Paid Leave and Beyond: The Urgency and Feasibility of Addressing Structural Inequalities Across Race, Gender, and Class

Goodman et al. (p. 1050) compellingly document marked inequalities in who is most at risk for lacking paid medical, caregiving, and parental leave in the United States. They find that just 47% of Hispanic workers, 59% of Black workers, 68% of Asian workers, and 67% of White workers had access to paid medical leave they could use for their own care and treatment. Even fewer had leave to care for an ill family member.

HOW GAPS IN PAID LEAVE WORSEN INEQUALITIES

These gaps have had profound consequences; while home to only 4% of the global population, the United States has accounted for 16% of COVID-19 deaths to date,¹ with Black, Latinx, and Indigenous Americans twice as likely to die from COVID-19 as White Americans.² Drivers of these disparities include higher rates of exposure and infection linked to working conditions.³ The enactment of emergency paid sick leave during the pandemic, despite not covering all workers, markedly reduced cases until Congress let it lapse at the end of 2020.⁴ Furthermore, even in nonpandemic years, paid sick leave has been shown to increase access to preventive care and treatment, reduce job loss, and increase return to work.

In short, had a robust, fully inclusive paid sick leave policy been in place when COVID-19 began to spread and for its duration, the United States could have avoided innumerable infections and deaths that occurred because people had to go to work when they were sick or send children to school sick, while also helping people keep jobs critical to their long-term well-being. Instead, we were ill equipped to respond to a virus that spread as rapidly as COVID-19—and unless policymakers act, we will be equally ill prepared for the next.

This vulnerability was not a surprise: the United States has known about the inequalities and gaps in sick leave for decades. More than 25 years ago, together with colleagues, we documented the large gaps overall and the significant racial inequity in access to paid sick leave among parents.⁵ The research by Goodman et al. importantly keeps focus on these costly gaps and clearly shows that, even with some improvements in overall coverage of paid sick leave, marked inequalities persist.

Goodman et al. also find that just 37% of Hispanic, 49% of Black, 52% of Asian, and 60% of White workers had access to paid parental leave. These gaps similarly have profound implications for racial health disparities, given the evidence that paid leave reduces infant mortality rates, improves mothers’ access to postpartum care, and increases rates of breastfeeding and on-time immunizations. The United States is the only high-income country where maternal mortality is rising, and we rank 33rd among the 38 Organisation for Economic Co-operation and Development (OECD) countries in infant survival.⁶ According to the Centers for Disease Control and Prevention, rates of infant mortality for Black infants are more than twice those of White infants, while maternal mortality is 2.5 times as high among Black as among White women.

CLOSING THE GAPS

These policy choices make the United States a global outlier. Goodman et al. note the United States is rare among OECD countries in not providing paid leave. In fact, we are even farther behind than that: 181 countries around the world guarantee paid sick leave at the national level.⁷ Similarly, 186 countries guarantee paid maternity or parental leave.⁸ While the US provides unpaid leave through the Family and Medical Leave Act (FMLA), because of racial wealth gaps—which stem from a long history of exclusionary policymaking, compounded by ongoing discrimination⁹—when the only leave available is unpaid, Black and Latinx workers are far less likely to be able to afford it. Moreover, the FMLA eligibility criteria for even unpaid leave exclude many part-time workers, the self-employed, workers starting a new job, and those working for small businesses, widening racial and gender disparities in access. Nearly every country globally guarantees sick leave without these exclusions.⁷

Fortunately, when it comes to paid leave, the solutions are straightforward: to both reduce disparities and improve health overall, Congress should adopt a permanent, comprehensive paid family and medical leave policy that covers all workers, with no exceptions. Yet, if we care about equality, our commitment to addressing structural discrimination across race, gender, and class that is embedded within policies cannot end there. From criminal justice to access to health care, education to housing, a wide range of other policy choices—both historic and contemporary—are perpetuating health disparities, and we must identify and tackle them systematically to improve health equity at scale.

STRUCTURAL INEQUALITIES BEYOND PAID LEAVE

Sentencing disparities is a well-known example. The 1986 Anti-Drug Abuse Act, which imposed the same mandatory minimum sentence for 5 grams of crack cocaine as for 500 grams of powder cocaine, substantially contributed to the disproportionate incarceration of Black Americans. While evidence shows that overall rates of substance use are similar among Black, White, and Latinx youths and adults,¹⁰ these inequalities in the law—combined with discriminatory policing practices and an overreliance on incarceration generally—have resulted in the United States becoming a country where one in 15 adults, including one in three Black men and one in six Latino men, can expect to be incarcerated in their lifetimes, with devastating health and economic consequences.¹¹ Yet, as with paid leave, this is an example in which the research on racial disparities is robust and the first steps toward remedying them, while improving public health more broadly, are clear: fully eliminate the sentencing disparity and stop treating addiction through incarceration.

Education is another. Research has long demonstrated that funding schools through local property taxes exacerbates racial and socioeconomic inequalities in school quality while reinforcing segregation. In most other high-income countries, federal and regional governments, rather than local governments, are the key funders of education, resulting in more equitable funding for schools—a critical piece of the solution.¹² At the same time, significant debate persists about the best ways to move forward on racial equity in education more broadly.

PRACTICAL STEPS TO ADVANCE EQUALITY IN US PUBLIC POLICY

These are two examples among many—and addressing the structural inequalities that exist across policies will require both preventing these inequalities becoming embedded in law in the first place and drawing on the best evidence available to dismantle those that have persisted for decades. Two actions could make a profound difference.

First, the National Academy of Sciences (NAS) should carry out a study to evaluate the extent to which existing laws and policies create or reinforce inequalities in areas that matter to health and synthesize the evidence about how those inequalities can be solved most effectively. By systematically measuring how laws and policies that appear “race-neutral” in fact widen inequalities—while also evaluating the evidence to support different solutions in areas where consensus is lacking—NAS could play a powerful role in providing actionable, objective information for policymakers who care about reducing inequality in the United States.

Second, when Congress considers new legislation—including new social policies—it should routinely assess who will be affected and how. Just as the Congressional Budget Office posts the costs of every new bill, the Congressional Research Service should publish estimates on coverage and implications for disparities across race, gender, and class.

In the wake of a public health crisis that has laid bare the consequences of US failure to address how underlying inequalities shape both direct health risks and families’ financial resilience, uprooting these structural drivers must be a top priority. Beyond paid family and medical leave, it is long past time that the United States stop passing new laws and amend existing legislation that reinforces inequality across race, gender, and class. A congressional process that provides information to all policymakers on new laws’ impacts on equality, alongside a NAS evaluation of existing major policies impacting health, could importantly accelerate laying a foundation to truly support equal opportunity for all.