Background: The United States is one of the only industrialized countries without a nationwide mandatory paid sick leave policy, which would give workers the ability to take time off work for their own health or the health of their children without jeopardizing their job standing or income. Taking time away from work to rest when sick has been shown to promote quicker recovery and prevent the transmission of illness and the progression of minor illnesses into more serious illnesses1; paid sick leave allows time for this rest without financial consequences to the employee. When workers are chronically ill, not being able to seek care could mean that they are not able to adequately care for their chronic disease. Although the health and work absence effects of having access to paid sick leave have previously been studied, they have not been investigated in a way that suggests causality. Paid sick leave also has the potential to affect how people use the healthcare system. Being able to take time off from work for the purposes of caring for health leads to quicker recovery and prevention of the progression of minor illnesses into more serious illnesses. It also helps to alleviate some of the access barriers that are often associated with not being able to seek care at an office-based medical provider by freeing up time during normal business hours to seek care without foregoing income. As a result, paid sick leave could help to control the amount of non-urgent emergency department (ED) visits, which are increasingly becoming an issue in EDs across the United States. Objective: The overall objective of this research is to determine the effect that paid sick leave has on work-absence behavior, general health, and healthcare use behavior for workers in the United States, with an additional focus on the subset of workers with chronic illnesses. Manuscript 1: Aim: Determine the effect of paid sick leave on work-absence behavior and general health status for workers in the United States, with an additional focus on workers with chronic illnesses. Methods: Fixed and random effects models were used with longitudinal data from the Medical Expenditure Panel Survey to model the effect of paid sick leave on work-absence behavior, and subsequently on the effect of work-absence behavior on general health status, both for our full sample of workers, and also for a chronically ill subset of workers. Results: Our overall results showed that paid sick leave does not have a large effect on self-reported general health status, and these results held consistent in both the full analysis sample as well as the chronically ill subsample. Our results also showed that the effect of paid sick leave on work absence days very much depends on the context with which the worker has paid sick leave – whether it is being gained and compared to those that workers never had paid sick leave, or it was held for the entire follow-up period and being compared to those that lost the benefit at some point during follow-up. Manuscript 2: Aim: Determine the effect of paid sick leave on emergency department use and office-based medical provider use volume for workers in the United States, with an additional focus on workers with chronic illnesses. Methods: Fixed effects models were used with longitudinal data from the Medical Expenditure Panel Survey to model the effect of paid sick leave on the volume of emergency department use and office-based medical provider use, both for our full sample of workers, and also for a chronically ill subset of workers. Results: Our results showed that the effect of paid sick leave on office-based medical provider use volume depended on whether the benefit had been gained and was being compared to participants that never had it, or instead had been lost over the course of follow-up and was being compared to participants that had never lost the benefit. Those that gained the benefit had less office-based medical provider visits as compared to those that never had paid sick leave, while those that had the benefit for the entire follow-up had more office-based provider visits compared to those that lost it, both for the full sample of workers and the chronically ill subset. Our results also showed that the effect of paid sick leave on emergency department use volume depended predominantly on whether we investigated the effect in the full analysis sample, or within the subset of chronically ill workers. While the full analysis sample showed no effect of paid sick leave on office-based medical provider use volume in either subsample, both subsamples in the chronically ill subset of workers showed an increase in the number of visits when those with paid sick leave were being compared to those without Conclusion: These analyses present a more nuanced and rigorous approach to analyzing the effects of paid sick leave on health, work absence behavior, and healthcare use behavior than previously existed in the literature. By performing analyses using longitudinal data, we were better able to approximate the counter-factual than previous studies on these topics, which all utilized some form of cross-sectional data. Additionally, these analyses filled an important literature gap by investigating the effects of paid sick leave on our outcomes of interest in a subset of workers with chronic illnesses, an analysis that had not been reported in the literature yet to date.
University of Minnesota Ph.D. dissertation. October 2016. Major: Environmental Health. Advisors: Patricia McGovern, Bryan Dowd. 1 computer file (PDF); ix, 259 pages.
Evaluating Health and Healthcare Use Effects of Changes in Paid Sick Leave Access for Workers in the United States.
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