Workers Without Paid Sick Leave Less Likely To Take Time Off For Illness Or Injury Compared To Those With Paid Sick Leave

The decision of when to seek medical care is a complex one made only more complicated by whether or not a person has access to paid sick leave benefits through an employer. Paid sick leave allows employees to leave work to seek care or recuperate at home without losing wages. Of twenty-two countries ranked highly in terms of economic and human development, the United States is the only country that does not mandate employers to provide paid sick leave. ¹ Workers in as many as 145 countries have some paid sick days through either employer-mandated sick leave or national social insurance plans. ² For many Americans, a day off work translates into lost wages or jeopardized employment.

Seventy percent of the US civilian population working full time have paid sick leave benefits, while only 19 percent of part-time workers have this benefit. That leaves nearly forty-nine million workers without access to paid sick leave. ³ Employees in higher-wage jobs or at larger employers have higher rates of paid sick leave than do their counterparts in lower-wage jobs or employed at smaller companies. ³ The Family and Medical Leave Act (FMLA) of 1993 mandates that companies with more than fifty employees offer workers up to twelve weeks of unpaid job-protected leave. However, the FMLA does not address short-term sick leave or leave for routine or preventive care. ⁴ Given these restrictions, the FMLA should not be considered a substitute or proxy for paid sick leave.

Access to paid sick leave varies by race, with Hispanic workers having the lowest rates of coverage. ³ This health-related employment benefit is also less common among those who are younger, less educated, low income, in fair or poor health, and uninsured. ⁵ Only three out of ten low-income workers with a child in fair or poor health have paid sick leave benefits. ⁶

Workers use paid sick leave benefits to care for their own health needs or the health needs of their family members. This is particularly important to the nearly 50 percent of US adults who have one or more chronic health conditions ⁷ and the more than half of working Americans who provide care to a child or family member. ⁸ Paid sick leave allows workers (and presumably their dependent family members) to receive prompt preventive or acute medical care, recuperate from illness faster, and avert more serious illness. ²

The American Public Health Association endorses and advocates for paid sick leave benefits as a public health policy. ⁹ Although peer-reviewed studies on this topic are limited, evidence suggests that benefits of paid sick leave include increased job stability and employee retention following illness, injury, or birth of a child; ¹⁰ increased worker productivity; ¹¹ decreased worker errors in production; ¹² decreased accidents or injuries on the job; ¹³ and increased mental and physical health of caregivers. ¹⁴ Additionally, when used to augment maternity leave, paid leave increases well-baby visits, maternal health, and the duration of breastfeeding, while also decreasing infant mortality. ¹⁵

This study extended the limited body of existing research and examined the relationship between paid sick leave benefits and delays in care and forgone care for both working adults and their family members. It also examined the risk of emergency department (ED) use and the risk of missing work because of illness or injury by paid sick leave status. Finally, we analyzed interaction effects between paid sick leave and family income and health insurance.

Study Data And Methods

Sampling And Data Collection

Our study used data from the National Health Interview Survey (NHIS), an ongoing data collection initiative that began in 1957 and was designed to provide data about a broad range of health topics. The 2013 NHIS cross-sectional sample used multistage area probability sampling to derive a representative sample of the civilian noninstitutionalized US population. Black, Hispanic, and Asian people were oversampled in the adult sample.

NHIS survey interviews were conducted at the household, family, and individual levels. One randomly selected adult from each family was interviewed on a complementary set of questions. Interviews were conducted on an ongoing basis by trained Census Bureau employees either in person or by phone.

Measures

The thirteen control variables included in the analyses were sex of adult respondent, highest level of education attained (seven indicators ranging from eighth grade or less to doctorate), race and ethnicity (Hispanic, non-Hispanic white, non-Hispanic black, non-Hispanic other), marital status (yes/no), family size, occupation of adult respondent (five categories based on the Standard Occupational Classification system), obesity in adult respondent (body mass index greater than $30\mathrm{kg}/{\mathrm{m}}^2$ ), full-time work status of adult respondent (yes indicated worked thirty-five hours or more previous week, no indicated worked fewer than thirty-five hours in past week), health insurance coverage status of adult respondent (insured or uninsured, meaning that no health insurance under private health insurance, Medicare, Medicaid, State Children’s Health Insurance Program, a state-sponsored health plan, other government programs, or military health plan was reported), health status of adult respondent (excellent, very good, or good versus fair or poor), presence of a limiting condition in adult respondent (yes meaning limited in any way, no meaning not limited in any way), total annual family income (less than $35,000, $35,000 to less than $75,000, $75,000 to less than $100,000, $100,000 or more), and age of adult respondent (in years). ¹⁶ The indicator measured for all analyses was self-reported paid sick leave status (yes/no). These control variables were selected based on theory and past empirical findings as being related to the outcome variables. An interaction between paid sick leave and family income was added since losing a few days of wages might be less relevant in deciding whether to visit a doctor or not for high-income respondents, but for low-income respondents, family income and the absence of paid sick leave would likely be much more significant.

The six outcome variables examined were as follows: respondent delayed medical care in past twelve months because of cost (yes/no), family member delayed medical care in past twelve months because of cost (yes/no), respondent needed medical care but did not get it in past twelve months because of cost (yes/no), family member needed medical care but did not get it in the past twelve months because of cost (yes/no), respondent had an ED visit in past twelve months (yes/no), and number of days respondent missed work at job or business because of injury or illness (excluding maternity leave). We examined these variables because of their important implications for public health.

Measurement limitations included the reliance on self-reported data for all measures, so the question of accuracy was raised. We found a similar percentage of the workforce with paid sick leave as the Bureau of Labor Statistics found. An additional limitation was that some variables, such as ED usage, pertained to only the respondent, not all household members. Finally, the data we used were cross-sectional; therefore, causation cannot be established.

Analytic Sample

Three 2013 NHIS core questionnaires were used: family core (all related family members in the same household), person core (all individuals within a family), and sample adult (age eighteen or older randomly selected from family). The analytic sample included 18,655 adults ages 18–64 with current paid employment selected from the sample adult file. Those working without pay, working in a family business, self-employed, looking for work, or not working were excluded.

Data Analysis

We estimated five multivariable logistic regression equations and one multivariable regression equation. We used the same control variables (sex, education, race/ethnicity, marital status, family size, occupation, full-time work status, health insurance status, health status, obesity, limiting health condition, family income, and age) and one predictor variable (paid sick leave status) in all six equations. The outcome variables are described above, in the Measures section. Interaction effects were added between paid sick leave status and family income and between paid sick leave status and insurance coverage.

Study Results

We identified 10,586 working adults (57.3 percent) with paid sick leave benefits and 7,879 (42.7 percent) without. Their full demographic profile is shown in online Appendix Exhibit 1. ¹⁷ Those without paid sick leave were more likely to be male, unmarried, less educated, and Hispanic; hold service occupations; work part time; be uninsured; have fair or poor health; have a limiting health condition; and have lower incomes ( Exhibit 1 ). Nearly 65 percent of families with incomes below $35,000 had no paid sick leave, compared to 25 percent of families who earned more than $100,000 a year. This disparity left the most economically vulnerable without the protective benefit of paid sick leave.

When considering the respondent’s delaying medical care for themselves or a family member in the past twelve months, we found that those who did not receive a paid sick leave benefit had a significant ( $p<0.05$ ) increase in predicted risk of delaying medical care (0.3 percent versus 0.9 percent) for themselves and a family member (0.8 percent versus 1.6 percent) compared to those with paid sick leave benefits ( Exhibit 2 ). (See Appendix Exhibits 2 and 3 for full regression results.) ¹⁷ While predicted risks were significantly increased when the respondent was uninsured, there was no significant interaction effect between paid sick leave benefits and insurance status. Predicted risks were highest for the lowest family annual income category and significantly lower as family income increased ( $p<0.05$ ). There was also a significant interaction between family income and paid sick leave benefits ( $p<0.05$ ). The gap between predicted risks of delaying medical care was significantly smaller for those with less than $35,000 family income (11.1 percent without paid sick leave versus 9.8 percent with paid sick leave for those without insurance coverage; 2.5 percent without paid sick leave versus 2.4 percent with paid sick leave for those with insurance coverage) compared to all other income levels ( $p<0.05$ ). As a depiction of the interactive effects among paid sick leave benefits, income, and insurance status, the predicted risks (from Exhibit 2 ) of the respondent’s delaying medical care are shown in Exhibit 3 . The significance of these findings was true not only for delaying medical care but also for the respondent’s forgoing needed care (see Appendix Exhibit 4 for full regression results and Appendix Exhibit 9 for a depiction of the interactive effects). ¹⁷ While paid sick leave was important, having insurance also had a major impact on the respondent’s forgoing needed care, especially for low-income respondents. This was true for those with and without paid sick leave benefits and across income groups. The risk of forgoing needed care because of costs dropped from 16.5 percent for those without insurance to 3.1 percent for those with insurance among low-income adults without paid sick leave and 13.5 percent for those without insurance to 2.8 percent for those with insurance among low-income adults with sick leave.

SOURCE Authors’ analysis of data from the National Health Interview Survey, 2013.

When considering the risk of a family member’s delaying medical care or forgoing medical care, we observed the same pattern and significance of risks as for the respondent, with the exception that the interaction between family income and paid sick leave benefits was not significant ( $p<0.05$ ) when we analyzed the variable whether to forgo medical care. (See Appendix Exhibits 3 and 5 for full regression results and Appendix Exhibits 8 and 10 for a depiction of the interactive effects.) ¹⁷

Paid sick leave benefits and family income had a significant interaction effect ( $p<0.05$ ) when we considered the risk of an ED visit in the past twelve months. (See Appendix Exhibit 6 for full regression results.) ¹⁷ However, insurance status and its interaction with paid sick leave benefits were not statistically significant. We found that respondents with family incomes below $35,000 had the highest predicted risk of an ED visit (10.7 percent) regardless whether or not they had paid sick leave or insurance coverage. When family income was $35,000 or above and the family had paid sick leave, the predicted risk was nearly constant between 9.1 percent and 9.5 percent. Yet when there was no paid sick leave, the predicted risk of an ED visit decreased from 9.9 percent to 7.6 percent as family income level increased. (See Appendix Exhibit 11 for a depiction of the interactive effects.) ¹⁷ For all people in the sample with incomes below $35,000, the risk of an ED visit was higher than in any other income bracket. For people with incomes of $35,000 to <$75,000, the predicted risk of an ED visit depended on both paid sick leave and insurance status. For people with incomes of $75,000 or above, the predicted risk of having an ED visit was higher if they had paid sick leave than if they did not. Properly interpreting these findings requires additional research, which further examines factors that may influence ED usage, such as severity of health crisis and ability to access treatment in primary care settings.

Finally, insured working adults with paid sick leave benefits missed 1.5 days more of work because of illness or injury compared to workers without paid sick leave. Uninsured working adults with paid sick leave missed one day more of work because of illness or injury compared to workers without paid sick leave. Predicted mean days lost because of illness or injury are also presented in Exhibit 2 . (See Appendix Exhibit 7 for full regression results and Appendix Exhibit 12 for the depiction of the interactive effects.) ¹⁷

Discussion

This research greatly enhances our understanding of the relationship between paid sick leave benefits and health care–seeking behaviors. Both full- and part-time workers without paid sick leave were less likely than those with paid sick leave to take time off work when ill or injured and more likely to either forgo or delay treatment for themselves or a family member. These findings hold true after we controlled for individual- and family-level variables (including income, education level, and health status), which might otherwise influence delays in care and forgone care. Moreover, interactions between income and paid sick leave status indicate that the lowest-income group of workers without paid sick leave are at the highest risk of delaying and forgoing medical care for themselves and their family members—making the most financially vulnerable workers the least likely to be able to address health care concerns in a timely manner.

Delayed And Forgone Care

While increasing the number of people who are able to obtain timely and needed medical care is an important national health care objective, ¹⁸ existing research regarding paid sick leave’s relationship to delayed and forgone care is limited. Roy Penchansky and J. William Thomas’s model of access to care asserts that affordability, accommodation, availability, accessibility, and acceptability are important determinants of health care access. ¹⁹ Previous research identifies nearly 30 percent of US adults as having experienced delays in care or unmet health care needs; these respondents identified worry about the cost of care (affordability) and being “too busy with work or other commitments to take the time off” (accommodation) as the most prevalent reasons. ²⁰ Access to paid sick leave benefits cuts across several of these determinants to improve access to care. It prevents wage loss (affordability), provides workers with the ability to take time off without risking losing their job (accommodation), and also increases workers’ ability to seek treatment during daytime work hours (availability).

Findings from the research presented here are consistent with Penchansky and Thomas’s theoretical framework. Our findings indicate that needed care is three times more likely to be delayed or put off entirely because of cost for the adult worker without paid sick leave. Family members are two times more likely to delay needed medical care and 1.6 times more likely to forgo needed care when paid sick leave is not present. Of note, these delays are attributed to cost. It is possible that the cost concerns identified reflect not only the direct cost of health care and perhaps more expensive urgent care but also the indirect costs associated with wage loss for those who do not have paid sick leave benefits. The risk for delaying medical care was significantly lower for higher-income respondents, which supports the idea that lost wages may be easier to handle when income is higher. The personal health care consequences of delaying or forgoing needed medical care can lead to more complicated and expensive health care conditions.

Staying Home From Work When Sick Or Injured

Consistent with previous research, this analysis found that US workers with paid sick leave were more likely to miss work because of being sick or injured compared to workers without paid sick leave. Put another way, they were more likely to take time off work to care for self or family when needed. This is important since increased work absences are associated with shorter recovery times and reduced complications. ²¹ Additionally, the ability to stay home from work because of illness also allows workers and their dependent children to self-quarantine when necessary, without concerns about income or job loss. The importance of having this option is underscored by experience during the 2009 H1N1 influenza outbreak. The Centers for Disease Control and Prevention recommended that people stay home if they were sick; yet estimates suggest that employees who did not stay home infected an additional seven million people. ²² Lack of paid sick leave is estimated to have resulted in 1,500 additional deaths during this outbreak. ²³ Supriya Kumar and colleagues estimated that paid sick leave benefits could reduce influenza in the United States by as much as 6 percent. ²⁴

More recently, in early 2016 the Chipotle restaurant chain, in response to its struggle with E. coli and norovirus, announced a new paid sick leave benefit for all employees to ensure that employees stay home when they are ill, thus avoiding the possibility of making customers sick. ²⁵

Policy Implications

In addition to illuminating the potential value of offering noncompulsory paid sick leave, findings from this research can inform the discussion about mandatory paid sick leave policy. Globally, paid sick leave benefits are designed either as a mandated private employer benefit or as part of a national health system. Four US states (Connecticut, California, Massachusetts, and Oregon) along with a few dozen municipalities, now mandate paid sick leave as an employee benefit. ²⁶ In September 2015 President Barack Obama signed an executive order requiring that federal contractors allow workers to earn one hour of sick leave for every thirty hours worked, accumulating up to fifty-six hours or seven days of sick leave per year. ²⁷ Comprehensive, long-term, peer-reviewed analyses of outcomes in the US regions that have passed sick leave legislation do not exist, but some research does exist that describes some health and business outcomes pertaining to paid sick leave in these regions. ^28,29 Our findings add to the body of research that policy planners can consider when weighing the issue of mandatory paid sick leave.

Reducing health disparities and improving access to medical care are national aspirations as documented in the Healthy People 2020 agenda. ³⁰ When one takes into consideration the differential access to paid sick leave by race and ethnicity, income, and health status, access to paid sick leave can be viewed as a modifiable health disparity. Understanding the public health impact of employment policy is an important step toward implementing sound workplace regulations that may lessen the longstanding health care disparities between higher- and lower-wage workers.

In addition to those weighing the value of mandatory paid sick leave, this research is of interest to stakeholders such as health planners, human resources managers, and employers who aim to voluntarily plan their benefit packages in a way that optimizes the health and productivity of employees, while also boosting their business performance. Although further research is needed, findings from this study suggest benefits associated with paid sick leave, which these stakeholders may want to consider.

Health system policies, which support expanded access to affordable after-hours and weekend health services, should also be considered so that those without paid sick leave are able to get preventive and routine treatment in nonemergency settings. Similarly, policy makers should also consider expanded access to health clinics in schools and work settings and the use of telemedicine appointments that could occur while at work or school. When workers report cost as the reason for delayed or no receipt of medical care, they are often counting the indirect costs, which include loss of wages in addition to the cost of the care itself. Being able to seek health care services after work hours would reduce the loss of wages. ³¹

Implications For Future Research

Future research should assess whether urgent care and ED use is significantly related to paid sick leave, considering the entire family unit and not just the adult worker. Future research should also examine whether family medical care costs are higher because of delayed or forgone care among those without paid sick leave. The relationship between paid sick leave and specific health outcomes for individuals, families, coworkers, and the patrons they come in contact with should be further investigated as well. Finally, gaps in insurance coverage and the quality of insurance coverage should be further examined in relation to these variables. Such research would help in the effort to relieve the burden of health care seeking for the most vulnerable members of the work force: those with lower incomes who lack paid sick leave.

ACKNOWLEDGMENTS

All analyses, interpretations, and conclusions from this research are attributable to the article’s authors and not to the National Center for Health Statistics, which is responsible for the initial data only.

NOTES

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