Why Employment During and After COVID-19 Is a Critical Women's Health Issue.

Abstract

The coronavirus disease 2019 (COVID-19) pandemic brings into sharp relief the inequities in U.S. society that produce poor health. These inequities disproportionately affect women, especially low-income women, immigrant women, and women of color (Kantamneni, 2020Kantamneni N. The impact of the COVID-19 pandemic on marginalized populations in the United States: A research agenda.Journal of Vocational Behavior. 2020; 119: 103439Crossref PubMed Scopus (249) Google Scholar; McClure et al., 2020McClure E.S. Vasudevan P. Bailey Z. Patel S. Robinson W.R. Racial capitalism within public health: How occupational settings drive COVID-19 disparities.American Journal of Epidemiology. 2020; 189: 1244-1253Crossref PubMed Scopus (116) Google Scholar). These same women are overrepresented among workers performing “essential” jobs during the pandemic (Cantor et al., 2020Cantor G. Sims L. Robbennolt S. The fragile financial stability of immigrant households in light of COVID-19.https://prosperitynow.org/resources/fragile-financial-stability-immigrant-households-light-covid-19/Date: 2020Date accessed: July 28, 2020Google Scholar; Centers for Disease Control and Prevention, 2020Centers for Disease Control and PreventionHealth equity considerations and racial and ethnic minority groups.www.cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html/Date: 2020Date accessed: August 7, 2020Google Scholar; Robertson and Gebeloff, 2020Robertson C. Gebeloff R. How millions of women became the most essential workers in America. The New York Times.www.nytimes.com/2020/04/18/us/coronavirus-women-essential-workers.html/Date: 2020Date accessed: August 15, 2020Google Scholar). Although essential jobs ensure the nation's continued access to necessary goods and services, they are often underpaid, provide few benefits, and expose women to greater risk of COVID-19 infection (National Conference of State Legislatures, 2020aNational Conference of State LegislaturesCOVID-19: Essential workers in the states.www.ncsl.org/research/labor-and-employment/covid-19-essential-workers-in-the-states.aspx/Date: 2020Date accessed: August 6, 2020Google Scholar; National Women’s Law Center, 2020National Women’s Law CenterEmployer immunity from COVID-19-related liability endangers women and people of color [Fact sheet].https://nwlc.org/resources/employer-immunity-from-covid-19-related-liability-endangers-women-and-people-of-color/Date: 2020Date accessed: August 3, 2020Google Scholar). Here, we highlight how the current pandemic draws attention to complex interdependencies between women's paid employment, health care access, and health outcomes. Income is a key social determinant of health (American Public Health Association, 2016American Public Health AssociationImproving health by increasing the minimum wage [Policy statement #20167].www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2017/01/18/improving-health-by-increasing-minimum-wage/Date: 2016Date accessed: August 2, 2020Google Scholar; Choi et al., 2020Choi H. Steptoe A. Heisler M. Clarke P. Schoeni R.F. Jivraj S. Langa K.M. Comparison of health outcomes among high- and low-income adults aged 55 to 64 years in the US vs England.JAMA Internal Medicine. 2020; 180: 1185-1193Crossref PubMed Scopus (17) Google Scholar); in the United States, employment is consequential for women's access to health care and health-promoting safety net programs. These interdependencies matter for women's health—and should matter for national policy making. Health equity efforts often focus on developing interventions and/or policy changes at the community level (Alexander and Hayes, 2017Alexander S. Hayes S. Viewing health policy through a gender lens: Highlights from several U.S. communities.Women’s Health Issues. 2017; 27: S2-S5Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar). However, community responses to COVID-19 highlight the disadvantages of a patchwork system of policies and heterogeneous resource availability. We argue, instead, that changes in national policies would benefit women throughout the United States. We focus on four ways that employment matters for women's health and consider policy implications for lawmakers taking office in 2021. Abundant evidence shows access to health insurance increases access to health care and improves health outcomes (Sommers et al., 2017Sommers B.D. Gawande A.A. Baicker K. Health insurance coverage and health—what the recent evidence tells us.New England Journal of Medicine. 2017; 377: 586-593Crossref PubMed Scopus (229) Google Scholar); uninsured individuals are more likely to have poor health and to die prematurely (HealthyPeople.gov, 2020HealthyPeople.govAccess to health services.www.healthypeople.gov/2020/topics-objectives/topic/Access-to-Health-Services/Date: 2020Date accessed: September 20, 2020Google Scholar). Particularly for women, health insurance is critical to both affordability and accessibility of health care (Kaiser Family Foundation, 2020bKaiser Family FoundationWomen’s health insurance coverage [Fact sheet].www.kff.org/womens-health-policy/fact-sheet/womens-health-insurance-coverage-fact-sheet/Date: 2020Date accessed: September 20, 2020Google Scholar). Uninsured women are less likely to have a regular provider and therefore more likely to delay or forego care; they are also less likely to receive preventive screenings (e.g., mammogram, Pap test, or colonoscopy) that can lead to early diagnoses when cancers are more amenable to treatment (Kaiser Family Foundation, 2018aKaiser Family FoundationWomen’s connections to the healthcare delivery system: Key findings from the 2017 Kaiser Women’s Health Survey.www.kff.org/womens-health-policy/issue-brief/womens-connections-to-the-healthcare-delivery-system-key-findings-from-the-2017-kaiser-womens-health-survey/Date: 2018Date accessed: September 20, 2020Google Scholar). Employer-based health insurance remains the largest source of coverage for working-age adults (Rae et al., 2020Rae M. McDermott D. Levitt L. Claxton G. Long-term trends in employer-based coverage.www.healthsystemtracker.org/brief/long-term-trends-in-employer-based-coverage/Date: 2020Date accessed: August 7, 2020Google Scholar), accounting for coverage of 60% of U.S. women ages 19 to 64 (Kaiser Family Foundation, 2020bKaiser Family FoundationWomen’s health insurance coverage [Fact sheet].www.kff.org/womens-health-policy/fact-sheet/womens-health-insurance-coverage-fact-sheet/Date: 2020Date accessed: September 20, 2020Google Scholar). Job loss frequently means a loss of insurance coverage. Adults who undergo even brief periods without insurance are just as likely as the long-term uninsured to have difficulties accessing, or paying for, medical care (Duchon et al., 2001Duchon L. Schoen C. Doty M.M. Davis K. Strumpf E. Bruegman S. Security matters: How instability in health insurance puts U.S. workers at risk: Findings from the Commonwealth Fund 2001 Health Insurance Survey [Report].www.semanticscholar.org/paper/SECURITY-MATTERS%3A-HOW-INSTABILITY-IN-HEALTH-PUTS-AT-Duchon-Schoen/3c0bc2e2e489af7b4f62aad278d5a621575101b7Date: 2001Date accessed: August 14, 2020Google Scholar). COVID-19 has resulted in record unemployment levels (Capps et al., 2020Capps R. Batalova J. Gelatt J. COVID-19 and unemployment: Assessing the early fallout for immigrants and other U.S. workers [Fact sheet].www.migrationpolicy.org/research/covid-19-unemployment-immigrants-other-us-workers/Date: 2020Date accessed: July 24, 2020Google Scholar). Women, particularly Black and Latina women, have been hit hardest (Gould and Wilson, 2020Gould E. Wilson V. Black workers face two of the most lethal preexisting conditions for coronavirus—racism and economic inequality.www.epi.org/publication/black-workers-covid/Date: 2020Date accessed: November 8, 2020Google Scholar; Gould et al., 2020Gould E. Perez D. Wilson V. Latinx workers—particularly women—face devastating job losses in the COVID-19 recession.www.epi.org/publication/latinx-workers-covid/Date: 2020Date accessed: November 8, 2020Google Scholar; Groshen, 2020Groshen E.L. Pandemic-related job disruptions by gender, race, and Hispanic ethnicity in May 2020.www.upjohn.org/research-highlights/pandemic-related-job-disruptions-gender-race-and-hispanic-ethnicity-may-2020/Date: 2020Date accessed: July 10, 2020Google Scholar; Kochhar, 2020Kochhar R. Hispanic women, immigrants, young adults, those with less education hit hardest by COVID-19 job losses.www.pewresearch.org/fact-tank/2020/06/09/hispanic-women-immigrants-young-adults-those-with-less-education-hit-hardest-by-covid-19-job-losses/Date: 2020Date accessed: July 9, 2020Google Scholar). Women comprise 46% of the U.S. workforce, but represent 54% of COVID-related job losses (Madgavkar et al., 2020Madgavkar A. White O. Krishnan M. Mahajan D. Azcue X. COVID-19 and gender equality: Countering the regressive effects.www.mckinsey.com/featured-insights/future-of-work/covid-19-and-gender-equality-countering-the-regressive-effects/Date: 2020Date accessed: August 7, 2020Google Scholar). As of July 2020, women still lagged behind men in returning to pre–COVID-19 employment levels (Hegewisch and Barsi, 2020Hegewisch A. Barsi Z. Economy adds more jobs for women than men, but women still 8 million jobs-on-payroll below February and majority of all who lost jobs [IWPR report # Q084].https://iwpr.org/publications/economy-adds-more-jobs-for-women-than-men-but-women-still-8-million-jobs-on-payroll-below-february-and-majority-of-all-who-lost-jobs/Date: 2020Date accessed: August 9, 2020Google Scholar). Affordability remains the top reason for women not having health insurance (Garfield et al., 2019aGarfield R. Orgera K. Damico A. The uninsured and the ACA: A primer — Key facts about health insurance and the uninsured amidst changes to the Affordable Care Act.www.kff.org/report-section/the-uninsured-and-the-aca-a-primer-key-facts-about-health-insurance-and-the-uninsured-amidst-changes-to-the-affordable-care-act-who-remains-uninsured-after-the-aca-and-why-do-they/Date: 2019Date accessed: September 20, 2020Google Scholar). Low-income women, immigrant women, and Black and Latina women are at greatest risk of being uninsured (Kaiser Family Foundation, 2020bKaiser Family FoundationWomen’s health insurance coverage [Fact sheet].www.kff.org/womens-health-policy/fact-sheet/womens-health-insurance-coverage-fact-sheet/Date: 2020Date accessed: September 20, 2020Google Scholar). But even with insurance, women may not be able to afford health care owing to the increase in high-deductible plans (Daly, 2019Daly R. Enrollment of large-company workers in high-deductible plans reaches a historic high.www.hfma.org/topics/news/2019/08/enrollment-of-large-company-workers-in-high-deductible-plans-rea.html/Date: 2019Date accessed: August 14, 2020Google Scholar; Kaiser Family Foundation, 2019aKaiser Family FoundationEmployer health benefits: 2019 summary of findings.www.kff.org/report-section/ehbs-2019-summary-of-findings/Date: 2019Date accessed: January 4, 2020Google Scholar; Levey, 2019Levey N.N. Health insurance deductibles soar, leaving Americans with unaffordable bills. Los Angeles Times.www.latimes.com/politics/la-na-pol-health-insurance-medical-bills-20190502-story.htmlDate: 2019Date accessed: January 4, 2020Google Scholar); 37% of women with employer-sponsored insurance reported difficulties in meeting their annual deductibles (Kaiser Family Foundation, 2020bKaiser Family FoundationWomen’s health insurance coverage [Fact sheet].www.kff.org/womens-health-policy/fact-sheet/womens-health-insurance-coverage-fact-sheet/Date: 2020Date accessed: September 20, 2020Google Scholar). Women who do not receive, or cannot afford, employer-based insurance may be eligible for Medicaid, which covers approximately 17% of adult women under 65 (Kaiser Family Foundation, 2020bKaiser Family FoundationWomen’s health insurance coverage [Fact sheet].www.kff.org/womens-health-policy/fact-sheet/womens-health-insurance-coverage-fact-sheet/Date: 2020Date accessed: September 20, 2020Google Scholar), or subsidized Marketplace plans under the Affordable Care Act (ACA). The majority of women who received Medicaid in 2017 were working (58%); many were employed in industries or firms that do not offer health insurance (Garfield et al., 2019Garfield R. Rudowitz R. Orgera K. Damico A. Understanding the intersection of Medicaid and work: What does the data say?.www.kff.org/medicaid/issue-brief/understanding-the-intersection-of-medicaid-and-work-what-does-the-data-say/Date: 2019Date accessed: September 20, 2020Google Scholar). It is not surprising that women comprise the majority of adult Medicaid recipients (Kaiser Family Foundation, 2019bKaiser Family FoundationMedicaid’s role for women [Fact sheet].www.kff.org/womens-health-policy/fact-sheet/medicaids-role-for-women/Date: 2019Date accessed: August 14, 2020Google Scholar), because they are more likely than men to live in poverty (≤100% federal poverty level [FPL]), or near poverty (100%–125% FPL) (Hokayem and Heggeness, 2014Hokayem C. Heggeness M.L. Living in near poverty in the United States: 1966-2012.www.census.gov/content/census/en/library/publications/2014/demo/p60-248.html/Date: 2014Date accessed: August 7, 2020Google Scholar). A woman working full time (35 hours/week) at the current federal minimum wage ($7.25/hour) earns an annual salary just above the FPL for a single-person household ($12,760) (ASPE, 2020ASPE(Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health & Human Services) HHS poverty guidelines for 2020.https://aspe.hhs.gov/poverty-guidelines/Date: 2020Date accessed: October 13, 2020Google Scholar), but well below the 138% FPL ($17,609) that qualifies her for Medicaid in states that elected to expand Medicaid under the ACA. In non-expansion states, more than 1 million women fall into a “Medicaid coverage gap”; they are ineligible for Medicaid, but have incomes too low to qualify for tax subsidies for plans purchased through the ACA Marketplace (Kaiser Family Foundation, 2020bKaiser Family FoundationWomen’s health insurance coverage [Fact sheet].www.kff.org/womens-health-policy/fact-sheet/womens-health-insurance-coverage-fact-sheet/Date: 2020Date accessed: September 20, 2020Google Scholar). Publicly subsidized insurance constitutes an important part of the safety net for low-income families in the United States (Sommers et al., 2017Sommers B.D. Gawande A.A. Baicker K. Health insurance coverage and health—what the recent evidence tells us.New England Journal of Medicine. 2017; 377: 586-593Crossref PubMed Scopus (229) Google Scholar). However, low wages substantially contribute to women's need for publicly funded health care. Research consistently illustrates the health benefits of higher earnings (American Public Health Association, 2016American Public Health AssociationImproving health by increasing the minimum wage [Policy statement #20167].www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2017/01/18/improving-health-by-increasing-minimum-wage/Date: 2016Date accessed: August 2, 2020Google Scholar; Link and Phelan, 1995Link B.G. Phelan J. Social conditions as fundamental causes of disease.Journal of Health and Social Behavior. 1995; 35: 80-94Crossref Scopus (3637) Google Scholar; Walters, 2004Walters V. The social context of women’s health.BMC Women’s Health. 2004; 4: S2Crossref PubMed Google Scholar), especially for women (American Psychological Association, 2010American Psychological AssociationWomen & socioeconomic status [Fact sheet].www.apa.org/pi/ses/resources/publications/women/Date: 2010Date accessed: October 11, 2020Google Scholar). Individuals with higher income enjoy longer life expectancy and lower rates of disease (Institute of Medicine, 2010Institute of MedicineResearch on determinants of women’s health.in: Women’s health research: Progress, pitfalls, and promise. The National Academies Press, Washington, DC2010: 35-94Google Scholar); they also have greater resources to access health care when they need it. Economic security affects health outcomes across the lifespan (Leigh and Du, 2018Leigh J.P. Du J. Effects of minimum wages on population health [Health policy brief]. Health Affairs.www.healthaffairs.org/do/10.1377/hpb20180622.107025/full/Date: 2018Date accessed: December 21, 2020Google Scholar). Women face risks to their economic security owing to gender- and race-based wage and wealth gaps (American Public Health Association, 2016American Public Health AssociationImproving health by increasing the minimum wage [Policy statement #20167].www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2017/01/18/improving-health-by-increasing-minimum-wage/Date: 2016Date accessed: August 2, 2020Google Scholar; National Women’s Law Center, 2020National Women’s Law CenterEmployer immunity from COVID-19-related liability endangers women and people of color [Fact sheet].https://nwlc.org/resources/employer-immunity-from-covid-19-related-liability-endangers-women-and-people-of-color/Date: 2020Date accessed: August 3, 2020Google Scholar). On average, women in the United States earn 81 cents for every dollar paid to men (U.S. Bureau of Labor Statistics, 2019U.S. Bureau of Labor StatisticsHighlights of women’s earnings in 2018 [Report 1083].www.bls.gov/opub/reports/womens-earnings/2018/home.htm/Date: 2019Date accessed: August 3, 2020Google Scholar). The wage gap is even more pronounced for most women of color: Black women earn 65 cents and Latinas only 62 cents for every dollar paid to White men (U.S. Bureau of Labor Statistics, 2019U.S. Bureau of Labor StatisticsHighlights of women’s earnings in 2018 [Report 1083].www.bls.gov/opub/reports/womens-earnings/2018/home.htm/Date: 2019Date accessed: August 3, 2020Google Scholar). Over a lifetime, these differences add up to hundreds of thousands of dollars in lost earnings (Tucker, 2019Tucker J. Women and the lifetime wage gap: How many woman years does it take to equal 40 man years? [Fact sheet].https://nwlc.org/resources/women-and-the-lifetime-wage-gap-how-many-woman-years-does-it-take-to-equal-40-man-years/Date: 2019Date accessed: August 3, 2020Google Scholar). Women, especially women of color, are disproportionately represented among minimum-wage earners (American Public Health Association, 2016American Public Health AssociationImproving health by increasing the minimum wage [Policy statement #20167].www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2017/01/18/improving-health-by-increasing-minimum-wage/Date: 2016Date accessed: August 2, 2020Google Scholar; Center on Budget and Policy Priorities, 2018Center on Budget and Policy PrioritiesPolicy basics: The minimum wage.www.cbpp.org/research/economy/policy-basics-the-minimum-wage/Date: 2018Date accessed: August 14, 2020Google Scholar). Women are also disproportionately “near-minimum” wage earners. Comprising approximately 30% of the U.S. hourly workforce, near-minimum wage workers earn more than their state's minimum but less than the proposed federal level increase to $15/hour (DeSilver, 2017DeSilver D. 5 facts about the minimum wage.www.pewresearch.org/fact-tank/2017/01/04/5-facts-about-the-minimum-wage/Date: 2017Date accessed: August 6, 2020Google Scholar). Many low-wage earners are the primary or sole providers for their families; approximately one-third have dependent children (American Public Health Association, 2016American Public Health AssociationImproving health by increasing the minimum wage [Policy statement #20167].www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2017/01/18/improving-health-by-increasing-minimum-wage/Date: 2016Date accessed: August 2, 2020Google Scholar; Allegretto, 2014Allegretto S.A. The impact of raising the minimum wage on women.https://irle.berkeley.edu/the-impact-of-raising-the-minimum-wage-on-women/Date: 2014Date accessed: September 17, 2020Google Scholar). The $7.25/hour federal minimum wage, which sets the wage floor, has remained unchanged since 2009. Twenty-nine states and the District of Columbia have passed higher minimum wage laws. The federal level applies to the remaining 21 states, which represent approximately 39% of the U.S. wage and salary workforce (DeSilver, 2020DeSilver D. When it comes to raising the minimum wage, most of the action is in cities and states, not Congress.www.pewresearch.org/fact-tank/2020/02/24/when-it-comes-to-raising-the-minimum-wage-most-of-the-action-is-in-cities-and-states-not-congress/Date: 2020Date accessed: August 6, 2020Google Scholar). In 2019 the House of Representatives passed the Raise the Wage Act to increase the minimum wage to $15/hour, but this bill died in the Senate. Women would benefit the most from increasing the national minimum wage. Evidence indicates that increasing the minimum wage increases birth weights, decreases smoking, and reduces the number of days individuals experience health limitations, including days missed from work (Leigh and Du, 2018Leigh J.P. Du J. Effects of minimum wages on population health [Health policy brief]. Health Affairs.www.healthaffairs.org/do/10.1377/hpb20180622.107025/full/Date: 2018Date accessed: December 21, 2020Google Scholar). Among women, it also significantly decreases suicides, one type of so-called “deaths of despair” (Dow et al., 2019Dow W.H. Godøy A. Lowenstein C.A. Reich M. Can economic policies reduce deaths of despair? [Working paper 25787]. NBER Working Paper Series.www.nber.org/papers/w25787/Date: 2019Date accessed: October 11, 2020Google Scholar). COVID-19 has foregrounded inequities in employment benefits that affect the health of women and their families. Not only are women overrepresented in low-wage jobs, but low-wage jobs often lack paid sick leave (Raghu and Tucker, 2020Raghu M. Tucker J. The wage gap has made some things worse for women on the front lines of COVID-19.https://nwlc.org/blog/the-wage-gap-has-made-things-worse-for-women-on-the-front-lines-of-covid-19/Date: 2020Date accessed: August 9, 2020Google Scholar). Paid leave is critical for women's ability to take time off, when needed, to care for themselves or their families (Tucker and Vogtman, 2020Tucker J. Vogtman J. When hard work is not enough: Women in low-paid jobs.https://nwlc.org/press-releases/low-paid-women-workers-on-the-front-lines-of-covid-19-are-at-high-risk-of-living-in-poverty-even-when-working-full-time/Date: 2020Date accessed: November 8, 2020Google Scholar). One out of three women's jobs has been designated “essential” during the pandemic (Robertson and Gebeloff, 2020Robertson C. Gebeloff R. How millions of women became the most essential workers in America. The New York Times.www.nytimes.com/2020/04/18/us/coronavirus-women-essential-workers.html/Date: 2020Date accessed: August 15, 2020Google Scholar). Although the definition of essential work varies by state (National Conference of State Legislatures, 2020bNational Conference of State LegislaturesCOVID-19: Impact on employment and labor.www.ncsl.org/research/labor-and-employment/covid-19-impact-on-employment-and-labor.aspx/Date: 2020Date accessed: August 6, 2020Google Scholar), it includes many predominantly female service-sector jobs such as child care, health care, social work, retail sales, and pharmacy (National Conference of State Legislatures, 2020aNational Conference of State LegislaturesCOVID-19: Essential workers in the states.www.ncsl.org/research/labor-and-employment/covid-19-essential-workers-in-the-states.aspx/Date: 2020Date accessed: August 6, 2020Google Scholar; Raghu and Tucker, 2020Raghu M. Tucker J. The wage gap has made some things worse for women on the front lines of COVID-19.https://nwlc.org/blog/the-wage-gap-has-made-things-worse-for-women-on-the-front-lines-of-covid-19/Date: 2020Date accessed: August 9, 2020Google Scholar; Robertson and Gebeloff, 2020Robertson C. Gebeloff R. How millions of women became the most essential workers in America. The New York Times.www.nytimes.com/2020/04/18/us/coronavirus-women-essential-workers.html/Date: 2020Date accessed: August 15, 2020Google Scholar). Low-wage workers in essential jobs are much less likely to have paid sick leave than their higher-wage counterparts; only 30% of private industry workers with wages of $10.48/hour or less have access to paid sick leave, compared with 90% of private industry workers with wages in the top quartile (Claxton and Levitt, 2020Claxton G. Levitt L. Paid sick leave is much less common for lower-wage workers in private industry.www.kff.org/coronavirus-covid-19/issue-brief/paid-sick-leave-is-much-less-common-for-lower-wage-workers-in-private-industry/Date: 2020Date accessed: October 11, 2020Google Scholar). A study of large service-sector firms found that 55% of workers did not receive paid sick leave; women were significantly less likely to receive it than their male co-workers (Schneider and Harknett, 2020Schneider D. Harknett K. Essential and vulnerable: Service-sector workers and paid sick leave.https://shift.hks.harvard.edu/essential-and-vulnerable-service-sector-workers-and-paid-sick-leave/Date: 2020Date accessed: July 9, 2020Google Scholar). Full-time workers are approximately three times more likely than part-time workers to have paid sick leave (Denton, 2020Denton S.L. Workers’ access to and use of leave from 2017-18.www.bls.gov/spotlight/2020/workers-access-to-and-use-of-leave/home.htm/Date: 2020Date accessed: August 7, 2020Google Scholar), and women are more likely to be part-time workers (Kaiser Family Foundation, 2020aKaiser Family FoundationPaid family and sick leave in the U.S. [Fact sheet].www.kff.org/womens-health-policy/fact-sheet/paid-family-leave-and-sick-days-in-the-u-s/Date: 2020Date accessed: September 20, 2020Google Scholar). When women do not receive paid sick leave, children are affected as well. Seventy percent of mothers with children under age 18 are in the workforce (Kaiser Family Foundation, 2018bKaiser Family FoundationWomen, work, and family health: Key findings from the 2017 Kaiser Women’s Health Survey [Issue brief].www.kff.org/womens-health-policy/issue-brief/women-work-and-family-health-key-findings-from-the-2017-kaiser-womens-health-survey/Date: 2018Date accessed: September 20, 2020Google Scholar). The health benefits of paid leave include lower infant and child mortality, increased breastfeeding and child immunizations, improved maternal health, and reduced psychological distress (Burtle and Bezruchka, 2016Burtle A. Bezruchka S. Population health and paid parental leave: What the United States can learn from two decades of research.Healthcare. 2016; 4: 30Crossref Scopus (48) Google Scholar; Lee et al., 2020Lee B.C. Modrek S. White J.S. Batra A. Collin D.F. Hamad R. The effect of California’s paid family leave policy on parent health: A quasi-experimental study.Social Science & Medicine. 2020; 251: 112915Crossref PubMed Scopus (21) Google Scholar; Nandi et al., 2018Nandi A. Jahagirdar D. Dimitris M.C. Labrecque J.A. Strumpf E.C. Kaufman J.S. Heymann S.J. The impact of parental and medical leave policies on socioeconomic and health outcomes in OECD countries: A systematic review of the empirical literature.Milbank Quarterly. 2018; 96: 434-471Crossref PubMed Scopus (57) Google Scholar; Rossin-Slater and Uniat, 2019Rossin-Slater M. Uniat L. Paid family leave policies and population health. Health Affairs [Health policy brief].www.healthaffairs.org/do/10.1377/hpb20190301.484936/fullDate: 2019Date accessed: December 21, 2020Google Scholar). Currently, the United States has no national paid leave policy. The Family and Medical Leave Act enables employees to take up to 12 weeks of unpaid, job-protected medical leave. However, only approximately 60% of the American workforce is eligible for Family and Medical Leave Act unpaid leave (Boushey et al., 2013Boushey H. Farrell J. Schmitt J. Job protection isn’t enough: Why America needs paid parental leave.www.americanprogress.org/issues/economy/reports/2013/12/12/80889/job-protection-isnt-enough/Date: 2013Date accessed: August 2, 2020Google Scholar; Kaiser Family Foundation, 2020aKaiser Family FoundationPaid family and sick leave in the U.S. [Fact sheet].www.kff.org/womens-health-policy/fact-sheet/paid-family-leave-and-sick-days-in-the-u-s/Date: 2020Date accessed: September 20, 2020Google Scholar). Almost one-half (46%) of eligible workers report struggling to afford unpaid time off (Rossin-Slater and Uniat, 2019Rossin-Slater M. Uniat L. Paid family leave policies and population health. Health Affairs [Health policy brief].www.healthaffairs.org/do/10.1377/hpb20190301.484936/fullDate: 2019Date accessed: December 21, 2020Google Scholar). Women are more likely than men to need, but not take, unpaid leave (Brown et al., 2020Brown S. Herr J. Roy R. Klerman J.A. Employee and worksite perspectives of the Family and Medical Leave Act: Results from the 2018 surveys.www.abtassociates.com/insights/publications/report/assessing-fmla-results-from-2018-surveys/Date: 2020Date accessed: November 11, 2020Google Scholar). Eight states and the District of Columbia have enacted laws to enable eligible employees to receive partially paid family leave; 10 states and the District of Columbia have passed laws requiring employers to provide paid sick leave to eligible employees. Given the overlapping challenges of employment and child care during COVID-19, state paid leave programs do not address the needs of women who have to stay home because of school or day care closures; leave durations are too short, partial wage replacement is too low, and the paid leave comes without job protection (Burtle and Bezruchka, 2016Burtle A. Bezruchka S. Population health and paid parental leave: What the United States can learn from two decades of research.Healthcare. 2016; 4: 30Crossref Scopus (48) Google Scholar). Recognizing the need to address shortfalls in employee leave provisions during the pandemic, Congress passed the Families First Coronavirus Response Act (FFCRA). The FFCRA provides up to 2 weeks of paid sick leave and 10 additional weeks of paid expanded family leave. These provisions apply to some public employers and private employers with fewer than 500 employees (U.S. Department of Labor, 2020U.S. Department of LaborFamilies First Coronavirus Response Act: Employee paid leave rights.www.dol.gov/agencies/whd/pandemic/ffcra-employee-paid-leave/Date: 2020Date accessed: August 3, 2020Google Scholar). The law exempts health care workers and emergency responders; 75% of excluded health care workers are women (Long and Rae, 2020Long M. Rae M. Gaps in the emergency paid sick leave law for health care workers.www.kff.org/coronavirus-covid-19/issue-brief/gaps-in-emergency-paid-sick-leave-law-for-health-care-workers/Date: 2020Date accessed: October 11, 2020Google Scholar). Paid leave supports women's participation in the labor force, protects women's income and employer-sponsored health insurance, and confers health benefits to both women and children (Nandi et al., 2018Nandi A. Jahagirdar D. Dimitris M.C. Labrecque J.A. Strumpf E.C. Kaufman J.S. Heymann S.J. The impact of parental and medical leave policies on socioeconomic and health outcomes in OECD countries: A systematic review of the empirical literature.Milbank Quarterly. 2018; 96: 434-471Crossref PubMed Scopus (57) Google Scholar). Although FFCRA expired on December 31, 2020, women's need for paid leave will outlive the current pandemic. The COVID-19 pandemic highlights the structural vulnerability of many women in the workforce. Structural vulnerability results from women's position in overlapping and mutually reinforcing power hierarchies (e.g., socioeconomic, institutional, policy) that limit access to health care, healthy lifestyles, and safety net benefits (Bourgois et al., 2017Bourgois P. Holmes S.M. Sue K. Quesada J. Structural vulnerability: Operationalizing the concept to address health disparities in clinical care.Academic Medicine. 2017; 92: 299-307Crossref PubMed Scopus (289) Google Scholar, p. 300). Access to disability benefits is important for maintaining women's health if they become unable to work owing to impairment. Individuals with disabilities have less access to health care and higher unmet health needs (World Health Organization, 2018World Health OrganizationDisability and health.www.who.int/en/news-room/fact-sheets/detail/disability-and-health/Date: 2018Date accessed: November 3, 2020Google Scholar). Compared with men, women with disabilities are more likely to live in poverty (Fins, 2019Fins A. National snapshot: Poverty among women & families, 2019.https://dev.devurl.info/nwlc2.org/issue/data-on-poverty-income/Date: 2019Date accessed: November 3, 2020Google Scholar) and receive lower Social Security Disability Insurance (SSDI) benefits (Ruffing, 2018Ruffing K. Women and disability insurance: Facts you should know.www.cbpp.org/research/social-security/women-and-disability-insurance-five-facts-you-should-know/Date: 2018Date accessed: November 3, 2020Google Scholar). The formula for calculating SSDI payments considers the applicant's age, income, and years worked (i.e., work credits earned). Women perform a disproportionate amount of unpaid care work; they are more likely than men to take time off to rear children or care for family members (Bruhn and Rebach, 2014Bruhn J.G. Rebach H.M. The sociology of caregiving. Springer, Dordrecht, the Netherlands2014Crossref Google Scholar; Lee and Tang, 2015Lee Y. Tang F. More caregiving, less working: Caregiving roles and gender difference.Journal of Applied Gerontology. 2015; 34: 465-483Crossref PubMed Scopus (76) Google Scholar; Lee et al., 2014Lee Y. Tang F. Kim K.H. Albert S.M. The vicious cycle of parental caregiving and financial well-being: A longitudinal study of women.Journals of Gerontology, Series B: Psychological Sciences and Social Sciences. 2014; 70: 425-431Crossref PubMed Scopus (37) Google Scholar). Because SSDI benefits are based on employment history, disadvantage accrues to women because they may lack earned work credits if they have worked part time or intermittently or joined the workforce later in life. The SSDI formula presumes a wage earner who works full time and continuously over a lifetime, is an “always-healthy, always-ready individual free from any caretaking responsibilities,” and is implicitly male (Albiston, 2010Albiston C.R. Institutional inequality and the mobilization of the Family and Medical Leave Act: Rights on leave. Cambridge University Press, Cambridge, UK2010Crossref Scopus (77) Google Scholar, p. 9). COVID-19–caused unemployment dramatically increased the need for short-term safety net benefits, such as community-based food banks (Feeding America, 2020Feeding AmericaFeeding America study projects local food insecurity rates amid pandemic could reach up to 1 in 3 adults and 1 in 2 children.www.feedingamerica.org/about-us/press-room/feeding-america-study-projects-local-food-insecurity-rates-amid-pandemic-could/Date: 2020Date accessed: August 9, 2020Google Scholar) and rent assistance (National Low Income Housing Coalition, 2020National Low Income Housing CoalitionState and local rental assistance.https://nlihc.org/rental-assistance/Date: 2020Date accessed: August 9, 2020Google Scholar). However, the Trump Administration's public charge rule could significantly impair access to state-supported programs, including the Supplemental Nutrition Assistance Program and Section 8 public housing for immigrant women and their families (Quinn and Kinoshita, 2020Quinn E. Kinoshita S. Overview of public charge and benefits.www.ilrc.org/overview-public-charge-and-benefits-march-2020/Date: 2020Date accessed: August 9, 2020Google Scholar). The new rule—suspended in July 2020 for the duration of the pandemic—determines whether noncitizens will be granted entry visas or permanent residency based on the likelihood they will avail themselves of publicly funded safety net programs (U.S. Citizenship and Immigration Services, 2020U.S. Citizenship and Immigration ServicesPublic charge.www.uscis.gov/green-card/green-card-processes-and-procedures/public-charge/Date: 2020Date accessed: August 14, 2020Google Scholar). Immigrants' fear of jeopardizing future residency applications has had a “chilling” effect on Medicaid enrollments (Tolbert et al., 2019Tolbert J. Artiga S. Pham O. Impact of shifting immigration policy on Medicaid enrollment and utilization of care among health center patients [Issue brief].www.kff.org/medicaid/issue-brief/impact-of-shifting-immigration-policy-on-medicaid-enrollment-and-utilization-of-care-among-health-center-patients/Date: 2019Date accessed: August 12, 2020Google Scholar), even among legal immigrant residents who qualify for government programs (Haq et al., 2020Haq C. Hostetter I. Zavala L. Mayorga J. Immigrant health and changes to the public-charge rule: Family physicians’ response.Annals of Family Medicine. 2020; 18: 458-460Crossref PubMed Scopus (12) Google Scholar). The negative health effects of the public charge rule include delaying medical care until treatable problems become emergencies, increased spread of communicable diseases (e.g., COVID-19), and increased rates of obesity and malnutrition among pregnant or breastfeeding women (Parmet, 2018Parmet W.E. The health impact of the proposed public charge rules. Health Affairs Blog.www.healthaffairs.org/do/10.1377/hblog20180927.100295/full/Date: 2018Date accessed: October 12, 2020Google Scholar). Immigration status exacerbates health disparities for women who are the least protected workers, among the lowest paid, and have the lowest access to health and safety net services. Newly elected lawmakers have opportunities to support employment policies that can improve health outcomes for women. Massive unemployment during COVID-19 underscores the precarity of relying on employer-sponsored health insurance. Instead, proposals such as the Medicare for All Act of 2019 would provide guaranteed, continuous coverage regardless of employment vicissitudes. Guaranteed, continuous health coverage would advantage women because many do not receive insurance as an employment benefit. Low-wage jobs keep many women in or near poverty while working, and provide no cushion against poverty after retirement. Women consume more health care throughout their lives than men, including care for reproductive health. Low wages impede women's ability to afford care, even if they have insurance. Improving women's health necessitates prioritizing women's long-term financial stability. The United States is unique among its peers in lacking a national paid leave policy (Nandi et al., 2018Nandi A. Jahagirdar D. Dimitris M.C. Labrecque J.A. Strumpf E.C. Kaufman J.S. Heymann S.J. The impact of parental and medical leave policies on socioeconomic and health outcomes in OECD countries: A systematic review of the empirical literature.Milbank Quarterly. 2018; 96: 434-471Crossref PubMed Scopus (57) Google Scholar). The Family and Medical Leave Act primarily benefits higher-income workers, since low-wage workers often cannot afford to take unpaid leave. Existing employer paid leave policies often exclude low-wage and part-time workers, who are more likely to be women. A federal paid leave policy would better protect women and their families across all occupational strata. Women are disadvantaged through lower accrued earnings, and also through gendered norms embedded in the U.S. social welfare system. According to one feminist theorist (Fraser, 1989Fraser N. Women, welfare, and the politics of need interpretation.in: Fraser N. Unruly practices: Power, discourse, and gender in contemporary social theory. University of Minnesota Press, Minneapolis, MN1989: 144-160Google Scholar, p. 147), women are doomed to perform “need” rather than being recognized as entitled to benefits. Women's structural vulnerability can be addressed by making changes to safety net programs, removing disincentives for immigrant access to health and social services, and accounting for women's work in ways that entitle them to health-promoting programs. Employment and women's health are multiply interconnected. Viable policy solutions must account for the intersectionalities of race/ethnicity, socioeconomic status, immigration status, and disability status that can multiply disadvantage women owing to sexism, racism, classism, ableism, and other forms of discrimination. Solutions implemented at the national level should guarantee work and health protections to women across the United States. Policies similar to the ones we propose have been adopted already in many developed nations. We recognize that implementing our recommendations in the current U.S. political context will not be easy, but failing to change existing policies will perpetuate inequities that adversely affect women's health. While the COVID-19 pandemic highlights these inequities, it also creates the opportunity, and hopefully the political will, to change policies to support women's health and well-being. Deborah Lefkowitz, PhD, is Assistant Professional Researcher for the Center for Health Disparities Research and Department of Anthropology at the University of California, Riverside. Her research focuses on health disparities, breast cancer survivorship, and women's access to health and legal services. Julie S. Armin, PhD, is an Assistant Professor in the Department of Family and Community Medicine at The University of Arizona. A women's health researcher, her research connects communities and clinical care along the cancer continuum, from prevention to survivorship.