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Support Decent Work for All as a Public Health Goal in the United States

  • Date: Nov 08 2022
  • Policy Number: 20223

Key Words: Occupational Health And Safety, Labor Issues, Compensation

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This policy promotes decent work as a U.S. public health goal through a comprehensive approach that builds upon existing APHA policy statements and addresses statement gaps. The International Labour Organization defines decent work as work that is “productive, delivers a fair income, provides security in the workplace and social protection for workers and their families, offers prospects for personal development and encourages social interaction, gives people the freedom to express their concerns and organize and participate in the decisions affecting their lives and guarantees equal opportunities and equal treatment for all across the entire lifespan.” The World Health Organization has emphasized that “health and employment are inextricably linked” and “health inequities attributable to employment can be reduced by promoting safe, healthy and secure work.” Here evidence is presented linking decent work and health and action steps are proposed to help achieve decent work for all and, thus, improve public health. In the United States, inadequacies in labor laws, structural racism, failed immigration policies, ageism, and other factors have increased income inequality and stressful and hazardous working conditions and reduced opportunities for decent work, adversely affecting workers’ health and ability to sustain themselves and their families. The COVID-19 pandemic highlighted these failures through higher mortality rates among essential and low-wage workers, who were disproportionately people of color. This policy statement provides a strategic umbrella of tactics for just, equitable, and healthy economic development of decent work and proposes research partnerships to develop, implement, measure, and evaluate decent work in the United States.

Relationship to Existing APHA Policy Statements

This proposed policy statement does not address a topic identified by the Joint Policy Committee or APHA as a policy gap. It does, however, integrate issues from three policy statements (200018, 20019, and 20136) that will be archived by 2023. Several APHA policies (20174, 20054, 20148, 20218, 202012, and 20213) recognize the relationship between adverse working conditions, such as job strain, unsafe conditions, inadequate protections, low wages, structural racism, and insecure work, and health outcomes that include workplace injuries and illnesses, for example cardiovascular and all-cause mortality, COVID-19 mortality, suicides, and opioid use disorder and overdose. Other policies (20167, 20174, 20136, 20068, 20148, and 20177) recognize the benefits of social and economic supports, such as a living wage, paid family and sick leave, and union protections, or called for special protections for immigrants, temporary workers, farmworkers, and essential workers during the COVID-19 pandemic. This policy builds upon and uses aspects of the following policies:

  • APHA Policy Statement 20019: Protection of Child and Adolescent Workers (archived)
  • APHA Policy Statement 20054: Occupational Health and Safety Protections for Immigrant Workers
  • APHA Policy Statement 20068: Resolution on the Right for Employee Free Choice to Form Unions
  • APHA Policy Statement 20136: Support for Paid Sick Leave and Family Leave Policies
  • APHA Policy Statement 20148: Ensuring Workplace Protections for Temporary Workers
  • APHA Policy Statement 20167: Improving Health by Increasing the Minimum Wage
  • APHA Policy Statement 20174: The Critical Need to Reform Workers’ Compensation
  • APHA Policy Statement 20177: Improving Working Conditions for U.S. Farmworkers and Food Production Workers
  • APHA Policy Statement 20179: Reducing Income Inequality to Advance Health
  • APHA Policy Statement 20213: A Comprehensive Approach to Suicide Prevention within a Public Health Framework
  • APHA Policy Statement 20218: Call for Urgent Actions to Address Health Inequities in the U.S. Coronavirus Disease 2019 Pandemic and Response
  • APHA Policy Statement 202011: Supporting and Sustaining the Home Care Workforce to Meet the Growing Need for Long-Term Care
  • APHA Policy Statement 202012: A Public Health Approach to Protecting Workers from Opioid Use Disorder and Overdose Related to Occupational Exposure, Injury, and Stress
  • APHA Policy Statement 202112: Lessons from the COVID 19 Pandemic: The Importance of Universal Health Care in Addressing Health Care Inequities
  • APHA Policy Statement 20197: Addressing Environmental Justice to Achieve Health Equity

This policy statement advocates for adoption of the broad framework of decent work initially developed by the International Labour Organization (ILO) as a sustainable health strategy for improving public health and well-being. Adoption of such a comprehensive policy gives APHA the ability to advocate in a timely manner for a wide range of potential initiatives and legislative proposals that affect worker, family, and community health.

Problem Statement

The term “decent work” was adopted by the ILO in 1999 to promote a human-centered approach to address the social impacts of working life. The ILO defines decent work as work that is “productive, delivers a fair income, provides security in the workplace and social protection for workers and their families, offers prospects for personal development and encourages social interaction, gives people the freedom to express their concerns and organize and participate in the decisions affecting their lives and guarantees equal opportunities and equal treatment for all.”[1] This definition applies a systems approach to include factors inherent to decent work and positive work experiences, such as jobs that are safe, healthy, and secure; provide adequate compensation to support a family; offer free time and rest; treat workers with respect; and provide social protection, including the right to free association (such as the right to form labor unions). To achieve its goal of ensuring decent work, the ILO’s decent work framework promotes a development strategy recognizing the central role of work in everyone’s life. The framework consists of four inseparable, interrelated, and mutually supportive strategic objectives: creating full employment, implementing and promoting standards that ensure workers’ rights, enhancing social protections for all, and strengthening engagement among government, industry, and labor, including through labor unions and community organizations.

The World Health Organization (WHO) has expanded the focus on health to emphasize that “health and employment are inextricably linked” and “health inequities attributable to employment can be reduced by promoting safe, healthy and secure work across all sectors of employment.”[2] Similarly, Benavides et al. argue that “decent work is a basic condition for the health and well-being of workers and their families.”[3] An International Commission on Occupational Health work group recently published a detailed framework on the connections between decent work and occupational safety and health.[4] In addition, the United States recently joined the ILO’s Climate Action for Jobs Initiative, which supports the creation of decent work and quality jobs as an integral part of its efforts to combat climate change and transition toward environmentally sustainable economies.[5] Finally, the U.S. surgeon general has called for improvements in work life to improve mental health and well-being across the U.S. workforce.[6]

Associations between work and health: Worker health can be affected by physical, chemical, biological, biomechanical, and psychosocial work hazards and by lower levels of income. For example, the original Whitehall studies demonstrated a stepwise increase in cardiovascular mortality as social class decreased, with a 3.6-fold increase in the lowest group relative to the highest.[7] Subsequent Whitehall II studies have revealed that increases in metabolic syndrome and cognitive decline, increased myocardial infarctions, and other adverse outcomes are associated with unfair supervisors, excessive overtime, and other workplace exposures.[8–11] Worker health is negatively affected by job stressors, including long hours, low job control, job strain, inadequate staffing and resources, effort-reward imbalances, and work-family conflict, as well as unemployment.[10] Extensive epidemiological research has demonstrated increased cardiovascular mortality and all-cause mortality associated with job loss, repeated episodes of job loss, duration of job loss, and threatened job loss.[11,12] In a prospective cohort study of 13,451 U.S. adults 51 to 75 years old who were followed from 1992 to 2010, Dupre et al. found that, after adjustment for multiple risk factors, acute myocardial infarction risks were significantly higher among the unemployed and that risks increased incrementally from one job loss to four or more cumulative job losses relative to no job loss.[13] Both repeated episodes of unemployment and long-term unemployment are associated with increased mortality.[14] The empirical literature on long-term unemployment and physical, mental, and psychological well-being is extensive; however, there are limited data on the effects of underemployment or nonstandard work (e.g., temporary or third-party contract work) on worker health and well-being.[15] Among American working adults, low income is associated with higher rates of hypertension, heart disease, diabetes, stroke, other chronic diseases, and psychological disorders.[16] Lower family income is also associated with increased risk of infant mortality, low birth weight, childhood asthma, heart conditions, hearing problems, digestive disorders, and childhood obesity.[16]

In part as a result of worsening work conditions, the United States is experiencing declining mental and physical health. Life expectancy decreased between 2015 and 2017 mainly because of an increase in death rates among working-age adults (25–64 years) from “deaths of despair” (i.e., drug, especially opioid, poisoning; alcohol-induced causes; and suicide) and other causes, including diabetes, obesity, and cardiovascular disease.[17] Adverse working conditions place workers at increased risk for depression and burnout, while more decent work conditions, such as having more job control, have a protective impact.[18] Health care workers experience exposures to biomechanical and chemical hazards, infectious diseases, understaffing, and workplace violence, resulting in burnout, musculoskeletal injuries, absenteeism, job resignations, early retirements, and posttraumatic stress.[19] Job stressors are risk factors for health issues such as suicide, suicidal ideation, and cardiovascular disease. Male-dominated occupations, occupational access to firearms, and access to medications can significantly increase suicide risk, particularly among women. In 2019, more law enforcement officers died by suicide than in the line of duty.[20]

Work can provide economic security, self-esteem, and social connectedness, and work that offers respect, control, and skill development may improve health.[2] Work that is dignified and respected and offers the opportunity to solve problems and develop new skills should be characteristic of all employment, irrespective of job type.[21] A series of Whitehall II studies have shown that workers who rate their immediate supervisors high on items such as respect, providing information, and providing positive feedback experience fewer coronary artery events, have a lower incidence of metabolic syndrome, and experience less cognitive decline after control for other risk factors.[22,23] Kivimäki and colleagues combined data from seven prospective European worker cohorts representing 1.8 million person-years at risk and 1,143 people with incident cases of dementia to explore the relationship between dementia and high versus low cognitive stimulation at work. Workers with high cognitive stimulation at work experienced a significantly lower risk of dementia after adjustment for multiple risk factors.[23]

The following section applies the ILO’s four objectives of decent work as an analytic framework to describe examples of current work conditions in the United States that fall short of decent work and highlights information gaps.

Employment creation: Over the past four decades, U.S. job stability has decreased and income inequality has increased as economic globalization policies have promoted “free trade,” including reductions in government spending on public services and deregulation of occupational and environmental health and financial sectors.[24] These policies have led to an increasing income gap, a decline in decent work, and an increase in economic migration. Privatization, downsizing, restructuring, and a lower prevalence of unionized workers have been associated with increases in precariousness, job insecurity, time pressure, workload, low job control, and low workplace support, especially in the presence of an inadequate social safety net among vulnerable workers.[25]

According to the U.S. Government Accountability Office, the Great Recession (2007–2009) accelerated the rise of part-time work, with the percentage of “standard part-time workers,” defined as those who have a standard employee relationship with an employer and are entitled to Fair Labor Standards Act protections, increasing from 11.9% to 16.2% between 2006 and 2010.[26] Workers in alternative work arrangements, such as “gig” workers (those using online work platforms and working on a freelance basis) and “contingent” workers (e.g., temporary help agency workers, on-call workers, contract workers, and independent contractors or freelancers), increased from 35.3% to 40.4% during this period.[26] Such arrangements exacerbate inequality; in gig work, for example, workers forgo all employee benefits while those who control the online work platforms reap large profits. Some forms of contingent work violate existing regulations (e.g., when workers are misclassified as “self-employed” to avoid employer responsibilities); however, enforcement of these regulations is inadequate. Current regulations fail to address many types of unstable work. Analyses of the General Social Survey of U.S. adults have shown that unstable work hours are common among standard part-time workers and that workers who are Black, young, and without college degrees are most exposed to volatile work hours, limited schedule input, and short advance notice to work.[27] Enormous job loss occurred initially during the COVID-19 pandemic among low-wage workers in the hospitality sector, including many immigrant workers who were ineligible for social supports. In 2021, 4 million U.S. workers settled for part-time work owing to reduced hours or an inability to find full-time jobs.[28]

Since 2001, there has been a 40% decline in grants to states through the Workforce Innovation and Opportunity Act, the primary U.S. law governing job training investments.[29] The United States invests less than every industrialized country other than Mexico in active labor market participation policies that help match workers with employment opportunities (e.g., employment services, job search assistance, job training programs, and employment subsidies).[29] Employer investment in workforce training has fallen in recent years for multiple reasons, including market pressure to focus on short-term results and greater movement among jobs by workers.[30]

The U.S. minimum wage is lower than that of other high-income countries. Forty-four percent of American workers 18 to 64 years of age are considered “low-wage workers,” with a median hourly wage of $10.22 and median annual earnings of $17,950.[31] Even workers in prestigious jobs may struggle financially: a recent report revealed that one in eight congressional staff members (those in junior-level positions, such as staff assistants, press assistants, and legislative correspondents) do not earn a living wage, defined as a wage needed to meet one’s basic needs, and often require side jobs or rely on family members to pay their bills.[32]

Fundamental rights at work: Decent work includes rights for personal development, social interactions, the expression of concerns, the ability to organize and participate in decisions affecting one’s life, and guaranteed equal opportunities and treatment for all. Below are selective examples of ways in which these objectives are thwarted.

Unionization promotes high-quality jobs with increased wages, high-quality benefits, decent working conditions, retirement security,[33] a “voice” for workers, and health and safety.[34] However, the unionization rate has declined in recent years; less than 11% of U.S. workers are currently union members, and employers can fire pro-union workers to derail unionization campaigns with minimal consequences.[35] The National Labor Relations Act allows states to pass “right to work” laws, which permit employees in unionized settings to refuse to pay union dues, thus weakening unions. A 2018 study showed that among states that had enacted right to work legislation, each 1% decline in union membership was associated with a 5% increase in fatal workplace injuries, for an overall increase of 14% in fatal traumatic injuries.[36]

Job stability in the United States is also weakened because this country, unlike most developed countries, permits widespread at-will employment. With some exceptions, the United States allows the dismissal of workers “at will” for any or no reason and does not address notification procedures for dismissal, thus creating fear of job loss that discourages workers, particularly low-wage, Black, and Hispanic workers,[35] from reporting discrimination and harassment, unsafe working conditions, or work-related injuries. 

Social protections for all: Decent work encompasses social protections such as work-associated benefits that protect the financial stability of workers and thus enhance the health of workers and their families. As described below, many U.S. workers do not have those protections.

There is currently no federal requirement for U.S. employers to offer paid sick, family, or medical leave, a responsibility present in many other wealthy countries. For example, in 2021, only 23% of workers had paid family leave through their employer.[37] Workers in occupations such as retail, home care, custodial, and food service; those in gig or informal work; and part-time or lower-wage workers are less likely to have benefits or access to affordable child care.[38] Benefit reductions for workers with occupational illnesses and injuries have resulted in significant cost shifts to injured/ill workers and to taxpayer-supported programs. Only 22% of workplace injuries and illnesses are covered by the workers’ compensation system, which costs the U.S. economy an estimated $249.6 billion; this adversarial system has contributed to depression, opioid addiction, and prolonged income loss among workers.[39]

Labor, industry, government, and community engagement: While decent work calls for a comprehensive approach to work and worker health, the United States has a “splintered” approach to labor, with enormous gaps in coverage for basic labor rights and sporadic programs by different levels of government and nongovernmental organizations that fail to provide comprehensive solutions.

The initial Occupational Safety and Health Act referred to employee-employer relationships, failing to address the self-employed or those in more fluid types of relationships that have since evolved. The standard-setting and enforcement activities of the Occupational Safety and Health Administration (OSHA) have eroded over time because of changes in workforce relationships and legal challenges. COVID-19 has further highlighted OSHA’s enforcement shortfalls, leading to calls for a regulatory overhaul.[40] The pandemic specifically demonstrated shortfalls in whistleblower protection for health care workers. OSHA requirements for health care worker safety are linked to place of employment (e.g., hospitals); thus, nurse practitioners, physician assistants, pharmacists, and others who practice in retail settings do not receive OSHA protections similar to their colleagues in recognized health care settings despite facing similar occupational risks.

OSHA is further constrained by the Constitution from regulating state or local government employees, although this can be remedied by state OSHA plans that either cover all workers or explicitly cover public employees. For example, OSHA has the authority to regulate workplace safety for health care workers in private hospitals but not for those in state or municipal hospitals; unless there is state-plan coverage for the latter, those workers have no protection. Similar limitations exist for other groups of workers. For example, the Fair Labor Standards Act has reduced labor protections for domestic workers and farmworkers in particular and has broadly failed to update the minimum wage or provide job security for these workers. Child labor provisions under the act are designed to protect the educational opportunities of youth (those younger than 18 years) and prohibit their employment in jobs that are detrimental to their health and safety. Hazardous orders are issued to establish minimum ages for workers to be hired to do certain jobs or tasks.[41] Unfortunately, limits for youth in agriculture have not been updated since they were first promulgated in 1970.[42] Regular reviews and updates of child labor regulations are essential to keep up with changes in workplace processes and equipment and to promote decent work opportunities for youth.

Multiple gaps in work-related data, standardized employment-related definitions, and metrics are hindering the ability to assess work-related problems and evaluate workplace interventions. For example, current discussions of job quality in the United States argue for increased pay, job security, opportunities for growth, and well-being in jobs, although there is no shared definition of well-being. While the U.S. Bureau of Labor Statistics (BLS) currently reports unemployment statistics, there are no well-defined indicators for underemployment. In addition, standardized definitions and metrics are lacking for emerging categories of precarious work.[15] Public health surveillance failures to include occupation and industry information other than for health care have severely limited our ability to understand the impact of the COVID-19 pandemic on many essential workers, despite extensive outbreak reporting. Furthermore, while identification of job characteristics associated with adverse health outcomes is increasing, further research to develop and test interventions designed to reduce stressful job characteristics is needed, as is research documenting health-promoting aspects of work interventions.

Dimensions of work beyond employed/unemployed are largely absent from examinations of health inequities in the United States.[43] As highlighted by the COVID-19 pandemic, Black and Latino workers were disproportionately likely to work in jobs with higher COVID-19 mortality and were also more likely to work in low-wage hospitality sector jobs in which job loss rates were higher.[44] African Americans experience systemic racial barriers and face higher unemployment, fewer job opportunities, lower pay, poorer benefits, and more job instability than others.[45] Jobs with higher risks of injury and illness pay less and are more likely to be held by workers who are Black, have a high school degree or less, or are foreign born.[31] Transgender/gender-diverse individuals face higher rates of unemployment, denial of job promotions, job loss, and workplace verbal harassment, physical attacks, and/or sexual assaults.[46] While issues surrounding immigration are outside the scope of this policy statement, all workers, including all immigrant workers, must be covered by workplace protections and supports to remedy the damage caused by the informal economy. Overall, there is limited information about exposures and health outcomes among groups of vulnerable workers, including workers who are unhoused, in prison, or working with disabilities, limiting the opportunities for developing actionable policies and programs.

Evidence-Based Strategies to Address the Problem

The decent work framework is not a specific set of prescriptive policies. The ILO’s decent work objectives offer a way of broadening the concept of work to focus attention on the array of diverse strategies needed to achieve healthier work. Although the United States lags significantly behind other high-income countries in many aspects of its approach to work, there is a growing evidence base of promising strategies that make decent and healthier work for all a possibility. The strategies described below are examples of key ways in which work can be enhanced to promote health. A decent work approach would create bridges across business and labor sectors and among these strategies so that they are consistent components within job creation and work policies and practices.

Employment creation: Several developed countries have demonstrated effective strategies that improve employment among job seekers through vocational training, including apprenticeships and other work-based learning programs. Such programs support the entry of youth into labor markets through hiring subsidies or subsidized employment, and standardized apprenticeship training supports school-to-work transition.[47] Although less common than in Europe, U.S. apprenticeship participation is on the rise; however, there is limited evaluation of the effects of such programs. The U.S Department of Labor’s Registered Apprenticeship, a career training program administered in conjunction with state apprenticeship agencies, offers structured on-the-job training combined with related technical instruction tailored to industry needs. In 2020, the Department of Labor administered almost $250 million in active apprenticeship expansion grants and established 3,143 new programs. The number of active Registered Apprentices grew by 51%, to 633,476, with 92% of apprentices retaining employment after completing a Registered Apprenticeship and earning an average starting salary of $72,000.[48] In the United Kingdom, an effort to promote quality work principles, including overall worker satisfaction, good pay, participation and progression, well-being, safety and security, voice, and autonomy, has improved technical workforce skills.[49]

Workforce development and community organizations have developed place-based innovative partnerships with employers to create pipelines for jobs for various groups of workers including, but not limited to, women, rural workers, and community college students.[50] Such investments in sector partnerships have shown promise and warrant further evaluation and strategic scaling up.

An alternative to providing unemployment compensation to workers who are laid off by employers experiencing financial loss is to keep workers on the job but working fewer hours. This approach, called short work, provides supplementary income for workers who have reduced hours instead of putting some workers out of work completely and providing them with unemployment compensation. Workers remain at least partially in the workforce, retain benefits, and avoid the adverse health effects of unemployment. In Germany, short work benefits are routine, while in the United States unemployment compensation is the rule. A 2012 study comparing two panel survey cohorts of German and U.S. working-age adults between 1984 and 2005 identified a significant unemployment-mortality association among Americans but not among Germans.[51] Although short work was authorized by the Department of Labor during the Great Recession, few states aggressively implemented it. Limited evaluations since 2008 suggest a positive impact on manufacturing job retention.[52]

Adequate compensation, including pay (wages or salaries), is a basic component of decent work. Better-paying jobs support basic needs, higher levels of consumption, and improved living standards.[53] For example, a multilevel analysis of 492,078 individuals in 139 countries showed that employed adults in countries with collective bargaining and generous wage-setting policies had a lower risk of being food insecure than those in countries with a low or no minimum wage.[54] A 10% minimum wage increase has been shown to reduce non-drug suicides among adults with lower levels of educational attainment by 2.7%, and a 10% increase in the Earned Income Tax Credit has been shown to reduce such suicides by 3.0%.[55]

Fundamental rights at work: Workplace policies and programs may contribute to improved work quality and increased worker resiliency and well-being. A variety of workplace programs have been shown to improve job quality and worker health. For example, a labor management committee at a Quebec hospital identified sources of stress at work and worked to redesign jobs over a 1-year period. Relative to a control hospital, the intervention hospital had improved job characteristics (job quality) and reduced levels of burnout at work.[56] Work should be fair and equitable, with basic work rights including, but not limited to, the opportunity to exercise voice and be free from discrimination and harassment. WHO and the National Institute for Occupational Safety and Health (NIOSH) have identified interventions that directly target the work environment.[57] Employers can explicitly change work environments in ways that can reduce stress, such as increasing worker control over scheduling and daily tasks, offering opportunities for unionization and collaboration, improving work-life balance, and placing limits on work demands and mandatory hours.[57] A series of Whitehall II studies demonstrated lower cardiovascular mortality, reduced metabolic syndrome, and higher cognitive function among workers whose supervisors provided them with adequate information and recognition relative to workers whose supervisors failed to do so.[9,10,22,23] A recent randomized trial revealed that improving technology workers’ control over their work schedules and training supervisors on family-supportive behaviors improved workers’ sleep quality.[58] Further intervention research is needed to assess the best ways to improve supervisor support.

Additional strategies to address worker mental health include facilitating help seeking and referrals to mental health care and supportive services for workers at risk; offering peer counseling; reducing stigma; implementing recovery-supportive workplace policies; providing resources and training to detect and respond appropriately to compromised mental health and risk for drug use, alcohol use, and suicide; and creating crisis response plans.[59,60]

Collective bargaining has been used to improve job quality, such as providing teachers with greater voice on the job.[33] During the pandemic, unionized workers negotiated additional pay, safe working conditions, paid sick benefits, job preservation, and voice at work, with associated improvements in mortality among long-term care residents in New York State attributed, in part, to workers’ greater access to personal protective equipment.[61] In the mid-Atlantic region, COVID-19 infection rates were lower among unionized grocery workers than in the regional population.[62]

Social protections for all: Provision of unrestricted cash through guaranteed income programs is being piloted in a growing number of U.S. cities. For example, an experiment conducted by the city of Stockton, California, demonstrated that program recipients receiving $500 per month for 24 months in guaranteed income secured full-time jobs at more than twice the rate of people in a control group who did not receive cash.[63]

Family leave improves parents’ mental health with long-term benefits for their children, and sick leave is associated with job satisfaction, improved worker health through the use of preventive health services, reduced absenteeism from work, and lower rates of occupational injury.[53] Currently, 14 states, Washington, D.C., and 20 other localities have laws requiring covered employers to provide eligible employees paid time off for their own illness or to care for sick children.[64]

Lax and Zoeckler reviewed the burden of occupational disease in New York State and recommended fundamental reform that will incentivize employers to engage in occupational disease prevention and eliminate barriers within the workers’ compensation system so that workers with occupational disease receive proper treatment, care, and compensation.[65] Washington State, with 10% of occupational injuries resulting in permanent impairment, implemented workers’ compensation reforms via its return-to-work programs. Recent data indicate that these workplace improvements support safe and sustained return-to-work outcomes that improve worker health, costs, and timely response.[66]

Labor, industry, government, and community engagement: Worker cooperatives (co-ops) hold promise for achieving decent work. An estimated 465 U.S. worker co-ops employ about 7,000 people and generate more than $550 million in annual revenues.[67] A study of Cooperative Home Care Associates in New York City revealed better worker outcomes (e.g., fair promotions, helpful supervisors, decision-making participation) than similar conventionally governed businesses.[68] Co-ops can build worker power and promote community health. For example, Washington farmworkers started a co-op that established a pesticide-free farm to protect worker and environmental health.

Federal legislative efforts have sought to support decent work. The Occupational Safety and Health Act has led to dramatic reductions in workplace injury fatalities. The Coronavirus Aid, Relief, and Economic Security Act provided unemployment support to gig workers and provided resources for personal protective equipment for health care workers. However, the employer-employee language in the act leaves many workers outside of OSHA protections. Other countries, such as Australia, have solved this problem by creating a duty for businesses to ensure, insofar as feasible, safety for their employees, contract or gig workers, customers, and the general public while on their premises or conducting work. Other approaches to improving alternative work arrangements range from regulatory enforcement of worker classification (proving that workers in a given situation function not as independent contractors but as employees) and creation of benefit pools for employers to fund on a prorated basis to creation of new work categories with intermediate regulations.[69]

OSHA cannot regulate state and local employees. State plan OSHA programs are able to include state and local employees, and a number of state plan states have adopted occupational safety and health standards such as illness and injury prevention program requirements that reduce injury rates, include farmworkers in their enforcement activities, and exceed federal OSHA protections. State laws and regulations have addressed health care work challenges. The California nurse-to-patient staffing ratio law was associated with a decrease in injuries among California nurses.[70] When nurses’ workloads in New Jersey and Pennsylvania were in line with California-mandated ratios, burnout and job dissatisfaction among nurses were lower. Lower nurse staffing was associated with higher 30-day inpatient mortality.[71] Several states’ laws or regulations outline basic requirements for workplace violence prevention in health care. An evaluation of the California Hospital Safety and Security Act of 1995 showed that assault rates in California emergency departments decreased 48% relative to rates in emergency departments in New Jersey.[72] Although state-based standards are exceptionally useful for providing protections beyond those provided by the federal government, many states lag behind in worker protections, and their workers would benefit from strengthened federal labor laws as well as strengthened OSHA standards.

Networks of worker centers, unions, community-based organizations, advocacy organizations, “high-road” employers (employers that pay family supporting wages and engage workers and their representatives in building skills and competitiveness), public health organizations, and local and state governments have organized to create new enforcement models that promote decent work, protect occupational health, and improve health equity. Successful examples of these models include the San Francisco Office of Labor Standards Enforcement and a coalition of worker centers and nonprofit legal advocacy groups that recovered more than $6 million in wages stolen from workers.[73] The National Domestic Workers Alliance has created networks of legislators and worker advocates that pass legislation identifying domestic worker protections. Ten states and two major cities have passed a domestic workers’ bill of rights, paving the way for enhanced worker protections and enforceable Occupational Safety and Health Act standards.[74] Attorneys general (AGs) have demonstrated their authority to protect the rights and health of their constituents by filing cases with a strategic or impact litigation focus aimed at having a broader effect on an industry or practice.[75] As of 2020, eight states and Washington, D.C., had dedicated workers’ rights units within state AG offices, and six were initiated in the past 5 years.[75] A review of activities from 2018 to 2020 described how state AGs play a growing role in protecting workers’ rights and use their civil authority to pursue employers that violate a number of laws, including laws related to wages, earned sick time, child labor, payroll fraud and misclassification, noncompete and no-poach/no-hire agreements, sexual harassment, and the platform or gig economy.[75] Models such as the Decent Work and Health Network in Ontario, a coalition of health workers advocating for decent work and patient and worker health, indicate a role for public health in designing and delivering interventions to increase decent work.[76]

Opposing Arguments/Evidence

Adopting decent work policy initiatives requires challenging our current economic systems and frameworks that favor the “free market” and profit maximization over investments in long-term workforce development and labor protections. Shifting the norms around these social and economic systems involves realization of the effects of jobs and the economy on current and future population health and well-being. This section includes an overview of some common arguments against elements of decent work with evidence in response.

Worker health can be viewed as the purview of government aid, and thus employers do not have a responsibility to protect or consider the health consequences of work environments. Elements of decent work, such as adjusting and aligning the minimum wage for workers, addressing workplace conditions to reduce psychosocial stressors (e.g., bullying and depression), providing more structure and participation for workers, or even upholding basic human rights at work, are seen as adding to the cost of businesses and affecting the price competitiveness of commodities or services. However, while employee work benefit desires vary slightly according to factors such as generational identity, the benefits embraced by the decent work framework are desired by the majority. Thus, employers reap the benefits of offering decent work through their ability to attract and retain employees.[77]

One opposing argument is that increasing the minimum wage can lead to employers reducing work hours or reducing the number of workers on staff. Such actions tend to affect groups associated with low-wage work, such as teenagers, women, and Black and Hispanic individuals, who are heavily overrepresented in the lowest wage categories.[78] However, a $15 minimum wage could contribute to the broader goal of reducing poverty and help millions of struggling households in small and mid-sized cities achieve self-sufficiency.[79] According to the U.S. Congressional Budget Office, the effects of raising the minimum wage are complex and vary owing to factors such as degree of wage increase, business reactions to increases, industry type, and worker skill levels.[80] Incremental increases in the minimum wage hold the potential to lower the percentage of families living in poverty. A 2022 national survey of U.S. economists revealed differing views on the benefits of minimum wage increases but general agreement that stronger social supports (a key component of decent work) would benefit workers.[81]

Another argument relates to the financial impact on employers and businesses of costs associated with benefits such as health insurance, paid sick days, and other days off. A 2021 report cited research indicating that paid leave for child care and personal or family health reasons was related to increased worker retention, thus overcoming costs associated with worker recruitment, hiring, and training. The majority of companies that have implemented paid leave programs have remained supportive of them over time.[82] A Wall Street Journal editorial argued against employer-offered health and retirement benefits, suggesting that these benefits should be obtained through nonprofit private sector buying cooperatives instead, in part as a means to impede the creation of a national health care solution.[83] However, according to estimates from several U.S. studies, annual workplace costs of mental health disorders in terms of absenteeism and low work performance are in the range of $30.1 billion to $51.5 billion.[84,85] Thus, employers can financially benefit from the employee supports they offer.

While specific elements of decent work may change organizational climate and culture and may increase some costs for employers, in the long term unsafe workplace conditions create more injuries and illness. For example, work-related injuries and untreated worker mental health conditions can lead to low work performance and productivity loss. The National Safety Council estimated that work-related injuries cost the U.S. economy roughly $171 billion in 2019.[86] That averages to roughly $1,100 per injured worker and $1.2 million per worker death. In addition, the council estimated that 55 million workdays were lost in 2020 as a result of disabling injuries sustained in 2019.[86]

Critics of immigration argue that decent work policies enable undocumented immigrants to benefit from breaking immigration laws and to undercut the wages of “American” workers. However, many immigrants suffer workplace abuse and wage theft in the United States because of their outsider status, language varieties, and threat of deportation. Thus, laws protecting the rights of immigrant workers and preventing wage theft would help prevent undercutting of the wages of native-born workers.

Action Steps

  1. The U.S. Senate should ratify relevant ILO conventions surrounding workplace safety and health and decent work.
  2. The White House should establish an interagency task force in partnership with multiple public and private sectors to explore, coordinate, and evaluate metrics, activities, and policies to develop and support implementation of a decent work strategic framework for the United States.
  3. The U.S Congress should (a) increase workforce development funding, (b) adopt evidence-based strategies (including apprenticeships and public-private sector partnership models) to boost employment creation, and (c) partner with other federal, tribal, and state agencies to identify best practices to help communities negotiate bringing jobs into their neighborhoods that provide decent work.
  4. The U.S. Congress should (a) update the definitions of employer and employee in all federal labor laws to reflect the current state of employment arrangements and remove the exemptions in place for farmworkers and domestic workers; (b) update the Fair Labor Standards Act to provide a minimum wage that is automatically inflation adjusted and ensure a wage no lower than 200% the federal poverty level for a family of four; (c) pass legislation to expand paid leave for all workers, regardless of employer size or industry sector; (d) pass legislation to remove administrative and legal obstacles for workers to form unions; (e) mandate a periodic review and update of all child labor regulations to keep pace with changes in workplaces; and (f) increase funding for OSHA enforcement activities.
  5. The U.S. Congress should amend the Occupational Health and Safety Act to (a) extend protections to farmworkers, domestic workers, and other workers in nontraditional employment arrangements; (b) redefine the duty of employers to ensure safety for all workers, customers, or members of the public; (c) require employers to abate hazards during a challenge to an OSHA citation; (d) streamline the process for issuing regulations; (e) require injury and illness recording and reporting for all employers; and (f) strengthen whistleblower protections.
  6. The U.S Congress should provide funding to NIOSH to (a) collaborate with other federal agencies to research, develop, and validate measures of decent work; (b) award research grants to investigate components of decent work, such as job and employment characteristics and their associated health effects and workplace justice initiatives designed to reduce racial and ethnic inequalities in work and health; (c) collaborate with state and community partners to evaluate the health and well-being effects of alternate models of worker protection and new participatory models of decent work, such as worker cooperatives; (d) establish with state agencies a robust surveillance program to investigate the prevalence of psychosocial, biomechanical, chemical, biological, and physical hazards across a representative sample of U.S. industries; and (e) establish partnerships with labor, economist, research, and employer organizations and other interested parties to explore the relationships among decent work, employment quality, and health and identify and evaluate interventions that promote health, safety, equity, and justice.
  7. The U.S Congress should provide funding to the Centers for Disease Control and Prevention to (a) strengthen existing data systems (e.g., the National Violent Death Reporting System and the Drug Overdose Surveillance and Epidemiology System) that can provide insights into the degree to which decent work objectives currently exist and measure changes in work structures and social supports that indicate whether strides are being made in adopting decent work and (b) integrate decent work as a social determinant of health and develop resources and tools to educate and engage employers in supporting workforce and population health and well-being.
  8. The U.S Congress should provide funding to the National Institutes of Health (NIH) to prioritize the role of work and connections among decent work, employment quality, aging, mental health, and physical health hazards across its centers and institutes. For example, the NIH should continue to support innovative population-based research that can contribute to identifying and characterizing pathways and mechanisms through which work or occupation influences health outcomes and health status among populations with health and/or health care disparities and how work functions as a social determinant of health.
  9. The BLS and the U.S. Census Bureau should expand the collection of data to include “decent work conditions” to complete refinement of data on work and employment status. In addition, the BLS should develop definitions and methods for collecting more detailed data on those who are underemployed and those who are employed as temporary workers, as gig workers, and in other work arrangements outside the traditional employer-employee relationship.
  10. The Centers for Medicare & Medicaid Services should require health care employers, organized labor, public health associations, and other interested parties to engage with the Agency for Healthcare Research and Quality, NIOSH, and the National Academies of Sciences, Engineering, and Medicine to examine the relationships among patient health and safety; health care worker health, safety, and well-being; and workplace policies and practices and to design strategies and tactics to promote decent work objectives at the federal, state, and local levels within the U.S. job market.
  11. State legislatures should (a) implement occupational safety and health coverage for state and local employees and amend workers’ compensation laws to provide universal coverage, including for migratory and seasonal agricultural workers, home care workers, caregivers for children and older adults, employees of small companies, and other categories of workers; (b) remove administrative and legal obstacles for workers to form unions; (c) direct state government agencies to eliminate loopholes for contracted work (to ensure that employees who work for temporary and staffing agencies can receive benefits) by requiring that contracting firms be held responsible for failure to have workers’ compensation policies; (d) evaluate and fund local alternate models of worker protection and enforcement strategies and fund the scaling up of successful models, including short work; and (e) evaluate and fund local industry partnerships for employment creation.


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