Proportion of Workers who were Work-injured and Payment by Workers' Compensation Systems — 10 States, 2007

DK Bonauto, MD; JZ Fan, PhD; TW Largo, MPH; KD Rosenman, MD; MK Green, MPH; JK Walters, MPH; BL Materna, PhD; J Flattery, MPH; T St. Louis, MSPH; L Yu, PhD; S Fang, ScD; LK Davis, ScD; DJ Valiante, MPH; KR Cummings, MPH; JJ Hellsten, PhD


Morbidity and Mortality Weekly Report. 2010;59(29):897-900. 

In This Article

Editorial Note

In the United States, the primary surveillance system for state and federal level estimates of occupational injury is the Bureau of Labor Statistics' Survey of Occupational Injury and Illness (BLS SOII), which relies on data collection through employer-based case reporting.[1] Employer-based reporting underestimates the full burden of occupational injury because of worker underreporting of occupational injuries to their employers or incomplete employer recording of injuries.[2,3] BRFSS can supplement employer-based occupational injury surveillance systems by providing population-based information on worker injuries. The findings presented in this report are a good example; BRFSS was used to estimate the proportion of occupational injuries for which the costs of medical treatment or advice were paid by workers' compensation programs. An advantage to using BRFSS to supplement occupational injury surveillance is that the injuries captured by BRFSS are broader than the injuries captured by BLS SOII, which generates estimates of occupational injury based only on those cases that are required to be recorded under Occupational Safety and Health Administration (OSHA) recordkeeping rules. OSHA recordkeeping rules do not include all injuries for which a respondent might answer positively to a BRFSS work injury question. For example, injuries OSHA defines as receiving first aid are not required to be recorded on the OSHA log.§ Examples of first aid include drilling a fingernail or toenail to relieve pressure, or cleaning, flushing, or soaking wounds on the skin surface. Further research could help determine the worker, employer, and injury characteristics of worker-reported occupational injuries that were likely recordable under OSHA recordkeeping rules but were not recorded.

In the United States, workers' compensation systems typically are state-regulated social insurance programs designed to extend no-fault liability for workplace injuries, coupled with guaranteed medical benefits and partial wage compensation to workers injured during employment.[5] In this report, the proportion of respondents with medical treatment paid for by workers' compensation varied greatly among the 10 states, from 47% in Texas to 77% in Kentucky. Several reasons might exist for this large variation. First, the ability to make state-to-state comparisons using workers' compensation data is substantially limited. In nearly all states, workers' compensation insurance is mandatory for most private and nonfederal public sector employers, with benefits available for most workers employed for wages.[5] However, highly variable state-specific exclusions for mandatory employer workers' compensation insurance exist for specific occupations (domestic workers or corporate officers), and small employers (typically employers ranging from one to five employees).[5] In Texas, employers may choose not to have workers' compensation insurance. In most states, self-employed workers are not required to have workers' compensation insurance and this was the rationale for exclusion of this population from the analysis. Second, although an injured worker might be covered by workers' compensation insurance, the particular injury sustained might not be compensable by the workers' compensation program. For example, injuries resulting from repetitive trauma or from an aggravation of a non–work-related injury or pre-existing injury might not be eligible for compensation in some states. Third, an injured worker with workers' compensation coverage and an eligible injury might not report an injury or seek compensation. Reasons for not reporting an injury to workers' compensation likely include, among others, access to alternative health-care insurance, less severe injuries, longer employment duration, low wages, poor job security, immigrant status, and concerns over employer or coworker retribution for injury reporting.[3]

Several state-based occupational injury surveillance systems identify hospitalizations as work-related if the payer was workers' compensation insurance.[6] The substantial portion of occupational injury cases where workers' compensation was not used for payment suggests that this methodology might yield underestimates of occupational injury rates.

The findings in this report are subject to at least three limitations. First, the recall period of 12 months increased the likelihood of reporting inaccuracy, although whether this resulted in underreporting or overreporting is unknown. Second, work-related injury rates vary by occupation and industry and employment by occupation and industry varies by state. However, standardized estimates (which would enhance state-to-state comparisons) could not be developed because respondent industry and occupation data were not collected. Finally, although the BRFSS weighting procedures correct for nonresponse, the low response rates increase the risk for response bias.

Evaluations of CDC's National Institute for Occupational Safety and Health (NIOSH) surveillance programs have recommended expansion of nonfatal occupational injury surveillance to include the use of nonemployer data sources such as BRFSS.[7] The analysis presented in this report is an example of how BRFSS can be used. NIOSH also is exploring the use of other population-based surveys, such as the National Health Interview Survey and the Current Population Survey, which is the primary source of U.S. labor force data.[8] In doing so, NIOSH is considering costs, the feasibility of producing reliable national and state estimates, the ability to address illnesses as well as injuries, the collection of industry and occupation data, the ability to address health disparities, and other factors. NIOSH also has initiated new research to examine underreporting of occupational injuries and illnesses, which will help inform surveillance expansion efforts.

§ Available at
Alternative federally administered workers' compensation programs cover federal, railroad, and maritime employees.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.