A family’s health is inextricably linked to its financial well-being. For many people, being sick, having a chronic condition, or caring for a loved one makes it challenging to remain in the labor force. It is even more challenging when employers fail to provide paid leave and paid sick days making it difficult or impossible for people to take time away from work to get care or treat a serious health issue – and when public policy gaps also fail to provide protections against job and financial losses. The absence of these supportive workplace Residents in the states that have expanded Medicaid coverage, a paid leave program, or paid sick days law can more easily access the care they need, get and stay healthy, and feel more economically secure.policies makes it harder for families to maintain their economic security and afford the health care they need.

In short, many people can’t afford to take time off from work if they’re sick and they can’t afford to seek care if they can’t work. Women are more likely to be the health care decision makers for themselves and their families and therefore are more likely to be affected by this problem. Policies that promote access to affordable, comprehensive health care and supportive workplaces can work together to improve both health and economic security and stability. For women and families with low incomes, the need for such policies is particularly important: less supportive and lower-paying jobs, more family care responsibilities and little to no financial cushion combine to create impossible choices and severe difficulties.

This issue brief demonstrates that very few states have policies to address the intersecting needs of women and families, and it outlines how the health and financial security of women and families are positively affected by having comprehensive health insurance and supportive workplaces. The brief also outlines how women’s lives are improved when policies to provide comprehensive insurance coverage (including abortion coverage) and access to paid family and medical leave and paid sick days are all implemented together.

Few States Have Policies to Address the Need for Comprehensive Health Coverage, Paid Leave and Paid Sick Days

Despite the evidence and research that comprehensive health coverage, paid leave and paid sick days can improve individual and families’ health and well-being, there are only a few states that are addressing all of these issues.

To better understand which states are comprehensively addressing both the need for health insurance coverage (including coverage for abortion care) as well as individuals’ need to take time off work for their own or a loved one’s health care needs, we analyzed four policy indicators:

• Expanded Medicaid coverage. Under the Affordable Care Act, states have the option to expand Medicaid coverage up to 138 percent of the poverty line for individuals and families.
• Medicaid coverage of abortion care. Although there are strict limits on the use of federal funds to cover abortion care, states have the option to cover abortion care with state funds.
• Paid family and medical leave. States can implement paid family and medical leave programs, which provide wage replacement for a worker who takes leave to care for a seriously ill family member, bond with a new child or address their own serious health condition.
• Paid sick days. States can implement paid sick days laws to ensure all workers can earn paid, job-protected time away from work for routine health needs.

Across all states, Medicaid expansion was the most commonly adopted policy (enacted in 36 states and the District of Columbia), followed by Medicaid coverage for abortion care (in place in 15 states). Very few states, however, also addressed paid family and medical leave (six states and the District of Columbia) and/or paid sick days (11 states and the District of Columbia). (See Appendix for a state-by-state table.) We found that:

• Four states – California, Massachusetts, New Jersey and Washington – have adopted all four policies.
• All states that have abortion coverage under Medicaid, paid family and medical leave or paid sick days have also adopted Medicaid expansion. These states are California, Connecticut, Maryland, Massachusetts, New Jersey, New York, Oregon, Vermont and Washington.
• Rhode Island and Washington, D.C., have adopted Medicaid expansion, paid family and medical leave and paid sick days, but do not cover abortion care under Medicaid.
• Only New York has expanded Medicaid coverage, has paid family and medical leave and has Medicaid coverage for abortion care, but lacks a statewide paid sick days law.
• Six states – Alaska, Hawaii, Illinois, Minnesota, Montana and New Mexico – have expanded Medicaid and cover abortion care under Medicaid, but don’t have a statewide paid sick days law or paid family and medical leave program.
• Four states – Connecticut, Maryland, Oregon and Vermont – have expanded Medicaid coverage, have a paid sick days law and Medicaid coverage for abortion care, but lack a paid family and medical leave program. Arizona would also be included in this category but the state Medicaid program does not pay for medically necessary abortions, despite a court order compelling it to provide coverage.
• Michigan has expanded Medicaid coverage and adopted a paid sick days law, but does not cover abortion under Medicaid and does not have a statewide paid family and medical leave program.

Residents in the states that have expanded Medicaid coverage, a paid leave program or paid sick days law can more easily access the care they need, get and stay healthy, and feel more economically secure.

States could be doing more to improve the health of women and families. The expansion of Medicaid in 36 states and the District of Columbia is a critical foundation for improving health.

To more fully address the needs of families, and improve overall health, policymakers should seek to expand Medicaid coverage in all states and use state funds to cover abortion care. In states that have already expanded coverage, policymakers should further improve health and economic security by implementing paid sick days and paid family and medical leave policies. The remainder of this issue brief details how these policies reinforce one another.

Health Insurance Coverage, Paid Leave and Paid Sick Days Improve the Health of Women and Families

Comprehensive Health Insurance Coverage

The Affordable Care Act (ACA) expanded insurance coverage to millions of previously uninsured people, including through the expansion of Medicaid coverage. Medicaid is a federal-state partnership that provides health insurance to millions of financially vulnerable people, including women and children, who would otherwise be uninsured.National Partnership for Women & Families. (2018, April). Medicaid: Ensuring Basic Health Care for Millions of Women and Children. Retrieved 30 November 2018, available here.

Robust research shows that expanding coverage means people have more access to care and are more likely to receive needed preventive care, primary care, chronic illness treatment, medications and surgery.Sommers, B. D., Gawande, A. A., & Baicker, K. (2017, August). Health Insurance Coverage and Health – What the Recent Evidence Tells Us. The New England Journal of Medicine. 377, 586-593. Medicaid, specifically, has helped make millions healthier by improving access to preventive and primary care. Medicaid coverage produces long-term health benefits; for example, low-income children are almost twice as likely to receive an annual well-child visit when their parent is enrolled in Medicaid.Center on Budget and Policy Priorities. (2018, October). Chart Book: The Far-Reaching Benefits of the Affordable Care Act’s Medicaid Expansion. Retrieved 15 October 2018, available here.

Families with Medicaid also have received multi-generational health benefits. Children with mothers enrolled in the expansion of Medicaid coverage in the 1980s and 1990s were healthier at birth, and more likely to graduate high school and have higher incomes.East, C. N., Miller, S., Page, M., & Wherry, L. R. (2017, September). Multi-Generational Impacts Of Childhood Access To The Safety Net: Early Life Exposure to Medicaid and the Next Generation’s Health. National Bureau of Economic Research. Retrieved 15 October 2018, available here. Recent studies found that people whose mothers received this prenatal care are now having children themselves with higher birth weights and fewer cases of very low birth weight.East, C. N., Miller, S., Page, M., & Wherry, L. R. (2017, September). Multi-Generational Impacts Of Childhood Access To The Safety Net: Early Life Exposure to Medicaid and the Next Generation’s Health. National Bureau of Economic Research. Retrieved 15 October 2018, available here.

Insurance coverage works best when it is comprehensive. Reproductive health care services help provide women the ability to determine whether and when to parent, to assess what is right for their health and their families, and to build economic security. However, most states do not require plans to provide abortion coverage, and many states explicitly restrict insurance coverage of abortion.Guttmacher Institute. (2018, September). Restricting Insurance Coverage of Abortion. Retrieved 2 November 2018, available here. Moreover, the Hyde Amendment withholds federal funds from covering abortion care for women enrolled in Medicaid. As a consequence, health care is pushed out of reach for millions of women – with the burden falling heaviest on low-income women, women of color and young women.

Access to comprehensive reproductive health care – including abortion care – improves health outcomes for women and families. A woman who is denied coverage often must postpone seeking care while trying to find the necessary funds or may not be able to access abortion care at all.National Women’s Law Center. (2017, December). State Laws Regulating Insurance Coverage of Abortion Have Serious Consequences for Women’s Equality, Health, and Economic Stability (p. 2). Retrieved 11 September 2018, available here. Even though abortion is extremely safe, delays in care increase the health risks of the procedure.Boonstra, H., Gold, R. B., Richards, C. L., & Finer, L. B. (2006). Abortion in Women’s Lives (pp. 15-17). Retrieved 11 September 2018, available here. Moreover, delays in obtaining care increase the cost of abortion services, reduce the number of available providers and may place additional legal restrictions on the procedure.Guttmacher Institute. (2018, September). Restricting Insurance Coverage of Abortion. Retrieved 10 September 2018, available here. Indeed, states that provide supportive health coverage for women, including abortion care, experience better health outcomes for women and children.Center for Reproductive Rights. (2017, August). Evaluating Priorities: Measuring Women’s and Children’s Health and Well-Being Against Abortion Restrictions in the States (p. 25). Retrieved 2 November 2018, available here. Women with access to abortion care are less likely to stay tethered to abusive partners, less likely to suffer negative mental health outcomes and possess greater economic security, which improves their overall health.Roberts, S., Biggs, M. A., Chibber, K., Gould, H., Rocca, C. H., & Foster, D. G. (2014). Risk of Violence from the Man Involved in the Pregnancy after Receiving or Being Denied an Abortion (p. 144). BMC Medicine, 12, 144. Retrieved 2 November 2018, available here.

Jerman, J., Frohwirth, L. F., Kavanaugh, M. L., & Blades, N. (2017). Barriers to Abortion Care and Their Consequences for Patients Traveling for Services: Qualitative Findings from Two States (pp. 95-102). Retrieved 11 September 2018, available here.

National Women’s Law Center. (2016, October). Women and Families Need Policies that Support Economic and Reproductive Justice (p. 2). Retrieved 2 November 2018, available here.

Paid Sick Days

Paid sick days allow workers to take paid time away from work for a brief illness, medical appointment or to care for a family member who is sick. Yet today in the United States, nearly three in 10 workers in the private sector – and nearly seven in 10 of the lowest-wage workers – do not have a single paid sick day at their jobs.Bureau of Labor Statistics. (March 2018). “Table 16. Insurance benefits: Access, participation, and take-up rates, private industry workers”. Retrieved 30 November 2018, available here. Workers without paid sick days are more likely to work sick and are more likely to delay or forgo needed medical care for themselves and their families, which can lead to prolonged illnesses and turn minor health problems into major, more costly ones.National Partnership for Women & Families. (2018, October). Paid Sick Days Improve Public Health. Retrieved 15 October 2018, available here. Children whose parents are able to earn paid sick days are 12.5 percent more likely to receive flu vaccinations, 13 percent more likely to attend annual checkups, have better maintenance of chronic illnesses and are less likely to receive delayed medical care or be taken to emergency care.Afsaw, A., & Colopy, M. (2017, March). Association between Parental Access to Paid Sick Leave and Children’s Access to and Use of Healthcare Services (Table II). American Journal of Industrial Medicine, 60(3), 276-284.

Paid Family and Medical Leave

At some point, nearly everyone will need time away from their job to address a serious health issue or care for a new child or sick loved one, yet today just 16 percent of workers in the private sector have paid family leave through their jobs, and only 42 percent have employer-provided short-term disability insurance for time away from work to address more serious health issues, including pregnancy complications and postpartum recovery and access is skewed heavily toward higher-wage workers.Bureau of Labor Statistics. (March 2018). “Table 32. Leave benefits: Access, private industry workers.” Retrieved 30 November 2018, available here.

Bureau of Labor Statistics. (March 2018). “Table 16. Insurance benefits: Access, participation, and take-up rates, private industry workers.” Retrieved 30 November 2018, available here.

Paid family and medical leave provides people with time and financial stability by allowing them to take paid time away from work to address serious illnesses and injuries as well as chronic health conditions afflicting themselves or their family members, or to care for a new baby or adopted child. Family caregivers help their loved ones recover more smoothly and quickly and avoid or delay institutional care.U.S. Department of Health and Human Services. (2011). Administration On Aging: FY 2011 Report to Congress. Retrieved 7 June 2017, available here.

National Academy of Sciences, Engineering, and Medicine. (2016, September 13). Families Caring for an Aging America. Retrieved 7 June 2017, available here. For seriously ill children, for example, the presence of a parent can help reduce the duration of a hospital stay by nearly a third.Heymann, J. (2001). The Widening Gap: Why America’s Working Families Are in Jeopardy – and What Can Be Done About It. New York, NY: Basic Books. For older adults, the presence of a caregiver has been shown to delay or prevent use of more care intensive health services like home health care and nursing homes;National Academy of Sciences, Engineering, and Medicine. (2016, September 13). Families Caring for an Aging America. Retrieved 7 June 2017, available here. in fact, California’s paid family and medical leave program was associated with reduced elderly nursing home usage.Arora, K., & Wolf, D. A. (2017, November 3). Does Paid Family Leave Reduce Nursing Home Use? The California Experience. Journal of Policy Analysis and Management, 37(1), 38-62.

Paid leave supports the health and well-being of people who have given birth. A New Jersey study found that the passage of that state’s paid leave program was strongly associated with improvements in women’s physical health, and with improvements in overall well-being for employed single mothers and women in low and lower-middle income families.Pal, I. (2016). Work, Family and Social Policy in the United States – Implications for Women’s Wages and Wellbeing. Doctoral thesis, Columbia University. Retrieved 30 November 2018, available here. Each week of leave a woman takes after having a baby is associated with a lower risk for postpartum depression symptoms, for at least 12 weeks.Kornfeind, K. R., & Sipsma, H. L. (2018). Exploring the Link between Maternity Leave and Postpartum Depression. Women’s Health Issues, 28(4), 321-326.

Research has consistently found that paid leave for new parents is associated with lower rates of infant and early childhood mortality and improved child health.Nandi, A., Jahagirdar, D., Dimitris, M, et al. (2018). The Impact of Parental and Medical Leave Policies on Socioeconomic and Health Outcomes in OECD Countries: A Systematic Review of the Empirical Literature. The Milbank Quarterly, 96(3), 434-471.

Ruhm, C. J. (2000). Parental leave and child health. Journal of Health Economics, 19, 931-960; Tanaka, S. (2005). Parental Leave and Child Health Across OECD Countries. The Economic Journal, 115: F7-28. According to one estimate, a 12-week increase in job-protected paid leave would reduce post-neonatal infant mortality by approximately 3.6 percent.Patton, D., Costich, J. F., & Lidströmer, N. (2017). Paid Parental Leave Policies and Infant Mortality Rates in OECD Countries: Policy Implications for the United States. World Medical and Health Policy, 9(1), 6-23. The children of women who take paid maternity leave are more likely to be breastfed and to have had checkups and immunizations.Berger, L., Hill, J., & Waldfogel, J. (2005). Maternity Leave, Early Maternal Employment and Child Health and Development in the US. The Economic Journal, 115(501), F44.

Appelbaum, E., & Milkman, R. (2011). Leaves That Pay: Employer and Worker Experiences with Paid Family Leave in California. Center for Economic and Policy Research Publication. Retrieved 7 October 2015, available here. California’s paid leave program is associated with improved health outcomes for children born after the program was implemented, particularly for children from less advantaged backgrounds.Lichtman-Sadot, S., & Pillay Bell, N. (2017). Child Health in Elementary School Following California’s Paid Family Leave Program. Journal of Policy Analysis and Management, 36(4), 790-827.

Insurance Coverage, Paid Leave and Paid Sick Days Improve the Financial Well-Being of Women and Families

Comprehensive insurance coverage contributes to a family’s peace of mind when they know that they can afford care if they get sick.Sommers, B. D., Gawande, A. A., Baicker, K. (2017, August). Health Insurance Coverage and Health – What the Recent Evidence Tells Us. The New England Journal of Medicine. 377, 586-593. Medicaid coverage, in particular, improves families’ economic security by protecting against high out-of-pocket medical costs. In states that have expanded Medicaid coverage, research shows that the share of people having trouble paying their medical bills dropped by 25 percent, helping to make individuals and families more financially secure.Center on Budget and Policy Priorities. (2018, October). Chart Book: The Far-Reaching Benefits of the Affordable Care Act’s Medicaid Expansion. Retrieved 15 October 2018, available here.

Katch, H. (2017, December). Yes, Medicaid Improves Access to Health Coverage and Care [Blog post]. Retrieved 15 October 2018, available here. Medicaid enrollees are also less likely than people with private coverage or the uninsured to have trouble paying for care and less likely to skip needed care due to costs.Katch, H. (2017, December). Yes, Medicaid Improves Access to Health Coverage and Care [Blog post]. Retrieved 15 October 2018, available here.

Research on paid leave programs and paid sick days also shows that they strengthen families’ economic security. When women have access to paid maternity leave, for example, they are more likely to be employed and to be paid higher wages in the year after their child’s birth, and both women and men who take paid leave are substantially less likely to use Supplemental Nutrition Assistance Program (SNAP) benefits and other public assistance programs in the year after a child’s birth.Houser, L., & Vartanian, T. (2012, January). Pay Matters: The Positive Economic Impacts of Paid Family Leave for Families, Businesses and the Public. Rutgers Center for Women and Work Publication. Retrieved 25 September 2018, available here. An analysis of California’s paid leave program also found that the program increases the short-term and long-term labor force participation rates of family caregivers with an 8-percent increase in the short run and a 14-percent increase in the long run. The long-term increase in labor force participation was higher among workers in lower-income households.Saad-Lessler, J., & Bahn, K. (2017, September). The Importance of Paid Leave for Caregivers: Labor Force Participation Effects of California’s Comprehensive Paid Family and Medical Leave. Center for American Progress Publication. Retrieved 5 November 2018, available here. Additionally, workers who lack paid sick days are less likely to be able to afford health care goods and services, more likely to incur high medical expenses and more likely to have a family income below the poverty threshold than those who have paid sick days.Stoddard-Dare, P., DeRigne, L., Mallett, C., & Quinn, L. (2018, March). How does paid sick leave relate to health care affordability and poverty among US workers? Social Work in Health Care, 57(5), 376-392.

Access to comprehensive reproductive health care further strengthens economic security for women and families. A woman who is denied abortion care is more likely to fall into poverty and is less likely to be working full-time one year later than a woman who was able to obtain the care she needed.National Partnership for Women & Families. (2016, September). A Double Bind: When States Deny Abortion Coverage and Fail to Support Expecting and New Parents (p. 3). Retrieved 2 November 2018, available here. Since a majority of women who seek abortion care are low-income and already have at least one child, granting a woman control over the future of her family structure – through access to contraception and abortion care – allows a woman to gain greater financial stability and to better care for her children.Guttmacher Institute. (2016, May). Characteristics of U.S. Abortion Patients in 2014 and Changes Since 2008. Retrieved 2 November 2018, available here.

National Women’s Law Center. (2016, October). Women and Families Need Policies that Support Economic and Reproductive Justice (p. 2). Retrieved 2 November 2018, available here. Moreover, abortion care access allows a woman to continue her education and remain in the workforce, which improves her overall earning potential and economic security.National Women’s Law Center. (2016, October). Women and Families Need Policies that Support Economic and Reproductive Justice (p. 2). Retrieved 2 November 2018, available here. This increased economic security drastically improves health outcomes for women and families.

Expanded Insurance Coverage and Workplace Supports Help Women and Families Thrive

The research is clear: women and families benefit from comprehensive insurance coverage, paid leave programs and paid sick days. Independently and together, these policies improve individual and families’ health and economic security.

The ability to take time away from work to deal with an acute or more serious health condition, or to access reproductive and other health care services, allows workers to improve or maintain their health, which makes it easier to stay in the workforce and contributes to their financial well-being. And, supportive workplace policies make it easier for individuals to use their insurance to access care, afford the health care they need, and stay healthy.

Appendix