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JAMA Forum
May 21, 2020

Prescribing Paid Sick Leave—An Important Tool for Primary Care During the Pandemic

Author Affiliations
  • 1Harvard T. H. Chan School of Public Health, Boston, Massachusetts
  • 2Harvard Medical School, Harvard University, Boston, Massachusetts
  • 3Alston & Bird LLP, Atlanta, Georgia
JAMA Health Forum. 2020;1(5):e200659. doi:10.1001/jamahealthforum.2020.0659

“14 days—no work, no outings. Please stay home.”

It is a conversation unfolding thousands of times daily across the US, as the coronavirus disease 2019 (COVID-19) pandemic spreads. On the telephone, via video consultation, or—increasingly rare these days—during an actual office visit, a primary care physician tells a patient, “Your symptoms sound like COVID-19.”

And many patients—the 25-year-old man working to stock grocery shelves, the 50-year-old woman driving a city bus, the restaurant line-order cook preparing takeout—ask anxiously, incredulously, or tearfully: “Stay home from work? I can’t.” Or “No puedo.”

Although primary care faces many new pressures and challenges due to the pandemic, no real clinical tools are available to actually treat patients with severe acute respiratory syndrome coronavirus 2 infection in the outpatient setting. The most common COVID-19–related interaction many primary care physicians have during the pandemic is trying to persuade patients who feel lousy—but not gravely sick—to stay home from work and other activities for 2 weeks (or even 7-10 days after a positive test result because quarantine guidelines have shifted).

This is hard for anyone but particularly for patients with low incomes, for whom 2 weeks without work can mean financial ruin. For patients who cannot work from home and cannot afford groceries next week without working today, how can clinicians possibly expect them to follow this advice? Yet this step is critical in reducing the spread of COVID-19.

Evidence suggests that most patients with COVID-19 do not have severe symptoms, and that is one of the main reasons it spreads so easily. Getting people who are mildly symptomatic to stay home is an uphill battle, especially when their livelihood and their family’s well-being are immediately at stake. A recent study suggests that paid sick leave matters tremendously in this calculation. Researchers in Israel found that 94% of people would comply with advice to self-quarantine when their earnings are guaranteed vs just 57% when this would mean the loss of wages.

Congress has stepped in to help address this aspect of the pandemic by requiring many employers to provide paid sick leave for any person given medical advice to stay home related to COVID-19 as of April 1, 2020. But this policy only works if patients know about it.

This is where primary care clinicians enter the picture, with perhaps the most important prescriptions they will write during the pandemic. “Stay home. And tell your employer it is because of COVID-19, so you can qualify for paid sick leave.”

The new federal law, the Families First Coronavirus Response Act, applies to private employers with fewer than 500 workers, as well as most public employers (without regard to employee count). The essence of the law is fairly simple. The employers who are covered by the law must continue to pay employees who (1) have been told by a physician to self-quarantine because they are sick with COVID-19, are suspected of having it, or have a high-risk medical condition, and (2) if they cannot work from home.

Under this new law, employees can obtain paid leave for up to 80 hours, with a maximum of $511 per day, and the federal government will fully pay the employer back with a tax credit. Firms with fewer than 50 workers are also subject to the law, though they can apply for an exemption if providing the leave would threaten the viability of the business. Employees are also eligible for up to 80 hours of paid leave at two-thirds of their pay rate if they are caring for another quarantined individual.

Workers technically do not need documentation from a health care professional to qualify. They just have to inform their employer and provide the name of the clinician recommending the quarantine. But a physician’s letter explaining their medical advice would likely facilitate patients’ efforts to get the paid leave for which they are entitled.

Of course, the new law is not a panacea. It is not as comprehensive as the mandated sick leave provisions in many other countries. Many individuals, including those working for large employers as well as those working in the health care industry, are not eligible for leave under the law. In particular, some analysts have criticized the law’s exclusion of companies with more than 500 employees. Although more than 90% of workers in these large companies already get paid sick leave, they may not receive benefits as generous as the new requirements. In addition to employees of large companies who do not get paid sick leave under company policy or the new law, some employees of small companies (with fewer than 50 workers) may also be excluded from coverage under the law’s viability exemption.

Paid sick leave also does not address many other burdens of quarantine. For people living in cramped housing, often with multiple generations of family members, trying to keep the rest of the household safe is difficult. Access to food and health care—particularly in states that still continue to defy strong public health and economic arguments to expand Medicaid—remains a major challenge. These factors are likely contributing to the large racial and ethnic disparities during the pandemic.

But paid sick leave is an essential part of the public health and humanitarian response, particularly for lower-income populations and communities of color that have been hit hard by the pandemic. Patients should not be forced to choose between their livelihoods and the health of the larger community. And now primary care clinicians have a new tool in this fight.

It is a simple prescription: “Stay home. Tell your boss I told you to, so you can get paid. And get better soon.”

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Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License.

Corresponding Author: Benjamin D. Sommers, MD, PhD, Harvard T. H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115 (bsommers@hsph.harvard.edu).

Conflict of Interest Disclosures: Dr Sommers reported personal fees from American Economic Journal, personal fees from Health Research & Educational Trust, non-financial support from University of Cincinnati, personal fees and non-financial support from Northwestern Medical Center, personal fees from Massachusetts Medical Society, grants from Baylor Scott & White, personal fees and non-financial support from University of Rochester, personal fees from Urban Institute, grants from Commonwealth Fund, grants from Robert Wood Johnson Foundation, grants from REACH Healthcare Foundation, and personal fees from AcademyHealth outside the submitted work. No other disclosures were reported.