Policymakers can protect Ohioans through paid sick days and increased funding for public health

Executive Summary

Coronavirus: How will Ohio fare?

Everyone wants assurance that if they or their loved ones get sick, they’ll get the care they need. If the economy goes south, we all want to know we will be able to weather the storm. Part of the reason we pool our resources in the form of taxes is so the government has enough to protect us in a time of crisis. Faced now by epidemic, we look to government to take extraordinary measures to protect and preserve life and limit the threat to our family, community and country.

Photo by Chad Davis via flickr

In this paper, we look at the public policy landscape as the threat of coronavirus grows. We find that decisions made by policymakers have made Ohio more vulnerable to crisis and could make it easier for the disease to spread. Ohioans who work in some of the state’s fastest-growing jobs are paid low wages and often don’t get basic protections at work. Retail or restaurant employers, for example, regularly don’t give workers paid sick time. Sick employees could spread coronavirus to the people they serve at work.

On top of that, over the past 15 years, policymakers have given tax cuts to the wealthy and corporations while underfunding Ohio’s public infrastructure, like local public health departments. That weakens state and local governments’ ability to respond quickly and robustly to the threat of disease and economic disaster for sick and quarantined workers and their families. Luckily, Governor Kasich chose to expand Medicaid to provide health coverage for low-wage workers, but state legislators have pushed unceasingly to freeze it, diminish it, or otherwise create barriers to enrollment. As a result, Ohio is one of only eight states where the number of people without health insurance went up between 2017 and 2018. This report contains short-term recommendations for the immediate threats and long-term recommendations to strengthen necessary public infrastructure for the future.

Recommendations include:

1) Policymakers must prioritize people with low incomes, elderly people, people with disabilities and homeless people in the public health response to the coronavirus. The best way to slow the spread of the virus is broad testing and treatment, as well as ensuring all Ohioans’ basic needs are met. There is a moral obligation, but there is also a public health urgency to this comprehensive approach.

2) In the short term, the governor can create a temporary paid sick day program. This can happen immediately to slow community spread of the virus. The DeWine administration could pay for it in four main ways: By declaring an emergency and using general revenue funding; utilizing money from the Controlling Board’s Emergency Purposes Fund; tapping into the Budget Stabilization Fund, which is already nearing full capacity, or by using funds from the Temporary Assistance to Needy Families program that have been reserved for emergencies and unforeseen circumstances. In the long run, legislators should pass a law like the Ohio Family Leave Act of 2008.

3) The Ohio Department of Job and Family Services, the Ohio Department of Medicaid and county Job and Family Service Offices should streamline eligibility and enrollment in public programs that provide health care as well as income and nutrition support to those whose incomes will be interrupted by economic dislocations or individual quarantine. This will take immediate action and it will take increased funds for county human service offices.

4) State policymakers should assure that the medical bills from coronavirus testing and treatment do not bankrupt people or that prohibitive costs cause people to avoid care. This reassurance should happen as soon as possible, to encourage and ensure people will get tested and treatment. If the epidemic lasts for a long time and many people fall into economic distress, the state will have to look to the federal government for assistance.

5) The epidemic will strain the financial resources of safety net providers that serve the uninsured and underinsured, and that are already under financial stress. Government should implement policies that will increase those providers’ revenues to sustain their operations. These policies should include, but not be limited to, rural providers identified as financially at risk. Lawmakers will need to look to the federal government for assistance if economic conditions deteriorate seriously for a prolonged period.

6) Health care providers should see patients even if they have outstanding debt for past care. They should suspend collections of patient debt during the epidemic.

7) The government and the private sector should collaborate to ensure that all health care workers have health coverage. Health coverage is essential to protect the health and safety of caregivers who will be on the front line of caring for those who are most medically at risk. If some providers are ineligible to receive public coverage (e.g., based on immigration status), the private sector should arrange for their coverage.

8) State and local governments should establish and engage advisory groups, comprised of public, corporate, and charitable organizations, health care providers and community leaders representing the diversity of Ohio’s population.

9) Crisis can bring change. Now is the time for policymakers to bolster support for public health. In the future policymakers can ensure there is a permanent program so that all workers get paid sick days. They can strengthen Medicaid and the Medicaid expansion by helping low-income people enroll and stay enrolled.

Trump Administration Secretary of Health and Human Services Alex Azar learned about coronavirus on January 3, 2020.[1] Two months later, the administration is just starting to respond. As this report goes to press on March 11, it appears fewer than 10,000 Americans have been tested[2] – but the pace is picking up as the disease spreads in the United States. Congress appropriated $8.3 billion for the response.[3] Governor DeWine and Public Health Director Amy Acton are holding press conferences and controlling attendance at mass events to prevent spread.[4] The governor has declared a state of emergency, which allows expedited action in contracting for needed services.[5] Yet over time, as a nation and as a state, policy decisions of elected leaders have eroded our ability to control this disaster. At the federal and state levels, tax cuts that have benefitted the wealthiest[6] have been accompanied by erosion of public services needed in the face of a pandemic.

The Democratic primary debates have focused attention on the recent elimination of the National Security Council’s global health unit by the Trump Administration and expiration of funds for global disease prevention and control.[7] Federal policymakers have also allowed funding for domestic public health programs to erode. Adjusted for inflation, they cut funding by 45%, from more than $900 million in fiscal year 2005 to $675 million in fiscal year 2020.[8] Grant programs for state and local public health emergency preparedness—the front lines in detecting and battling new disease—have been especially hard hit.[9]

Ohio policymakers’ support of local public health agencies has dwindled over time. In Ohio’s current state budget, lawmakers boosted funding for the Department of Public Health by 18.8%.[10] Even so, state funding dedicated to local public health departments operations identified in the Legislative Service Commission’s budget green books appears to have fallen by about 30%, adjusted for inflation, compared to 2005 (Chart 1). About two-thirds of Ohio’s funding for public health comes from the federal government, and even that is low: The Columbus Dispatch reports Ohio ranks 47th among the states in federal funds received from the Centers for Disease Control and Prevention.[11]

Ohioans are in poor health compared to most other states in the nation. Ohio ranks 43rd in terms of overall health, rated on many factors. Weakness in public health is identified as one of the factors that creates poor outcomes. [12] The Trust for America’s Health ranks Ohio among the bottom tier of states in preparedness for a public health crisis.[13]

Ohio’s local public health agencies get most of their funding from the federal government, but a substantial share comes from local government, through property tax levies, licensing and other fees. In 2019 there were 50 health levies in cities and counties in the state.[14] State policymakers eliminated tax reimbursements to these and other levies, which they provided after they scrapped a major business property tax in 2005. Health and health and human service levies lost $33 million a year in state funding from this source.[15]

Counties and cities have not been in a position to backfill for these losses. State lawmakers cost local governments $1.3 billion a year in state funding, adjusted for inflation, by eliminating the tax reimbursements and the estate tax, slashing local government fund, and other cuts. Even the new revenues from casino gambling and the recent rise in the gas tax did not restore big holes in local budgets.[16]

Local health departments face the coronavirus threat with diminished resources and little opportunity to raise funds on their own.

Low income workers and individuals, particularly elderly people, people with disabilities or homeless people, could too easily be forgotten in the public health response. The best way to slow the spread of the virus is broad testing and treatment, as well as ensuring all Ohioans’ basic needs are met. There is a moral obligation, but there is also a public health urgency to this comprehensive approach:

• Policymakers must provide funds for outreach to homeless shelters, food pantries and senior centers to make sure the most vulnerable people are tested, treated, and cared for if sick.
• Arrangements for shelter and medical treatment for the homeless are urgently needed. Some homeless shelters are not equipped to isolate people who test positive for the virus. Some shelters report it may take weeks to get hand sanitization placed in them.[17]
• Policymakers need to shore up the state’s foodbank system. Ohio’s foodbank inventories stand at between 17 days to 70 days at present. Those resources could be depleted in a matter of days if schools close and 700,000 plus children lose free and reduced meals and low-income working people go without pay because they are sick.[18] Policymakers must provide funds to ensure food for affected households and communities during the crisis.
• Congress approved $8.3 billion for response to coronavirus. If it takes a long time for federal funds to get distributed, Ohio’s legislators should consider using rainy day funds, as Maryland lawmakers did.[19]
• Ohio Department of Health took a helpful first step by creating a toll-free number to field questions about coronavirus. A known, coordinated source for information on policy questions could stem confusion: Superintendents may worry about feeding children who depend on school lunches during school closures, for example, or doctors may wonder about providing and monitoring medication needed by quarantined patients undergoing treatment for addiction.
• Government and the private sector should collaborate to deliver food, medicine and sanitation supplies to those who are quarantined or isolated.
• The state should consider relaxing policies to allow health care providers to reach patients through expanded telehealth services and even telephone. This could be particularly important for prescribers, who could face workforce shortages due to the epidemic, allowing them to keep in contact with patients, manage medications and symptoms, and make needed adjustments as well as regular refills.

Millions of workers have employers that don’t provide them with paid sick days. They may have to choose between going to work sick and paying the rent, or possibly losing their jobs. These are the retail clerks who ring up our purchases of hand sanitizer and face masks; who prepare and serve our food at restaurants, fast food stores and in grocery stores; who take care of our children, elderly and disabled people.

Nationally, 27% of all private sector workers lose pay – or their jobs – if they are sick and don’t report to work. In the Midwest it’s worse: 34% of private sector workers lack paid sick days. [20] After the spread of the H1N1 (Swine flu) virus in 2009, an estimated 8 million workers without sick time went to work while ill, spreading the virus to another 7 million.[21]

Businesses and policymakers who oppose paid sick time policy make a simple calculation of the cost of paying workers who aren’t on the job. It’s not that simple. There’s a larger cost of not having paid sick days: More workers out sick because of those who are spreading the virus in the workplace, as well as decreased economic demand stemming from greater rates of illness among potential customers.

We’ve seen the havoc this can wreak in Ohio. In 2008, 509 people were sickened with norovirus in Kent: The outbreak was caused by a restaurant that didn’t give its workers paid sick days. The outbreak cost people in the Kent community a lot of suffering, and it also cost between $130,233 and $305,337 in lost wages, tuition paid by students for classes not attended, taxpayer education subsidies, lost income tax revenues, and health care costs. Paid sick days would have cost the Chipotle location that was identified as the source of the outbreak between $12,601 and $26,087 annually.[22]

People who earn low wages are more likely to work in jobs that require substantial contact with the public—food service, early care and education, home health, restaurants and transportation (Uber and Lyft, etc.).[23] When workers or their family members are sick, they shouldn’t have to decide between staying home from work and paying rent or putting food on the table. But choices made by federal and Ohio lawmakers today leave millions of people facing that hard choice – an increasingly dangerous choice for workers themselves and for the public serve, as coronavirus spreads.

Access to paid sick days declines with pay.[24] Among the lowest paid quarter of workers nationally, 49% lack paid sick days; among the lowest paid 10% of workers, the figure rises to 69%.[25] A 2012 study by the Food Chain Workers Alliance found 79% of food workers get no paid sick days.[26] About half have come to work sick in the past simply because they had no choice. An Economic Policy Institute report estimated in 2017 that for an average worker without access to paid sick days, the lost wages associated with staying home for about three days would amount to their household’s entire monthly grocery budget or monthly utilities budget.[27]

It’s tough in the lowest paid sectors, but it’s not so great in other sectors, either. In 2018, a third of manufacturing workers nationally lacked paid sick days. If that figure holds true for Ohio, about 236,000 manufacturing workers face a dilemma if they feel sick and have trouble breathing but can’t afford to lose a day of work. In wholesale and retail trade the national average for workers without paid sick days is 46.9%; if this holds true here, 400,000 Ohioans working in warehouses, grocery stores, shopping malls and small businesses may face hard choices when coronavirus sweeps through their community. In construction, 56.1 percent lack paid sick days, which, if it holds true for Ohio, would be about 128,000 Ohioans.[28]

There is no federal requirement that employers offer employees paid sick days when they or a family member has a short-term illness that does not permit them to work, but public policy can address that. For example, the Obama Administration issued an executive order that requires federal contractors to offer employees at least seven days of paid sick time annually.[29] At the time of enactment, this applied to approximately 300,000 people working on federal contracts. Furthermore, pubic employees generally have sick leave: In 2018, 91% of workers in public administration had paid sick time.[30]

Introduced in Congress in 2019, the Healthy Families Act would require employers nationwide with 15 or more employees to provide at least one hour of earned paid sick time for every 30 hours worked (up to a maximum of 56 hours per year). Employees would be able to use sick leave for their own illness, or to care for a sick family member.[31]

On March 6, 2020, legislators in the U.S. House of Representatives introduced new, emergency paid sick days legislation, building on the Healthy Families Act (HFA). The bill would provide paid sick days immediately to workers in light of the coronavirus crisis, and in preparation for future public health emergencies. This emergency paid sick days legislation requires all employers to allow workers to accrue seven days of paid sick time and to provide an additional 14 days available immediately in the event of any public health emergency, including the current coronavirus crisis.[32]

Eleven cities or states mandate sick leave: Research shows it makes a difference.[33] In the figure above, which was originally published in the Washington Post, the thick vertical black line represents the point at which the sick leave cities implemented their policies. The blue line going left to right represents the flu rate in the sick leave cities, relative to those without policies: If that line is lower than the zero or “no change” marker, it means the sick leave cities have a lower flu rate than those without such a policy.

Many Ohio employers provide paid sick days because they recognize that it is better for their customers, clients, workforce and productivity.[34] In response to public pressure and increasing concern as coronavirus cases increase in the U.S., the Darden family of restaurants, which includes The Olive Garden, extended sick leave to all hourly workers.[35] More employers should follow suit. But if the national figures for lack of sick leave among all private sector workers holds true for Ohio, 27%—an estimated 1.3 million Ohio workers—cannot take a paid day off when they are sick.[36] House Democratic lawmakers sent a letter to Gov. Mike DeWine urging him to consider creating a temporary paid sick days program to ease the impact of coronavirus.[37] The Ohio General Assembly could do more, and pass actual legislation mandating paid sick days as in other states and cities. This has been considered before. The Ohio Healthy Families Act (2008) would have required businesses with 25 or more employees to provide seven paid sick days to full-time employees each year. Part-time employees would earn paid sick days on a pro-rated basis. Advocates turned the proposed legislation into an initiated ballot measure, but opposition from the business community and the governor stopped it from reaching the ballot box.[38] Yet research shows paid sick day policies provide an overall economic advantage to individual companies, communities, workers and the economy.[39]

• In the short term, the governor should do as Democratic leaders have requested and create a temporary paid sick day program. This should happen immediately to slow community spread of the virus. The DeWine administration could pay for it in four main ways: By declaring an emergency and using general revenue funding; utilizing money from the Controlling Board’s Emergency Purposes Fund; tapping into the Budget Stabilization Fund, which is already nearing full capacity, or by using TANF funds that have been reserved for emergencies and unforeseen circumstances.[41] In the long run, legislators should pass a law like the Ohio Family Leave Act of 2008.
• Private companies should extend paid sick days and family leave to employees immediately to encourage people to stay home if sick, and as long as needed to recover. This will prevent the spread of disease.
• The Ohio Department of Job and Family Services should boost funding for county Job and Family Services Offices to ensure timely enrollment in needed services and should stipulate that TANF prevention, retention and contingency funds (PRC) be expanded for use to prevent eviction, keep the heat on, and otherwise help households with unusual economic circumstances due to quarantine or illness.

Six of Ohio’s 10 largest occupational groups are made up of low-paid workers. Median wage in these jobs is so low, and employer health benefits so rare, that a full-time worker with two children is eligible for insurance through Medicaid.[42] That coverage is one of our best tools to treat people infected in the pandemic and save lives. But Ohio’s legislators have vigorously fought to dismantle Medicaid coverage for low-wage working adults and passed legislation that will make it hard to get or stay enrolled in Medicaid. An information system to enroll people in Medicaid has been plagued with problems; some county agencies have struggled to get people into the system and to keep them enrolled.[43] Ohio was one of eight states that experienced a real increase in the share of people without health insurance in 2018 compared to 2017—the second year in a row that Ohioans lost coverage, bringing the number of uninsured Ohioans to 744,000, up 58,000 from 2017, and bringing the share of uninsured children to 5.5%.[44]

Nationally, the Republican congress and president have tried repeatedly to eliminate the Affordable Care Act, which provides health coverage for the growing number of low-wage workers and their families.[45] Twenty Republican Attorneys General joined in a lawsuit, Texas v. United States, to dismantle it.[46] Yet the expansion of health care to low and moderate income families through tax credits and Medicaid expansion is a critical tool now in the face of the pandemic.[47] In addition to providing millions of Americans, and hundreds of thousands of Ohioans, with health care, it has strengthened America’s health system, particularly in rural areas.[48]

At present, an estimated 9% of Ohio’s 58 rural hospital systems are considered financially vulnerable.[49] The Medicaid expansion has been critical to strengthening that system, which is vitally important in a public health crisis.[50] Yet Ohio legislators have tried over and over to undermine that protection for people, families and communities by creating barriers that will knock people out of enrollment, endangering health.[51] Policymakers in other states imposed harsh new reporting requirements that knocked thousands of people out of Medicaid enrollment, yet Ohio plans to implement the same requirement in 2021.[52] Legislators have tried to find indirect ways of cutting Medicaid, such as by boosting the cost of services, offering diminished health care services to the poorest people, and cutting people off who fall behind in paying monthly premiums.[53] Many Republican legislators voted to freeze Medicaid expansion enrollment in past budget bills. That would have eliminated the program within 18 months because people are not on it permanently.[54] In the churning American economy, low-wage jobs start and stop, so people cycle on and off of Medicaid. A freeze cuts them out of coverage after the next layoff or plant closure.

Restricting Medicaid in these ways endangers the broader public, because it makes it more likely fewer people will seek testing and treatment, facilitating spread of disease.

The Ohio Department of Job and Family Services, the Ohio Department of Medicaid and county Job and Family Service Offices should streamline eligibility and enrollment in public programs that provide income and nutrition support to those whose incomes will be interrupted by economic dislocations or individual quarantine. This will take immediate action and it will take increased funds for county human service offices. Funds could be taken from the same sources as those recommended for paid sick days: Declaring an emergency and using general revenue funding; utilizing money from the Controlling Board’s Emergency Purposes Fund; tapping into the Budget Stabilization Fund, which is already nearing full capacity, or by using TANF funds that have been reserved for emergencies and unforeseen circumstances. Other recommendations include:

• The information technology system for Medicaid and other human services, “Ohio Benefits,” is riddled with 1,100 glitches, which make enrolling people and keeping them enrolled more difficult.[55] The state and the private consultant, Accenture, must get the system fully functional to handle the epidemic.[56]
• Government should suspend the termination of public health coverage and streamline the enrollment of the uninsured in public health insurance programs, so that as many Ohioans as possible have the assurance that affordable treatment will be available when they seek care.
• The Ohio Department of Medicaid should work with Managed Care Organizations (MCOs) to strengthen outreach with enrollment centers, equipped with computers and phones, in food pantries, homeless shelters, schools, community centers and hospitals. The MCOs should help fund county caseworkers to staff these outreach centers to help people enroll in Medicaid and other services.
• Managed Care Organizations should require health care providers help eligible patients enroll in Medicaid and stay enrolled, to protect the integrity of the health care system and ensure ongoing, uninterrupted care for their patients.
• Health care providers should see patients without regard to whether they have outstanding debt incurred for past care and should suspend collections of patient debt for the duration of the epidemic.

Ohio’s policymakers can make changes now that will prepare the state to better meet crises in the future. The most pressing concern is to take care of those most threatened by the epidemic and most likely to be overlooked: low-income workers and their families, as well as elderly, disabled and homeless people. Basic needs, like food and shelter, may be threatened if people lose their income for extended periods of time and face eviction or foreclosure. The state must attack the social and economic problems that will emerge as well as the medical problems.

In addition to the short-term recommendations above, which are needed immediately, lawmakers should enact long-term measures to rebuild a diminished public service infrastructure.

• Governor DeWine and Public Health Director Acton can petition Washington for flexibility in use of critical federal safety net funds like Supplemental Nutrition Assistance Program (SNAP, also known as food stamps) and Temporary Assistance for Needy Families (TANF) for families who lose their income through the epidemic. Their voices will be essential in getting federal policies in place that can protect Ohioans.
• Lawmakers need to boost state funding for local public health operations substantially—both now and in the future—and restore cuts to both public health agencies and local health levies.
• The state should restore local government funding since local government is responsible for so much of the health and human service funding and delivery in Ohio. This epidemic will further strain critical services funded largely by local governments and local levies.
• State lawmakers should protect public health and Ohio’s workers by mandating paid sick days. They should also pass a law mandating paid family leave.
• State policymakers should assure that the medical bills from coronavirus testing and treatment do not bankrupt people or that prohibitive costs cause people to avoid care. This reassurance should happen as soon as possible, to encourage and ensure people will get tested and treatment. If the epidemic lasts for a long time and many people fall into economic distress, the state will have to look to the federal government for assistance.
• The epidemic will strain the financial resources of safety net providers that serve the uninsured and underinsured, and that are already under financial stress. Government should implement policies that will increase those providers’ revenues to sustain their operations. These policies should include, but not be limited to, rural providers identified as financially at risk. In this area, as in others, lawmakers will need to look to the federal government for assistance if economic conditions deteriorate seriously for a prolonged period.
• Ohio policymakers should provide more substantial administrative funds for county Departments of Job and Family Services. Lawmakers must ensure sufficient funding for important services like food assistance, health care and Temporary Assistance for Needy Families.
• To protect the health and safety of caregivers who will be on the front line of caring for those who are most medically at risk, government and the private sector should collaborate to ensure that all health care workers have health coverage that assures them access to necessary treatment. If some providers are ineligible to receive public coverage (e.g., based on immigration status), the private sector should arrange for their coverage.
• Both the state and local governments should establish and engage advisory groups, comprised of public, corporate, and charitable organizations, health care providers and community leaders representing the diversity of Ohio’s population.

We look to government to provide protection and services in times of crisis. We recognize that these health emergencies will be repeated, taxing an already weakened delivery and response system. After years of anti-government rhetoric, tax cuts for the wealthy and corporations, and erosion of funding for essential human services, the nation and Ohio face the coronavirus epidemic with uncertainty. Crisis can bring change. This is the time to bolster public health; ensure all workers get paid sick days, strengthen Medicaid and Medicaid expansion, and help low-income people enroll and stay enrolled.

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2020Basic NeedsCoronavirusHealth EquityMedicaidWendy Patton