Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line (2020)

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1 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line S.1 Background Transit workers experience more health and safety problems than the general work- force, primarily due to physical demands, environmental factors, and stresses related to their jobs. Finding explanations for these poor health outcomes and identifying poten- tial solutions is the primary focus of this report. To accomplish these objectives, the Econometrica team undertook a multifaceted research project that used diverse sources of information, including case studies, interviews with industry and health experts, primary data collection, and rigorous statistical-econometric analysis. Health and safety risk factors for transit workers include the sedentary nature of the job, shift work, environmental factors (e.g., noise and air quality in and around the vehicle), constant daily interaction with hundreds of passengers (any of whom might engage in unruly or risky behavior), continual stressful engagement (performing difficult maneuvers) in traffic, responsibility for fare collection, and a work schedule that limits the ability to maintain healthy habits such as regular exercise, sufficient sleep, and a healthy diet. Additionally, prior research has demonstrated that transit work has been associated with higher rates of risky behaviors (including poor diet, smoking, and alcohol use) and chronic conditions (such as diabetes, primarily Type 2; cardiovascular disease; and musculoskeletal disorders). This report identifies and examines the reasons for these outcomes and provides poten- tial strategies to improve transit worker health. It provides a summary of previous research on methods to improve the workplace environment and establish effective practices for health promotion and wellness programs. Research in this area includes reports previously published by the Transportation Research Board, including TCRP Report 169: Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention (Gillespie, Wang, and Brown 2014), TCRP Report 174: Improving Safety Culture in Public Transportation (Roberts, Retting, and Webb et al. 2015), and additional public and private sources. To date, there is limited research on the effectiveness of health promotion programs for transit workers as measured by the reduction of sick or personal days, workers’ compen- sation payments, or health claims. Econometrica builds on the scant existing research by estimating the potential beneficial effects of health promotion programs based on data collected from five locations. The project team gathered data in five locations: Rochester, New York; Louisville, Kentucky; Indianapolis, Indiana; Des Moines, Iowa; and Los Angeles, California. This report contributes to the literature with econometric and statistical analysis, using primary source individual-level data collected from the wellness programs of four metropolitan transit agencies (the exception being Los Angeles, which only provided aggregate data). S U M M A R Y

2 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line The results obtained using these data provide additional information on the participation in and effectiveness of health promotion programs for transit workers. In addition to identifying and examining the reasons for these health outcomes and providing strate- gies to improve them, the project team completed an investigation of the costs associated with health and safety issues to accurately chronicle the full extent of the problem. These costs include out-of-pocket medical, safety, and other job-related expenditures by transit workers, payments by insurers, costs of covering shifts for workers absent due to sickness and injury, and costs of supporting disabled workers through state workers’ compensation or federal disability programs. S.2 Prevalence and Costs of Health Conditions The research team identified national estimates of healthcare costs and worker pro- ductivity to establish a baseline for the health outcomes discussion and subsequent quantitative analyses. These estimates are presented in relation to transit worker illness and injuries for comparison and eventual evaluation of transit agency health promotion programs. The report reviews studies on the prevalence of health conditions of transit and transportation workers compared to the general population and then develops health cost estimates associated with health conditions relevant to transit/transportation workers. Table S-1 presents prevalence estimates of six chronic conditions for transit workers identified from government sources or peer-reviewed journals: cardiovascular disease, diabetes, hypertension, musculoskeletal disorders, mental health, and respiratory illness. For comparison purposes, the table also presents the prevalence rate among workers in the general population. Table S-1 shows that transit workers experience much higher rates of all six of these chronic conditions. For diabetes, musculoskeletal, and respiratory conditions, the rates are at least twice as high for transit workers. For cardiovascular, hypertension, and mental health, the rates for the general worker population are high initially, but occurrence rates for transit workers are still at least 50% greater. The analysis starts from this baseline: Transit workers are in worse health than the general population. Table S-1. Prevalence of chronic conditions affecting transit workers compared with the general workforce. Condition Source Period Transit Workers General Workers Cardiovascular Highmark, Inc. (CDC–NIOSH) *, a 2002–2005 14.5% 8.1% Diabetes Highmark, Inc. (CDC–NIOSH) *, a 2002–2005 17.3% 7.8% Hypertension Highmark, Inc. (CDC–NIOSH) *, a 2002–2005 41.5% 27.6% Musculoskeletal Survey of Occupational Injuries and Illnesses b 2016 1.7% 0.3% Mental health Highmark, Inc. (CDC–NIOSH) *, a, c 2002–2005 16.2% 10.5% Respiratory Survey of Occupational Injuries and Illnesses d 2016 0.04% 0.01% * Researchers with the Centers for Disease Control–National Institute for Occupational Safety and Health (CDC–NIOSH) worked with Highmark, Inc., to assemble a multi-year database for the purpose of calculating industry-specific, prevalence rates of 15 diseases. Highmark, a BlueCross BlueShield insurer, provides health insurance for the majority of the working population in Western Pennsylvania, plus other areas not covered by these data. The Highmark, Inc., information included in this table was reported in Bushnell, Li, and Landen (2011). The code titles used for the various conditions followed the BLS (2012). Sources: a Bushnell, Li, and Landen (2011); b BLS (2017a); c Wulsin, Alterman, and Bushnell et al. (2014); and d BLS (2019b)

Summary 3 The additional medical expenditure costs as a result of these health differences are high. Table S-2 presents the average annual medical expenditure for a person in the United States by each of these same six conditions as reported in the 2015 Medical Expenditure Panel Survey (MEPS 2015) next to the prevalence rate for the transit worker population from Table S-1. The fifth column in Table S-2 takes the number of transit workers afflicted by this condition and multiplies it by their average per person medical expense amount (e.g., $4,556 for cardiovascular) to provide an estimate of the total annual expenditures for the transit worker population for that particular chronic condition (i.e., approximately $238 million per year for cardiovascular). The fifth column shows the approximated annual costs for transit workers beyond that of the general popula- tion given the greater prevalence of these conditions among transit workers (i.e., the costs beyond what they would be if transit workers experienced the conditions at the same level of prevalence as the general population). For example, the annual medical expenditures for transit workers for cardiovascular disease are estimated to be $238 mil- lion per year ($4,556 per transit worker per year, multiplied by 14.5%, the prevalence rate for the transit worker population). If transit workers experienced cardiovascular disease at the same preva lence rate as the general population (8.1%), the cost would be considerably lower: $133 million. Consequently, the costs of the greater prevalence of cardiovascular disease among transit workers come to $105 million ($238 million minus $133 million). This research shows the additional chronic condition medical expenditures of transit workers above that of the general population. The large difference suggests that directing resources toward the alleviation and prevention of transit worker health problems should result in some cost savings in addition to potential improvements in health and quality of life for transit workers themselves. The findings suggest that the higher preva- lence of chronic conditions in transit workers relative to the general working popula- tion (Table S-1) may translate into considerable expenditures by workers, employers, and Condition U.S. Average Medical Expenditures per Person (2015) Prevalence: Transit Workers a (Table S-1) Prevalence: General Workers (Table S-1) Approximated Annual Expenditures for Transit Workers (2015 Dollars) b Approximated Annual Expenditures for Transit Workers Above Those of General Workers (2015 Dollars) c Cardiovascular $4,556 14.5% 8.1% $238,000,000 $105,000,000 Diabetes $3,402 17.3% 7.8% $212,000,000 $116,000,000 Hypertension $823 41.5% 27.6% $123,000,000 $41,000,000 Musculoskeletal $2,000 1.7% 0.3% $12,000,000 $10,000,000 Mental health $1,992 16.2% 10.5% $116,000,000 $41,000,000 Respiratory $1,633 0.04% 0.01% $234,000 $175,500 a Calculations are based on a transit worker population base of 359,669 workers (APTA 2018). b Calculated as transit worker population × transit worker prevalence × average medical expenditure per person. c Calculated as transit worker population × (difference between transit worker and general population prevalence) × average medical expenditure per person. Sources: Highmark, Inc. (CDC–NIOSH) as reported in Bushnell, Li, and Landen (2011); BLS (2017a); Wulsin, Alterman, and Bushnell et al. (2014); and BLS (2019b) Table S-2. Medical expenditure approximations for the transit worker population.

4 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line society through out-of-pocket spending, employer-based insurance, and federal insur- ance sources (Table S-2). Directing resources to prevent or attenuate these conditions could result in savings. S.3 Additional Costs of Transit Worker Health to Individuals, Employers, and Society The processes by which health issues convert to expenditures and costs also are examined. The focus is on quantitative estimates of expenditures because those are more easily tracked through the existing data. Examples of expenditures by workers and their families, employers, and state and federal agencies are provided. The research compares transit workers to the general population and estimates the difference between their costs and those of the general population. The costs (payment categories) examined include: • Injuries; • Mortality; • Absenteeism; • Workers’ compensation; • Social Security Disability Insurance (SSDI), a form of disability payment; • Supplemental Security Income (SSI), also a form of disability payment; and • Medicare. Table S-3 summarizes the results of calculations made in Chapter 5 to understand the costs associated with transit worker health conditions. The research team identified mechanisms through which costs are transmitted from individuals to employers and society, such as workers’ compensation and disability payments. A better understanding of these mechanisms can help transit agencies decide which conditions to target to reduce costs. In all the expenditure categories examined, the costs for transit workers were found to exceed the costs for general workers by amounts ranging from tens of millions to hundreds of millions of dollars. The excess costs for transit workers across six chronic health conditions (cardiovascular, diabetes, hypertension, musculoskeletal, mental health, and respiratory) are related to their excess costs in some of the categories listed in Table S-3. Chronic conditions can lead to higher injury and mortality rates, as well as the necessity of drawing on dis- ability and Medicare at earlier ages. The excess costs found across payment categories result directly from the costs of the conditions examined. Cost (Payment Category) Transit Worker Cost Cost per Transit Worker Excess Cost * Excess Cost per Transit Worker Workers Injury costs $853,768,760 $2,374 $403,284,268 $1,121 Mortality costs $189,174,784 $526 $61,171,511 $170 Employers and society Absenteeism $314,301,144 $874 $25,144,092 $70 Workers’ compensation $261,780,645–$413,826,181 $728–$1,151 $121,139,893– $140,199,032 $337–$390 Disability (SSDI) $405,770,309 $1,128 $128,342,087 $357 Disability (SSI) $115,238,954 $320 $36,445,966 $101 Medicare $315,484,742 $877 $99,780,303 $277 * Excess cost is calculated as the difference between the average transit worker cost and the average general worker cost. Source details about both transit worker costs and general worker costs are provided in Chapter 5. Table S-3. Compilation of annual excess cost estimates (2018 dollars).

Summary 5 S.4 Case Studies These findings on expenditures, health conditions, and costs served as a basis for the case study analysis. Cataloging the degree to which transit agencies target areas where cost savings might be achieved was a key objective. The case studies provide considerable new information on wellness programs and their potential impact on transit worker health. The case studies were selected based on specific criteria. First, using survey results from TCRP Report 169, the team created a list of 17 agencies and 5 unions that reported tracking metrics for programs or estimated a past or projected return on investment (ROI). Next, the team sent a query to the APTA’s Workforce Development Committee Listserv, asking for interest in the study. This query generated 14 leads, and four sites—agencies in Rochester, New York; Louisville, Kentucky; Indianapolis, Indiana; and Des Moines, Iowa—met the criteria of having both a comprehensive health promotion program and individual-level data. A fifth case study site with aggregate data (Los Angeles, California) also was selected. The case studies help identify scalable and sustainable strategies that have been suc- cessfully initiated and implemented in transit agencies. These programs provide multiple features to participants, such as workshops on diet and exercise, biometric screenings, targeted education to avoid common types of injury (e.g., musculoskeletal injuries), finan- cial planning, fitness challenges, and onsite gyms. For four of five of the case studies, the research team conducted a benefit-cost analysis to determine if measurable benefits are associated with participation in these programs. Baseline data were collected reflecting periods before and after the comprehensive health and wellness programs began. The data included individual records of absenteeism (both sick and personal days taken), workers’ compensation payments, and measures of participa- tion (after). Because data were also available on age, gender, race, day of hire/termination, and rates of turnover (in some cases), participants could be compared to non-participants based on their characteristics and tenure in the program. Each case study location’s work organization and environment was unique, and each agency faced different health, wellness, and safety challenges. Commonalities were found across the locations, however: For example, at all five locations, the majority of bus operators work split shifts. This impacts their access to healthy food, affects their sleep patterns, and limits their ability to participate in certain health and wellness program activities. Comparing the top three health, wellness, and safety concerns expressed by manage- ment and labor representatives and insurance claims data, the researchers found that hypertension, musculoskeletal injuries (back and neck pain), and diabetes are the most commonly shared concerns for frontline transit workers across locations. Other issues include sleep apnea, cardiovascular diseases (i.e., heart conditions), injuries from bus accidents, obesity, stress/fatigue, and cholesterol disorders (hyperlipidemia). Using primary data collected from transit agencies at the employee level, the research team generated informative descriptive statistics that expand on the research available in recent literature on the effectiveness of health promotion programs. These data have not been released publicly and represent a new source of information. Although these case studies produced limited results that could translate into quantifiable cost savings for agencies, the information gathered adds a host of new information on employee absence/ sick leave patterns as they relate to health, wellness, and safety program participation among transit employees.

6 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line S.5 Study Limitations The research in this report is subject to several limitations. Some additional cost catego- ries, such as quality of service, could not be itemized (primarily from a lack of available data). Also, cost categories can overlap and are not additive as a function of comorbidi- ties. The research primarily used cross-sectional data because it was the only data readily available for a sufficient number of transit workers to answer the fundamental research questions. Cross-sectional data can yield distorted results because it cannot account for the life trajectories of transit workers who are forced to leave transit work early due to health issues, or transit workers whose lives are shortened by health and safety issues related to their work. The study also could not include controls for differences in gender and age in the data analysis about condition costs and prevalence, as this level of detail was beyond the scope of the research. Exploring differential response patterns affected by gender and age would be worth examining, recognizing that transit workers are disproportionately older and male in comparison to the general population. Last, this study could not account for differences in local regulations. Local agencies are numerous and diverse, and examining how local regulations might affect outcomes could be a fruitful area for future research. The research conclusions recognize and have accommodated these limitations, and they reflect a careful implementation and consideration of the level of detail represented in the original research work plan. S.6 Wrap-Up The goal of this study was to identify ways to improve employee health and safety outcomes resulting from work conditions and broader health promotion practices and their impacts on transit agencies’ bottom line. The research focused on the preva- lence of conditions, costs associated with conditions, and statistical analysis of data on participation in and the results of health and wellness promotion programs. This report documents the chronic conditions that are most prevalent among transit workers (cardiovascular disease, diabetes, hypertension, musculoskeletal disorders, mental health, respiratory disorders) and documents that annual costs are higher for transit workers compared to the average worker. These excess costs also were observed in the payment types examined—injury, death, absenteeism, workers’ compensation, disability (SSDI and SSI), and Medicare. In all cases, the annual costs of these categories for transit workers exceeded the costs for the average worker. The project team extended the initial investigation through case studies on health and wellness programs at five transit agencies, documenting not only the substance of the programs offered to transit workers but the resources and organizational strategies that agencies and unions used to put the programs in place and make them sustainable. Although no programs addressed all of the chronic conditions most common among transit workers (few seemed to address respiratory health, for example), they did focus on issues that affect transit workers’ overall health and work performance. Statistical analysis of the four sites that provided individual-level data yielded results that are more sugges- tive than definitive; however, this analysis provides a model for further analysis that sites with the appropriate data can use to evaluate their own programs. The implementation strategy discussed in Chapter 7 provides an analysis of how well the programs are doing in terms of following the “roadmap for transit and health safety” provided in TCRP Report 169. The information provided about the health and wellness programs in the case studies and the implementation strategy chapter offer detailed information that could guide transit agencies currently designing new health, wellness,

Summary 7 and safety programs or provide guidance on how to improve current programs. In terms of how to use this report to design wellness programs that benefit the health of transit workers, the authors of this report recommend a two-step approach: 1. Review the background research on the types of health issues workers are most likely to experience and the programs that are most effective in addressing them. Although the programs in the case studies were considered beneficial by employees and transit agencies, the research team could not find measurable impacts or detect statistically valid effects. 2. Determine the issues facing the agency’s employees, the types of programs they would use, and a means of evaluating the impacts of those programs before initiating them. Over time, assess the programs’ ROI and make adjustments as needed. Prior TCRP publications have included resources to help design and track such programs. In parti- cular, the project team recommends a spreadsheet titled “Transit Operator Workplace Health Protection and Promotion Planning, Evaluation, and ROI Template.” The spread- sheet file is available for download at no charge from the TCRP Report 169 webpage at www.trb.org. This report adds another layer of research to past studies that explored health and safety outcomes for transit workers and health promotion programs by quantifying the costs of widespread and consistently poor health and safety outcomes and the cost savings, if any, that can be attributed to those health promotion programs. Dangerous and strenuous work environments exact a toll on workers that also affects their employers and society. A better understanding of that toll, its costs, and the potential means of mitigating it are valuable contributions to the literature on the subject.