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Journal Issue: Work and Family Volume 21 Number 2 Fall 2011

Children with Health Issues
Mark A. Schuster Paul J. Chung Katherine D. Vestal

Types of Parent Support

Employed parents in the United States tend to rely on a haphazard mix of support to care for their children’s health needs, including federal, state, and local leave laws and programs. The extent to which parents can care for their children’s health is largely determined, however, by their working conditions, including flexibility in duties, locations, and schedules, as well as other employer-provided benefits. In the United States, where the availability of paid sick leave is limited, parents who have paid sick days are more than five times as likely to be able to care for their sick children themselves as parents who do not have paid sick leave.57 According to the 2010 National Paid Sick Days Study, about 64 percent of all workers report that they are eligible for paid sick days from their employer (including those receiving “paid time off” days, also known as PTO days, which combine time off for sick leave, vacation, and other reasons).58 However, only 47 percent of workers receive paid sick days that they can use for sick family members. Without flexible scheduling or paid leave to care for children’s health needs, employed parents may forgo disease prevention activities or experience wage and job loss when they take time off to seek or provide care for their children. For example, studies in Haiti, Indonesia, and the United States have found that parents report work schedule conflicts as a significant barrier to getting their children immunized.59 Among U.S. workers with paid sick days, 14 percent have sent a sick child to school or day care; among those without paid sick days, 24 percent have done so.

Federal Support
The federal government guarantees unpaid leave to some workers but does not mandate paid leave. The federal FMLA provides up to twelve weeks a year of unpaid leave with job protection (that is, protection from being fired) to certain workers to care for themselves or ill family members.60 The FMLA also requires that an employee’s group health benefits be maintained during the leave. Signed into law in 1993, the FMLA was the first federal leave legislation to address the competing demands of work and family. About half (47 percent) of workers are eligible for FMLA leave;61 eligibility depends on the size of the employer (fifty or more employees), the number of hours worked, and the duration of current employment (at least 1,250 hours for the same employer in the past twelve months). Many employees, however, cannot afford to take unpaid leave. Of the 3.5 million employees who needed but did not take leave in 2000, 78 percent cited inability to afford leave as a reason. Of these, 88 percent said they would have taken leave if they had received either some pay or (if already receiving partial pay) additional pay.62

Two pieces of proposed federal legislation, the Healthy Families Act and the Family Leave Insurance Act, would partially address concerns about employees who lack access to paid leave that can be used to care for themselves or family members. The Healthy Families Act would create a new national standard guaranteeing employees one paid hour off for each thirty hours worked and enabling them to earn up to seven paid sick days a year that they could use for the health needs of themselves or family members. It would also be available to more workers than the FMLA is, because it applies to employers with at least fifteen employees and has lower hour requirements. Costs would primarily fall upon employers, who would be responsible for paying employees’ wages when they use their sick leave. The Family Leave Insurance Act would create an insurance program, funded through employer and employee payroll tax contributions, to provide up to twelve weeks of paid FMLA benefits. Employees would receive a specified percentage of their daily earnings and be subject to a waiting period of five workdays before receiving benefits. The Family Leave Insurance Act would also have somewhat broader eligibility than the FMLA: it would apply to employers with twenty or more employees (as opposed to fifty or more) and to employees who have worked at least 625 hours for the same employer in the past six months (compared with 1,250 or more in the past twelve months).

Research shows general public support for government-mandated paid sick days. According to a nationally representative study in 2010, across all socio-demographic and political groups, the majority of Americans believe that paid sick leave to care for themselves or for immediate family members should be a government-guaranteed right for workers.63 Sixty-nine percent of respondents said that paid sick days were “very important” for workers, and 75 percent favored a law that guarantees paid sick days for all workers.

State or Local Support
In 2004 California attempted to extend the FMLA’s approach by instituting the Paid Family Leave Insurance (PFLI) program, which uses a payroll tax to create an insurance pool with broad eligibility that partially funds up to six weeks of leave for a child’s (or other immediate family member’s) illness or a child’s birth or adoption.64 The PFLI covers most part- and full-time employees at about 55 percent of their salary up to a maximum in 2010 of $987 a week;65 it does not, however, include job protection. Benefits apply after employees miss one week of work for a given illness (continuously or cumulatively). A statement signed by a physician or other clinician documenting the illness is required. New Jersey implemented a similar law in 2009. Washington state passed more limited family leave legislation (covering leave only for parents with a newly born or newly adopted child) in 2007 but has yet to implement its program.66

In addition, several states, including California, Connecticut, Hawaii, Washington, and Wisconsin, have flexible sick leave laws that entitle all workers who have access to sick leave to use some of their sick days to care for a sick child.67 A few cities, including San Francisco (2006), the District of Columbia (2008), and Milwaukee (2008), have also passed sick day ordinances that guarantee paid sick days for all or most workers.68 Legislators in other states and cities are also working on paid leave initiatives, and there are ongoing congressional efforts to pass the Healthy Families Act. Tables 1 and 2 compare the provisions and characteristics of these various laws and proposals.

Employer-Provided Support
Employers, meanwhile, provide a patchwork of formal and informal solutions to support parents, including sick days (often used for children without explicit employer approval, which can place parents at risk for termination); flexible paid time off that combines vacation, sick time, and family leave; telecommuting; and programs that allow employees to donate or share unused paid leave days. Individual supervisors and coworkers also use their discretion to informally enable parents to leave work for hours or days (as in “Just go, and I’ll cover for you,” or “Just go, and you can make the time up later”). Employees caring for dependent family members face complex challenges in their personal and professional lives. When the dependent is a child with special health care needs, workplace programs can help families more effectively use employee benefits and access public and private resources. Employee assistance and work-life programs are particularly well suited for addressing the needs of these employees and their children. In 2005, for instance, investigators examined how three separate large U.S. employers implemented programs specifically for employees with chronically ill children.69 Their approaches included establishing a parent network, independently testing and refining the company’s employee assistance program/work-life resource and referral service to better serve these parents, helping to guide employees when choosing health plans, and coordinating the company’s clinical services with public programs to assist families with chronically ill children. The employers reported a positive impact on employee retention and commitment, improved use of employee benefit programs, and improved promotion of corporate diversity objectives.

International Comparisons
The United States is one of only a few industrialized countries that do not have national laws providing paid leave for children’s health needs. At least forty-three countries, including Australia, Canada, France, Japan, Nicaragua, and South Africa, specifically guarantee parents some type of paid leave when their child is ill, and more than half of the forty-three provide full wages.70 Although length of leave varies, an analysis of thirty-seven countries that offer paid leave for children’s health needs found that fourteen guarantee eleven or more days of paid leave, six give seven to ten days, and ten give one to six days.71 Types of paid leave arrangements also vary. For instance, El Salvador provides up to fifteen days for serious illness or injury of a child, while Norway typically provides ten days annually as a base, fifteen if the employee has more than one child, and twenty if the employee has a chronically ill child. In addition, at least thirty-four countries guarantee discretionary leave (seventeen with pay) that can be used for ill children.72

Countries that offer paid leave for children’s health needs use different methods of negotiating and administering their paid leave benefits, but cost-sharing between employers and the state is common. For instance, Denmark has traditionally used collective agreements to determine most of the benefits available to workers, with employment laws focused mainly on establishing rules for collective bargaining and enforcing agreements.73 Lately, however, the Danish government has moved more toward directly applying statutory requirements to employers. Under most circumstances, the Danish law requires the employer to pay the cost of paid-leave benefits for the first two weeks of a period of absence; any remaining costs are paid by the claimant’s residential local authority, a decentralized municipality that imposes taxes and also receives funds from the state.74 In contrast, Sweden establishes employment standards primarily through laws rather than collective bargaining, despite high levels of unionization.75 Like Denmark, though, the cost of benefits is divided between employers and the state’s social security system, with employers paying during an initial period, and the social security system covering the remainder.76 The same is true of Poland.77