"The USA's Ticking Time-bomb" by Lara Boyle
Lara Boyle is a current MD/PhD student at Columbia University Irving Medical Center in the Neurobiology and Behavior program. Her article below was originally published July 12, 2020 in PhDISH, a science blog run by graduate and medical students at Columbia. You can read more about Lara’s academic work at her ResearchGate or follow her on twitter @LaraBintheBrain
Author’s Note: Patient details were altered for the purpose of maintaining confidentiality.
I started my hospital rotations before the Covid-19 pandemic began. Even then, every doctor with whom I worked had seen patients who were balancing the treatment of their illness with the financial burden of this care. Now, as Covid-19 cases skyrocket across the United States, I worry that we will see a similar spike in the number of people who must choose between supporting themselves or their loved ones and financial ruin.
With the Covid-19 pandemic, the issue of paid sick-leave has catapulted to the political main stage. Although the recently passed Families First Covid-19 Response Act (see description at end of this article) addressed some of the immediate crisis, I, like many, wonder what happens next. Viruses similar to Covid-19 cause long-term damage to lungs, hearts, and other tissue long after the initial illness [1, 2]. Meanwhile, sickness and social isolation trigger and aggravate psychiatric disorders like depression and anxiety [3, 4].
Many Americans know people who have made difficult health care decisions, but fewer are aware of what kinds of safety net structures exist in the United States. I want to share one of the stories from my time in the hospital – specifically, during my rotation in the psychiatry – to walk through what structures people can rely on when their health goes south and show what gaps in the system remain. If we do not close the gaps in this net, the aftermath of Covid-19 will lead to many more desperate situations than just the current crisis.
The case of Mona
“You don’t know the service industry,” she said. “They’ll cut my hours until I make nothing. They’ll give someone else my shifts until I’m forced to get a second job.”
It was after morning rounds that Mona caught me in the hall to ask whether we could talk. She wore her usual baggy grey sweatshirt and black sweatpants, and her blond hair curled where it hit her shoulders. Her eyes were puffy from crying, which I hadn’t seen since our first few conversations after she entered the psychiatric unit. Two weeks ago, she had tried to commit suicide by swallowing a bottle of sleeping pills. A combination of time, daily therapy, and medication had improved her mood and she was no longer suicidal. Her sudden distress surprised me.
“I’m submitting my three-day notice,” she said as she handed me a note, folded on baby blue paper. Opening it, I recognized her simple cursive script. “I’m sorry,” she said, “I just can’t lose my job.”
By exercising her right to a “three-day notice,” Mona was essentially forcing staff to evaluate immediately whether she might hurt themselves or others. If no threat existed, we would immediately discharge her from the hospital. With an immediate discharge, Mona would be left out in the cold, not supported by the standard planning that physicians and social workers make on behalf of patients. That might mean no outpatient provider and a limited supply of essential medications.
Mona’s filing of her three-day notice told of her desperation. She worked in a service industry job that she loved, but day-by-day was more anxious about the stability of her position. She was a young adult with little in savings and depended on her job for her health insurance, but the position did not offer any compensated sick leave.
The financial burden itself was hard for her to bear, but worse was the threat of losing the job entirely. The night before our conversation she received a call from her employer informing her that he had hired someone to cover her shifts. When my attending suggested to Mona that firing someone due to their psychiatric disability was against the law, she pushed back. “You don’t know the service industry,” she said. “They’ll cut my hours until I make nothing. They’ll give someone else my shifts until I’m forced to get a second job.” I didn’t know how to respond.
The timeline of stay in an inpatient psychiatric unit, especially after an attempted suicide, is not obvious. The price of discharging an unstable patient can be their life. Mona’s case was complicated, so she had been in the hospital for almost two weeks. Mona was right that our team could not guarantee the safety of her job; we could only prioritize her mental stability. But in what scenario is someone’s mental stability not linked to their financial and personal stability? How could we discharge her knowing there was a chance she might lose her employment-covered insurance, leaving her with medications and therapy she could no longer afford?
A sickly state: absence of paid time-off in the United States
There are two roads by which patients in the United States can take time away from work for an extended period of illness: paid time-off or unpaid time-off. Paid time-off can come in a variety of forms, from days specifically set aside for illness, or more general paid time-off that does not differentiate between vacation and sickness. Employers either set a fixed number of sick-leave or allow employees to accrue days by working a certain number of hours. Since vacation days often need to be approved in advance, they are generally only useful to patients who know in advance the days they will need to leave work, such as in the case of an elective surgery.
In the United States, 1 in 4 of civilian workers do not have access to paid sick-leave [5,6]. The percent of workplaces offering sick-leave is on the rise; the number was 62% in 2011 and has slowly, but steadily, increased each year [7]. There remains a large gap between low- and high-wage earners, with 92% of the 25% highest paid workers receiving paid sick leave versus just 51% of the 25% of lowest paid workers. An increasing number of states, although still far from the majority, are passing laws mandating sick leave for employees.
Even as the percent of workers covered increases, the United States lags other countries; a study from the Center for Economic and Policy Research compared paid sick-day and paid sick-leave policies found that of twenty-two examined countries, “the United States is the only country that does not guarantee that workers receive paid sick days or paid sick leave [8].” Paid time-off is also generally not protected in the United States. It is up to the employer to abide by the policies they create regarding sick-leave unless explicitly guaranteed in an employee’s contract. In other words, patients can be fired for sick-leave even if they validate their illness and stay within the company standards for time-off [9].
Supporters of a national sick-leave policy argue that forcing sick employees to go to work spreads disease and undermines public health efforts, particularly in the time of Covid-19 [10]. Opponents claim that forcing companies to enact sick-leave policies could reduce other employee benefits or result in companies decreasing the number of working employees [11].
There are two current bills that aim to establish a national paid sick-leave policy. One is the Healthy Families Act, which has cycled through multiple rounds in Congress and stipulates that employers with fifteen or more employees must allow workers to earn at least one hour of paid sick-leave for every thirty hours worked [12]. For a full-time employee, this law would result in a minimum of seven sick-leave days per year. The second proposal is called the Workflex in the 21st Century Act [13]. Introduced in 2017 and last discussed in 2018, the bill aims to provide incentives to employers who offer paid sick-leave by giving exemptions from state and local paid time-off rules.
Non-paid sick leave and other protections
Apart from sick leave, two major laws, both enacted in the early 90’s, act as the safety net protecting patients from losing their employment while hospitalized. The first is the Family and Medical Leave Act (FMLA) [14]. This law requires that employers provide job-protected time-off for family and medical reasons, including personal illness. Patients can receive up to twelve weeks of non-paid leave over a one-year period.
There are two main requirements to qualify for FMLA: first, the patient must have worked at their company for at least one year, with at least 1,250 hours worked over 12 months. Second, the patient must work at a location where the employer has 50 or more working employees within the local area. An employer can argue that refusal of time-off “is necessary to prevent substantial and grievous economic injury to the operations of the employer,” but this defense puts the burden of proof on the employer.
The second law protecting patient employment is the Americans with Disabilities Act (ADA) , which fights against discrimination based on one’s long- or short-term physical or mental disability at companies with greater than fifteen employees [15]. The law requires employers to grant “reasonable accommodations” for disabled employees that are not an immediate threat to themselves or others, including unpaid time-off. Employers can reject the request for time-off if they can show it creates undue hardship for the employer, and the employee must still perform all the essential functions of the job with the granted accommodations. The strength of the ADA, then, is not that it automatically guarantees employment for those living with disability; rather, it forces an employer to have a conversation with their employees about how reasonable accommodations can be established that allow these employees to fulfill their duties.
Losing one’s job due to illness can have devastating consequences. A little over half of Americans receive health insurance through their employer [16]. Patients who lose their employment and their job-based insurance can retain some coverage through COBRA, a federal law that allows patients to stay on employee health insurance for a limited time after the end of employment [17]. Alternatively, patients can currently enroll in a Marketplace plan set up via the Affordable Care Act, which may be cheaper than the high premiums and fees associated with COBRA [18]. Regardless, it may be difficult for patients to pursue or afford these options while recovering from major illness.
We cannot undo our response to the initial pandemic, but we can prepare for its aftermath.
The case of Mona, revisited
Was Mona right that she would lose her job if she stayed in the unit? Psychiatric disorders are covered by the ADA, so Mona could not be terminated unless her employer could show she was a direct threat to herself or others upon her return to work or if her absence created an “undue burden” on the company. Getting fired is not the only way that Mona’s life could be affected. The ADA allows employers to reduce their disabled employees’ hours and pay. Depending on how long she worked at her job and the size of her company, Mona may or may not have qualified for the protected unpaid sick-leave guaranteed by the FMLA. Even if these laws protected Mona, the fact her job did not provide paid sick leave means she would face the financial consequences of an extended period of unpaid leave.
Acknowledging Mona’s financial and interpersonal relationships was a key part of her care. My attending met the difficult situation with a compromise: she began to lay out for Mona a timeline for discharge. Mona withdrew her three-day notice.
Over the next week, we created a concrete plan for Mona to go home. It included a roadmap of her first few months outside the unit and a comprehensive suicide prevention plan. Social work connected her to an outpatient care facility close to her apartment, where she would have an appointment within a few days of her discharge.
As time ticked onwards, the news about Mona’s job was indeed troubling. Her boss hired someone else to cover her shifts and asked to have a conversation with her when she returned to work. Yet Mona was afloat, if not at peace. “I might be catastrophizing,” she told me in one of our sessions, “I don’t know what he wants to talk to me about.” She sighed. “Even if he fires me, I can get another job…it’ll be okay.” Given Mona’s her strong support network and personal strength, we had much hope it would.
If the United States began preparations for Covid-19 just two weeks earlier than it did, experts estimate 90% of deaths could have been prevented
A temporary fix for a long-term problem: The Families First Covid-19 Response Act and what comes next
At the beginning of this article I mentioned that Congress recently passed a new act to address the immediate financial healthcare burdens of Covid-19. This act is the Families First Covid-19 Response Act [19]. The act provides:
Mandatory paid sick leave for those affected by Covid-19 by businesses with fewer than 500 employees
Paid family and medical leave by businesses with fewer than 500 employees
Tax credits for providing paid leave
Expansion of unemployment insurance and programs
Multiple other stipulations including free Covid-19 testing, increases in the budget for medical services, and food assistance
While this bill is absolutely essential, it is set to last until December 31st, 2020. Aside from the fact that Covid-19 will likely still be around beyond December, physicians expect long-term complications of the current pandemic to extend far into the future.
If the Covid-19 pandemic does indeed result in long-standing physical and mental disorders, there will be a surge in cases like Mona’s. When is the right time for us as a nation to prepare for these lasting effects? Let us consider. If the United States began preparations for Covid-19 just two weeks earlier than it did, experts estimate 90% of deaths could have been prevented [20].
We cannot undo our response to the initial pandemic, but we can prepare for its aftermath. Congress must act now to make sure that future patients won’t have to make the impossible choice between their health and their financial stability. How? Pass acts that will increase rates of paid sick-leave, increase job security, and provide support for those who lose their ability to work.