Implications

Lack of access to paid leave is a significant barrier to health care access and to work retention for parents, caregivers, and workers with serious health issues. Because of its high correlation with income, race, economics, labor force participation and job quality, access to paid leave should be considered a social determinant of health for rural workers just as access to health care facilities and other economic stability indicators are. For rural women of reproductive age, the overlapping effects on abortion restrictions, low levels of access to paid leave, and long distances to travel for hospital-based obstetrics care creates particular barriers—and this is especially true and dangerous for Black women whose maternal mortality rates are high.

The private sector has not increased access to paid leave at the scale needed, except when required by public policy interventions like earned paid sick days laws and the establishment of statewide paid family and medical leave programs. Employers can, of course, provide access to job-protected paid sick time and paid family and medical leave on their own, but if history is a guide, access to these protections are seen as fringe benefits rather than as essential to a healthy, thriving workplace within a vibrant community, a mechanism to attract workers to a particular geography, and a retention tool. While higher-wage, professional workers may be offered paid leave, middle- and lower-wage workers generally are not—even though their needs may be greater and going without pay is more difficult. The rural employment outlook—the types of jobs that are likely to be created, especially in leisure and hospitality, retail, and (to a lesser extent) education, health and social services where wages tend to be low and benefits are typically sparse—makes significant expansion of paid leave access unlikely without public policy interventions.

We therefore recommend as a rural health and economic imperative, public policies that provide access to paid sick time and paid family and medical leave either through federal legislative action or at the state level. Fortunately, there are strong models to learn from and build on. Eleven states plus the District of Columbia have paid family and medical leave programs in place or in the process of implementation; these are social insurance programs that guarantee new parents, family caregivers, and most workers access to paid family and medical leave. Fourteen states and 26 localities have paid sick time laws, that entitle workers to earn an hour of paid sick time for health and medical needs of their own or a loved one for every 30-to-40 hours they work, up to a cap. Federal legislation could create these policies at the national level, and states can continue to adopt policies on their own.

Rural people are highly supportive of public investments and requirements that guarantee access to paid leave. In November 2020, 78 percent of rural voters said they supported a national paid sick days law and 80 percent expressed support for a permanent paid family and medical leave program for people with illness or child or family care—support equal to that of voters overall.¹ The same was true in 2018 with respect to a national paid family and medical leave plan, with 80 percent of rural voters saying it is important to create a national policy that makes paid leave available and affordable for higher wage, management-level people in a workplace as well as for middle-level and lower-wage, front-line workers, and 76 percent said they supported a national fund paid for by small payroll deductions that would guarantee paid leave for up to 12 weeks to new parents, family caregivers, workers with serious health issues, and military family care.²

In November 2020, 80 percent of rural voters said they supported a permanent paid family and medical leave program and 78 percent said they supported a national paid sick days law.

How policy is designed will matter substantially for rural workers. In particular:

• The higher share of part-time workers and the higher share of smaller businesses in rural areas mean that eligibility rules must be expansive to include workers in non-traditional and part-time jobs, and that businesses of all sizes must be included—with paid leave that is job-protected. For example, a qualitative study of women cancer survivors in rural Illinois concluded that existing federal policies meant to protect workers with serious illnesses—the Family and Medical Leave Act and the Americans With Disabilities Act—do not protect rural workers effectively because these policies do not apply to smaller workplaces or, in the case of the FMLA, to workers with temporary or limited work histories at their current jobs. Researchers found that paid leave, workplace flexibility, and supportive workplaces, along with informal decision-making by managers and supervisors, were facilitators of continued employment for cancer survivors, whereas those in temporary or informal jobs did not have access to these supports and were more likely to leave work. They identified more inclusive workplace policies, including paid medical leave for all workers, as supporting employment for cancer survivors. They noted that informal workplace accommodations, as opposed to standardized, universal baseline policies, are unequally applied and not subject to oversight, which harms cancer survivors in lower-quality jobs.³
• The higher share of lower-wage jobs and lower-income households in rural areas mean that wage replacement rates for public paid leave programs must be high. Most newer state paid family and medical leave programs guarantee 80 to 100 percent wage replacement for low-wage workers and an average of about two-thirds for most other workers, up to a cap.⁴ Wage replacement at this level will help ensure that taking paid leave is affordable for rural workers over a multi-week span. Paid sick days should replace 100% of workers' usual wages for the limited number of days a law requires.
• The growing share of the aging population and the smaller share of younger people to provide care in rural areas means that it is important for policies to cover caregiving for a range of family members and loved ones. The ability to care for extended family and loved ones is especially important for rural families where substance use disorders among parents mean children are living with relatives, or where extended family members are caring for adults with substance use challenges. All but one state program (Delaware) allows workers to take leave to care for their grandparents, and many include a provision that allows workers to care for extended family, including “chosen” family as well.⁵

Outreach to rural communities will also be important—and there are likely to be lessons learned from the implementation of paid family and medical leave programs in the rural counties of California, New Jersey, New York, Washington, and Massachusetts, as well as from the roll-out of Medicaid expansion and the Affordable Care Act. There may also be applicable lessons to draw from the federal emergency paid sick and child care leave provisions that were briefly in place in 2020 to address the COVID-19 pandemic and applied to most workers in businesses with fewer than 500 employees.⁶ These are areas for future study, pilots, and innovation.