The critical public health importance of paid family leave (PFL) was convincingly reinforced by Hutcheon et al. in this issue of AJPH (p. 316). Using interrupted time series analysis of New York State population-based, all-payer hospital discharge records, they found that hospitalization rates for respiratory syncytial virus bronchiolitis and any acute lower respiratory tract infection among infants aged 8 weeks or younger decreased by 30% after the introduction of New York’s paid family leave program in 2018. This research adds to a growing body of evidence that PFL programs have a positive impact on the health of birthing people and their families, including improved postpartum mental health, increased breastfeeding and infant immunization rates, and decreased infant mortality rates.1,2
At the time it was implemented in 2018, New York’s PFL program was the most comprehensive in the country and provided 8 weeks of paid leave to care for a new baby, a seriously ill family member, or one’s own serious illness. Hutcheon et al. focused on infants 8 weeks of age or younger. These children were the most likely to have had fewer respiratory infections had they benefitted from the program through delaying the start of out-of-home childcare. To rule out the possibility that the decreased rate of hospitalization for respiratory infection was caused by something other than the new PFL law, the authors conducted a negative control analysis with 1-year-old infants, a population that should not have been affected by the law because leave to care for a new baby must be used within 12 months of the child’s birth. As expected, rates of respiratory syncytial virus bronchiolitis and any acute lower respiratory tract infection were unaffected by PFL in this older age group.
Like much of the literature linking PFL laws to health outcomes, Hutcheon et al. used an intent-to-treat analysis that estimates the impact of New York’s state paid family leave policy as implemented in a real-world setting, which, as the authors point out, is particularly useful to policy-makers. This also avoids the selection bias that is common in observational studies of paid leave and other workplace benefits. Workers with access to paid leave differ in meaningful ways from workers without access to paid leave. Without any national PFL program in the United States, access to paid leave depends on individual and occupational characteristics. For example, 40% of US workers in the highest-wage occupations have access to PFL through their jobs, but just 7% of workers in the lowest-wage occupations do.3 Similar disparities exist by industry, firm size, and full- versus part-time work hours. Workers of color are also less likely to have access to paid family leave through their jobs,4–6 which could be attributable to institutional racism in workplace benefit policies and structural racism resulting in occupational segregation. Intent-to-treat analysis reduces statistical bias that derives from observed and unobserved differences in access to PFL and avoids overestimating the efficacy of PFL. However, this approach ignores the underlying inequities in the impact of state PFL policies in real life.
DESIGN AND IMPLEMENTATION CHALLENGES
While PFL laws strongly contribute to increasing access to paid leave, passing a law is not enough to ensure equitable access to the health benefits we know are possible. We continue to see inequitable access to paid leave even in states with PFL laws, such as New York. This is because of several policy design and implementation issues that have plagued PFL laws in the United States.
First, state PFL laws do not cover all workers. Many, like New York’s, require minimum hours worked or program contributions or include only private-sector workers—restrictions that disproportionately exclude workers of color.7
Second, state PFL programs suffer from low public awareness. Appelbaum and Milkman found that just 49% of California workers who had recently experienced a qualifying event (e.g., becoming a parent or having a close family member become seriously ill) were aware of the state’s PFL program five years after the policy went into effect, with even lower awareness among low-wage, immigrant, and Latina/x/o workers, and workers who had not finished high school.8 More recent qualitative studies in California and elsewhere provide evidence of continued low awareness.9
Third, these policies are complex and many workers do not receive adequate support and information. Even those who have heard of state-level policies often misunderstand key policy elements, including eligibility.10 Workers and their employers also confuse different laws and programs, potentially preventing workers from taking advantage of all available leave. For example, in their study of 75 lower-income mothers who had recently used California’s PFL program for the birth of a child, Winston et al. reported that several participants realized during the focus groups that they had misunderstood the state benefits and, as a result, had requested or received substantially less paid leave than they were eligible for.9 In our study of San Francisco, California’s Paid Parental Leave Ordinance, lower-income parents were significantly less likely than their higher-income counterparts to report that their employer helped them learn about their parental leave benefits. In fact, the most common source of information about parental leave among lower-income parents was “nobody.”10
Finally, most paid leave programs do not provide full pay or job protection,11 which prevents some workers from taking full advantage of the laws.12 The fact that most workers face separate eligibility for job protection and wage replacement, where available, contributes to the confusion described previously.
MOVING TOWARD POLICY SOLUTIONS
A growing body of literature suggests that PFL policies have the potential to have a positive impact on health, but without understanding and addressing these implementation barriers, positive health impacts may be limited to the most advantaged workers. Workers in the United States face huge inequities in access to PFL that are driven by structural forces. Now is the time to decide whether we in the public health community are going to focus on making sure workers have access to PFL. It is time we move from documenting the problem to identifying and enacting policy solutions.
As public health researchers focusing on the health impacts of PFL and other social policies, we need to explicitly examine the heterogeneous impacts of these policies across a population to determine whether they are reaching all of their intended beneficiaries. Furthermore, we need to interrogate the policy design elements that contribute to those differential impacts. Who is covered by a policy? Who is left out? Are benefits comprehensive enough to be truly accessible? What protections are in place for workers who face retaliation for using benefits defined in the law? Do people even know the policy exists?
PFL and other social policies of critical public health importance are being considered in the Build Back Better Act and in state and local governments across the country. By asking these questions, our research can inform these ongoing policy discussions to ensure the public health benefits are equitably distributed.
ACKNOWLEDGMENTS
This work was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health under award K12HD043488.
Note. The content is solely the responsibility of the author and does not necessarily represent the official views of the National Institutes of Health.
CONFLICTS OF INTEREST
The author has no conflicts of interest to disclose.
Footnotes
See also Hutcheon et al., p. 316.
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