees or “losing” injury and illness reports. In other cases, legitimate claims were not processed because the documentation was not available. Some workers claimed they were misled by their employers and the statute of limitation expired before the claims could be processed. While such problems were reported by workers in every industry we interviewed, day laborers and construction helpers appeared to be the victims of some of the worst abuses.
System Barriers. Lack of knowledge about workers’ compensation benefits, uninsured employers, language barriers and the complexity of the process were major problems preventing many workers from filing or pursuing claims. In almost all cases, workers were only able to successfully pursue claims when they had legal support, which was often not easily available to them.
Many of the occupational injuries and illnesses experienced by low-wage workers are preventable. Simple measures– proper procedures, adequate training, the use of safe equipment and products —are often all that is necessary to avert serious injury and illness. Despite this, prevention efforts are minimal, if not entirely lacking, in many businesses that employ low-wage workers.
Intense Competition. The increasing practice of outsourcing janitorial services, coupled with the ease of starting a janitorial service, has resulted in the proliferation of many small companies and intense competition for contracts. Many of these small companies operate without business licenses or insurance and often violate wage and hour laws and health and safety requirements. With such artificially lower overhead costs, they are able to underbid legitimate building maintenance firms. As a result, cost-cutting is a hallmark of the industry and prevention efforts suffer.
Site Visit Findings. As discussed in Chapter 4, a Department of Health Services contract industrial hygienist visited ten Bay Area janitorial companies to identify risk factors and to assess prevention practices. Heavy, fast-paced workloads and numerous chemical exposure, ergonomic, safety and other risk factors were observed during the site visits. Prevention programs at these sites were generally poor or absent. All but one company lacked an injury and illness prevention programs (required by California law). Hazard communication and training efforts were generally inadequate, inconsistent and infrequent.
Employers cited a variety of barriers to implementing health and safety programs for their workforces. These included time limitations, high worker turnover which made cohesive training difficult, language barriers, difficulty getting workers to follow instructions provided by training, no space available for training (since many employers have no offices), not being aware that health and safety problems exist, not having financial resources and not knowing where to go for help.
Access to appropriate medical care was one of the most important issues raised by workers and agency staff interviewed. Most low-wage and uninsured workers currently obtain their health care at public and nonprofit community clinics, which generally have the language skills and cultural competency skills needed to serve them effectively. Interviews were conducted with a small sample of these facilities to assess knowledge and awareness of occupational health issues and practices with regard to workers’ compensation. Slightly over half of the facilities interviewed reported that they routinely screened for work-related causes, but only 27% had treatment guidelines for occupational injuries or illnesses or a protocol for workers’ compensation cases. Many reported not filing workers’ compensation reports because of worker fear of retaliation or because the paperwork and system were too complex. Clinician training in occupational health issues was limited, though interest in more training was high.
Chapter 6: Recommendations
There was substantial consensus about what needs to be done among respondents to this study and in recent reports published by various concerned groups and other researchers. This report focuses on a “short list” of what appear to be the most pertinent and feasible recommendations, which include:
Increase inspections of health and safety conditions in target industries. Study respondents and other observers generally consider increased enforcement of target industries to be the most important remedy the state could consider adopting to improve conditions for low-wage workers. The highest priority could be given to increasing the number of bilingual inspectors, revitalizing the state’s task forces on underground industries, and increasing a program of unannounced inspections at low-wage workplaces.
Explore increasing the capacity of local governments to participate in compliance efforts. Pilot projects could be funded to develop innovative enforcement and outreach strategies at the local level and to explore the possibilities for enhancing local inspection efforts and the use of legal remedies by district attorneys and other local regulators to address health and safety compliance at the local level.
Promote efforts by community-based organizations to assist workers with filing claims, obtaining medical services and negotiating the workers’ compensation claim process. Models exist of community-based organizations that effectively help workers file claims, report problems, access occupational health care and negotiate the workers’ compensation process.
Encourage advisory boards to include representation from community-based organizations.
Encourage development of an outreach campaign to communicate worker rights, responsibilities and resources in vulnerable communities. As is evident from the success of tobacco education and other public health programs, social marketing campaigns can have an enormous impact. They save lives and save money. Current outreach and education efforts in occupational health are sporadic and rely heavily on written materials, which often do not reach their intended audience or serve the needs of low-wage workers. More innovative, creative, and coordinated approaches to outreach are needed. The use of media—especially ethnic media—to reach low-wage populations is one important and not necessarily costly strategy.
Provide understandable health and safety and workers’ compensation information in the language and at the literacy level appropriate for low-wage workers.
Establish an ad hoc committee to review legal remedies and fines and penalties for health and safety violations. Effective legal remedies do not exist for repeated violations of health and safety standards or instances in which large groups of workers are adversely affected by company practices (e.g., long-term exposure to toxic chemicals.) Many of the fines and penalties for labor and health and safety violations were established years ago and do not act as effective deterrents. Statutes of limitations also make it difficult to pursue claims where medical problems from workplace exposures (e.g., cancers) do not show up until later years or when information about workers’ compensation benefits was not provided to workers by their employers.
Provide web-based public access to workers’ compensation insurance coverage information for California businesses. California should follow the lead of other states, notably Texas, that have developed publicly-accessible electronic database systems that quickly and easily provides this information.
Explore the possibility of creating a safety net for the most vulnerable workers by encouraging pilot projects to provide limited, confidential access to occupational health care to low-wage workers in target industries. Several free or low-cost worker-oriented clinics have been started in the last few years to respond to the problem of lack of access for low-wage workers. There are no funding streams available to support these clinics and at the same time allow them to provide care to patients who are risk of retaliation or to patients whose workplace injuries are not covered under workers’ compensation insurance. Pilot projects should be developed to gather data on the costs and impacts of providing medical care to workers in designated industries where a high risk of retaliation exists.
Strengthen the ability of public and community health clinics to provide occupational health care for low-wage workers. Training in occupational health care and in the laws and regulations governing workers’ compensation should be provided on an ongoing basis to community and public health clinics. Regulations that mandate the inclusion of qualified community and public health clinics on insurer-preferred provider lists for employers with low-wage workforces and efforts should be adopted to assist them in developing individual or shared billing services.
Determine if the medical treatment provided under SB 899 works effectively and efficiently for low-wage workers. One of the most consistent complaints from workers in the focus groups was about inadequate care received from employer-designated doctors. SB 899 gives even greater control to employers over the choice of health care providers and greatly limits employees’ ability to seek care elsewhere if they are dissatisfied. Analysis of this process should take into account the special needs and circumstances of low-wage workers.
Enhance Prevention Efforts in Low-wage Industries. The Working Immigrant Safety and Health Coalition provided a useful list of recommendations which would enhance prevention efforts in low-wage industries, including: (a) disseminating information about existing solutions for serious hazards in these industries; (b) providing incentives for employers including tax credits, grants and insurance rebates for implementing approved health and safety measures; and (c) supporting research on new workplace solutions.
Explore the feasibility of implementing a regular reporting mechanism beyond the Workers’ Compensation Information system (WCIS) and the annual survey by the Department of Labor Statistics and Research (DLSR) of the Bureau of Labor Statistics, and a study of surveillance efforts and recommended improvements for tracking injuries and illnesses among low-wage workers. Without data to identify risk factors and track improvements, clear goals cannot be set for resolving the immediate problems identified in this and other reports, including recommendations for more useful and accessible performance data on inspections and other DIR programs.
Provide publicly accessible county-level data on injuries to facilitate local involvement. Regular reporting should be made publicly available and cover occupational illnesses and injuries, claims information, Cal-OSHA inspections, emergency room cases and other available data to assist local surveillance efforts.