Awareness and Use of California's Paid Family Leave Insurance Among Parents of Chronically Ill Children
Dec 31, 2007
About 15 percent of children in the United States are chronically ill. These children with special health care needs (CSHCN) account for half of all child hospital days nationwide, require many more medical visits than other children, and miss many more days of school. Their parents face special challenges as they struggle to balance work and the needs of their sick children.
The federal Family and Medical Leave Act (FMLA) was intended in part to provide help by guaranteeing parents of ill children up to 12 weeks of unpaid leave, with protection against being fired. The effect of FMLA, however, has been limited. Fewer than half of U.S. employees are eligible for the program; in a national survey, nearly 80 percent of eligible parents who didn't take advantage of FMLA said they couldn't afford to take the unpaid leave.
In response to this need for greater access to both leave and pay during leave, the federal government and several states have considered enacting paid family leave programs. California was the first state to implement one, beginning the Paid Family Leave Insurance (PFLI) program in 2004. The adoption of PFLI provided a natural experiment, allowing a team of RAND analysts to assess use and health effects of paid and unpaid leave among parents of CSHCN in California before and after PFLI and to compare those effects with leave-taking among similar parents in another state over the same time frames.
To provide a baseline against which to measure PFLI's effects, RAND researchers conducted a survey of parents of CSHCN shortly before PFLI was implemented (see Figure 1).
Researchers randomly sampled CSHCN who had received care before PFLI implementation in either Mattel Children's Hospital at the University of California, Los Angeles, or Children's Memorial Hospital in Chicago, Illinois. Hospitals such as these provide the majority of care for children with serious chronic conditions.
Between November 2003 and January 2004, researchers interviewed about 375 employed parents of CSHCN at each site, asking them about their jobs and job benefits, their need for and use of leave, and how their leave-taking affected their family's health and finances.
About half of the parents interviewed were eligible for FMLA, and about two-thirds of those who were eligible were aware of the law. About 80 percent of the parents interviewed had missed work—via FMLA or other leave—to care for their child; their absences ranged from less than a week to more than three months (see Figure 2).
Parents who were eligible for FMLA and were aware of their eligibility or who had access to employer-provided leave (paid or unpaid) were more likely than other parents to stay home to care for their child. But even among parents who did stay home, 40 percent said they had to return to work sooner than was optimal for their child's health.
Findings from this baseline survey suggested that parents of CSHCN might benefit from access to paid leave. California's adoption of the PFLI program in 2004 provided an opportunity to explore this hypothesis.
Adopted in 2004, California's PFLI program provides up to six weeks annually of non–job-protected leave for most employees at 55 percent of salary, up to a maximum weekly benefit of $728 in 2004. About 18 months after PFLI benefits began in July 2004, the RAND team identified and surveyed a second group of parents of CSHCN and gathered the same kind of information elicited in the first survey (see Figure 1). In addition, the team asked parents whether they were aware of, and had used, PFLI.
Even parents who might be particularly expected to use paid leave were unlikely to do so: Among parents who missed enough work to fulfill PFLI's mandatory one-week waiting period and thus qualify for benefits, fewer than 15 percent were aware of the program, and only 6 percent had used it. Lack of readily available information about the program probably contributes to the widespread lack of awareness—employers are only required to make information about PFLI available to new employees and those who specifically inquire about family leave.
Despite adoption of the PFLI program, California parents of CSHCN still have substantial unmet need for leave to care for their chronically ill children. What does PFLI's poor performance in this population imply for the design and implementation of similar programs in other states?
Providing protection from being fired would remove one barrier, as would reducing a leave program's waiting requirements and other administrative barriers, and increasing pay levels.
But dissemination is likely key. Information about a leave program needs to be made widely available, not just given to new employees or those requesting leave. FMLA, for instance, benefited from an intensive publicity campaign and mandatory public posting in the workplace, resulting in high levels of awareness. Even with PFLI, pregnant women in California automatically receive information about PFLI when they apply for state pregnancy/postpartum disability insurance (since PFLI and disability insurance are administered by the same agency); consequently, the overwhelming majority of PFLI claims in the state are for maternal-infant bonding. Similar dissemination strategies aimed at employees more generally would likely have a substantial impact on uptake among parents of CSHCN, who remain under-informed and highly vulnerable. Finally, health practitioners who care for CSHCN could also play a key role in dissemination by educating parents about leave laws.