As the coronavirus illness known as COVID-19 spreads and fears follow, one segment of the population is especially at risk, according to health experts: the working poor.
With a vaccine likely more than a year away, people who suspect they’ve been infected are being asked to seek medical treatment, but also to stay home if they’re sick. For low-wage workers lacking health insurance and paid sick leave from work, both remedies may be out of reach.
“We are encouraging people to self-quarantine — to stay away from others when they’re sick,” says Jeanne Ayers, the state health officer in the Wisconsin Department of Health Services. “And if you don’t have access to paid sick time, it has a cascading effect on all the other assets that are important to your health — the stability of your housing, your ability to purchase medication. So access to paid sick time is a pretty important health equity issue.”
“Taking needed sick time means workers go without pay or must show up at work while sick and delay seeking treatment for themselves or their dependents,” economists Elise Gould and Jessica Schieder wrote in a 2017 paper for the Economic Policy Institute in Washington, D.C.
Citing 2019 federal data, the EPI says that more than nine out of 10 private sector workers whose wages are in the top 10% are eligible to take time off with pay when they get sick. For the bottom 10% of wage earners, just three out of 10 are able to do that.
“Service occupations, and people working part time, and people working in sectors like construction and farming are a lot less likely to have paid sick leave than people who are working in management and professional sectors, or people who are working full-time,” says William Parke-Sutherland, health policy engagement coordinator for Kids Forward, a Madison-based statewide policy and advocacy group for children and families.
Child care, food service and retail workers all tend to have lower wages and frequently lack sick pay or health insurance coverage. “And especially, a lot of those jobs also only offer part-time hours,” Parke-Sutherland says. “This might mean people have to choose between coming to work, which puts them at risk and puts everybody else at risk, or staying home, which might mean they lose a job because they miss shifts. Or if they can keep their job, it may mean they will lose wages. And those lost wages might mean not having enough money for groceries, not having enough money to pay a utility bill or pay their rent, which then exacerbates these consequences of getting sick.”
To expand the availability of paid sick leave, some cities have passed ordinances requiring employers to provide it. A 2017 paper by economists Stefan Pichler and Nicholas R. Ziebarth found that in cities with such a mandate, the number of flu cases dropped by 6% to 7%.
But in Wisconsin, the Republican-controlled Legislature in 2011 passed and then-Gov. Scott Walker signed legislation rolling back Milwaukee’s paid sick leave mandate and forbidding any city or county in the state from enacting one.
Workers with leave who don’t take it
Even just having access to sick leave may not always be enough, if workers are discouraged from taking it at their workplace.
Public Health Madison & Dane County encountered one example in an outbreak of food-borne illnesses last summer, says Allison Dungan, one of the combined city-county health department’s two health-equity coordinators.
“When food-borne illness outbreaks happen it’s most often because a kitchen staff person has norovirus, and has come to work,” Dungan explains. The department examined whether workers were coming to work sick because they lacked paid sick leave at their jobs.
Investigation found that in some such instances, “it was provided but the workers didn’t feel culturally like they could use it,” she says.
The finding has led the department to consider public outreach on the impact of not providing food and hospitality workers with benefits, sick pay and other rights on the job — “so that diners understand that if they’re getting sick from their dining experience, it could be because of worker justice issues and not cleanliness of the kitchen,” says Dungan.
Racial and ethnic disparities exacerbate the problems. Often, says Dungan, people of color who might have a sick leave policy at work may be reluctant to use it because they are viewed with greater skepticism than their white coworkers. That’s part of a broader racial marginalization that led the Dane County Board of Health a year ago and the city of Madison last fall to declare racism as a public health crisis, she adds.
Immigrant populations encounter similar challenges, says Josh Knox, a Milwaukee physician assistant who teaches in Marquette University’s physician assistant program and works in three Milwaukee free clinics.
While one clinic he works with has developed a strong bond with its Latino and Latina patients, elsewhere “there’s a lot of fear in those clinics for a lot of justifiable reasons, in terms of being deported, or just the fear of government and the police state in general,” Knox continues. “And so with a lot of people, that mistrust spills over to a lot of institutions,” including health care providers.
Ayers points to research that found having just six days of paid leave a year helped people make more use of preventive services, boosting the rate of vaccinations and reducing emergency room use for them and their families.
“And the people with even six days of paid leave miss less work than people without paid leave,” says Ayers. For workers whose jobs involve contact with large numbers of people, “having access to paid leave is actually protecting all of us.”
Access to health care
Despite the Affordable Care Act, which has made it possible for more people to buy health insurance at lower cost, access and expense remain a problem, says Knox.
Although the ACA mandates free preventive care for people who buy health insurance through the health insurance exchange at Health.gov, many of the working poor whom Knox treats don’t make enough to afford health insurance on the exchange. Yet, Knox adds, they still make more than the federal poverty line, so that they don’t qualify for BadgerCare, the state’s Medicaid program.
In the face of a potential pandemic, “this underscores the need for Wisconsin to expand BadgerCare,” Parke-Sutherland says.
Gov. Tony Evers, although he took office campaigning to accept federally subsidized expansion of Medicaid that would make the health insurance plan available to more people, has so far been blocked from doing so by the Republican-led Legislature.
Knox observes that even if poor patients want preventive care, they might not be able to get off from work during the day to visit a primary care doctor, if they even have one.
And if a coronavirus vaccine does eventually become available, low-wage people might feel they cannot afford it.
“If they’re going to have a choice between putting food on the table or keeping the car going or maybe just having enough to get on the bus route, whatever the case may be, they’re certainly not going to pay for a vaccination,” says Knox. “The coronavirus really is going to be disproportionately borne in this country by the poor and the uninsured.”