Paid sick leave is associated with fewer ED visits among US private sector working adults

Abstract

Context

The United States (US) is the only developed country that does not guarantee short-term or longer-term paid sick leave.

Objective

This study used a multiyear nationally representative database to examine the association between availability of paid sick leave and frequency of emergency department (ED) use among US private sector employees.

Study sample

We used the National Health Interview Survey data (2012-2014). The final study sample consists of 42,460 US adults between 18 and 64 years of age and working in nongovernmental private sector.

Results

Our results suggest that availability of paid sick leave is significantly associated with lower likelihood of ED use, for both moderate (1-3 times/year) and repeated users (4 or more times/year). After controlling for confounding factors, respondents with paid sick leave are 14% less likely to be moderate ED users (adjusted odds ratio, 0.86; 95% CI, 0.79-0.93) and 32% less likely to be repeated ED users (adjusted odds ratio, 0.68; 95% CI, 0.50-0.91).

Discussion

Although expansion of health insurance coverage under the Affordable Care Act has not been shown to reduce utilization of high cost health care services such as the ED, our study suggests other factors such as the availability of paid sick leave may do so, by allowing patients to seek care through other more cost-effective mechanisms (eg, primary care providers). To reduce ED utilization, health policymakers should consider alternative reforms including paid sick leave.

Introduction

Emergency department (ED) use is a major contributor to health care costs in the United States (US). The Affordable Care Act (ACA) has increased the number of Americans with health insurance through Medicaid expansion or health insurance exchanges [1]. However, the effect of increased access to health insurance on ED utilization remains unclear. Although there is some evidence of reduced ED utilization, especially among younger adults [2], [3], high-volume ED use by the newly insured patients is an unaddressed concern [4]. Evidence from Massachusetts and Oregon suggests an increase in ED use after Medicaid expansion [5], [6].

Improved access to health insurance through ACA may not reduce ED utilization unless other economic barriers to regular primary care access are addressed (eg, availability of paid sick leave). The US is the only industrialized country in the world that does not provide paid sick leave for employees [7]. It is estimated that more than 40 million private sector workers in the US did not have access to paid sick leave in 2015 [8]. Although some US states and cities have passed regulations or are currently proposing legislation to guarantee paid sick leave, there is no federal requirement. On the eve of Labor Day, 2015, President Obama signed an executive order to enact a federal law requiring the private sector companies that work with the federal government to provide annual paid sick leave up to 7 days or more to employees, including paid leave allowing for preventive care, family care, child care, and parent care [9].

Empirical research has shown that paid sick leave is associated with cost saving for employers, higher employee retention, healthier workforce, and overall job growth [10], [11], [12], [13], [14]. One recent survey found that 9 in 10 US workers, across all political affiliations, favor a law guaranteeing workers up to 7 paid sick days per year. Nearly 1 in 4 workers report that they have lost jobs or were threatened with job termination for taking time off due to personal or family illness [15]. Evidence also suggests that availability of paid sick leave allows employees to access preventive care and may reduce overall health costs and improve outcomes. One previous study found that US workers with paid sick leave were more likely to undergo screening for five different types of cancers [16]. Another recent study found that a higher percentage of female US workers with paid sick leave received mammography as compared to those without paid sick leave [17]. Although paid sick leave can reduce the number of ED visits, mainly through allowing individuals to see a regular provider and timely access to preventive care, the relationship is not very clear. A study conducted before ACA implementation attempted to examine the relationship between paid sick days and ED visits for US working adults. However, the study did not find any significant relationship at that time. One important limitation of this study was that it included all US working adults. However, public sector employees are more likely (around 90%) to have paid sick leave benefits; therefore, including these public sector employees in the study sample likely diluted the effect of paid sick leave [18].

Our study uses a multiyear nationally representative database from the years following the passage and implementation of the ACA to examine the association between availability of paid sick leave and ED utilization among US private sector employees. Guided by the Andersen Model for health services utilization, we hypothesize that the availability of paid sick leave is associated with a reduced frequency of ED utilization among US private sector employees.