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The fight to expand access to paid sick leave continues even after President Biden decided not to include more than one day of paid sick leave in the recently “settled” contract for rail workers.

Last week, more than 70 members of Congress sent a letter to Biden calling on him to use an executive order to grant seven days of paid sick leave to rail workers. Unions across the country, including those representing pilots and graduate school workers, are putting sick and family leave at the center of their negotiations.

Paid sick leave is the right thing to do for individual and public health. Yet the United States is unique among high-income countries in not mandating that employers provide their workers with access to it. To be sure, the Family and Medical Leave Act provides for unpaid sick leave to workers, and 16 states have laws that can be used for sick leave. But that leaves millions of American workers forced to forgo pay when they are out sick.


In response to the Covid-19 pandemic, the Families First Coronavirus Response Act, which went into effect in mid-March of 2020, made limited paid sick leave available to workers employed in businesses with fewer than 500 workers and some public sector workers. It expired at the end of 2020, meaning that, even in the midst of huge waves of the Covid-19 pandemic, many workers have had no guarantee they will be paid while out sick.

A study published earlier this year estimated that, in 2018, only 62% of private sector workers had access to paid sick leave. Even with the state laws that went into place in the intervening time, this proportion was only a 5% increase in access to this kind of support compared to 2006. The study also revealed disparities in access. In particular, Hispanic workers and workers with lower levels of education were the least likely to have paid sick leave.


I recently completed a similar analysis using data from the 2020 National Health Interview Survey. Despite the passage of the Families First Coronavirus Response Act, many workers in 2020 still reported not having access to paid sick leave, and this access varied widely by occupation. In particular, workers in vital occupations such as farming, construction, food preparation, building cleaning, transportation, and health care support had lower access to supported sick leave than the average for all workers. Workers in many of these occupations tended to have higher rates of Covid-19 death during the pandemic.

Scatterplot of paid sick leave by occupation and Covid-19 death rates
Graph based on the author’s analysis of data from the 2020 National Health Interview Survey Courtesy Devan Hawkins

This potential association between access to paid sick leave and Covid-19 is not surprising. Providing workers with access to it makes it possible for them to quarantine while sick to prevent the virus from spreading to their co-workers and those using public transportation. When such protections are not provided, many workers, especially the most economically vulnerable — who also tend to be at higher risk for other negative health events — will choose to work and avoid losing their pay.

Paid sick leave is protective against other problems beside the spread of Covid-19 and other infectious diseases. A growing body of literature shows that workers with access to it have a variety of positive health outcomes compare to workers without it, including fewer emergency department visits, lower levels of psychological distress, lower rates of occupational injuries, and higher use of preventive medical services. One study even found that workers with access to paid sick leave had lower mortality rates, which may be at least in part due to lower rates of drug overdose and suicide among workers in occupations with higher access to paid sick leave.

The lack of access to paid sick leave in the U.S. is an important public health concern. The motivation for denying workers access to paid sick leave is often to protect profits. In the case of the railway industry, providing workers with multiple paid sick leave days is seen as a threat to the precision scheduling system that essentially requires workers to be on call for weeks at a time. The system allows the railway industry to maintain fewer employers and therefore lower its labor costs, resulting in record earnings for the industry. At the same time, the costs of the harm this policy does to employees falls on the workers themselves, their families, and society at large.

Paid sick leave is not the only leave policy that workers in the United States do not have a federal right to. Paid parental leave is another. The health impacts of lack of access to parental leave fall on the workers as well as their children. With respect to maternity leave in particular, studies have found that workers with paid maternity leave have better mental health as well as higher rates of breastfeeding, especially when the leave is of longer duration. As is the case for paid sick leave, workers without access to paid maternity leave are more likely to be Black or Hispanic, and to have lower levels of education.

The federal government has the power to act to mandate both paid sick leave and paid parental leave — after all, paid sick leave was made available during the pandemic and Congress has considered proposals for paid family leave. The president has said that “every worker in America deserves” should have access to paid sick leave, though it is difficult to gauge the strength of this commitment considering he did not strongly advocate for the House of Representatives resolution that was passed to add seven days of supported sick leave to the railroad contract, and has so far not acted on calls to issue an executive order to provide seven days of it to rail workers.

The rules in place in the U.S. regarding paid sick and family leave should represent what Americans value as a society. It is a fundamental choice between making it possible for workers to recover when sick or injured, to take themselves or a family member to a medical appointment, and to spend essential time with a newborn child versus higher profits for business. For working people and their families, the best choice is clear.

Devan Hawkins is an assistant professor of public health at MCPHS University in Boston.

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