Economists’ Rx: “Sick? Stay Home!”

Yves here. It’s a sad testament to the state of our society that economists have to study the question of whether sick leaves work. It ought to be obvious that having sick people come to work is unlikely to be a plus for the enterprise. The not-well person won’t be fully productive and has good odds of passing his ailment on to others. And it’s a loss society-wide, since the sick worker who is nevertheless required to turn up at his place of employment won’t just expose co-workers, but also people on his commute, and at places he visits, like a coffee shop.

So why do employers insist sick workers turn up? The obvious reasons reflect badly on the bosses (quelle surprise!):

They’d actually have to manage if an employee or two didn’t turn up due to illness, like figure out what tasks might be postponed or call in someone to substitute or (horrors!) roll up their sleeves and pitch in. So much easier to play Lord of the Manor

They believe they own employees, so employees staying home is insubordination

They believe employees are conniving, so if they are taking a sick day, it’s really so they can go engage in a nefarious activity, like drive out to the nearby Indian reservation and gamble…or even vote! This sort of supervisor would regard using a banked sick day to go to the dentist or doctor or the DMV as an abuse

In other words, the resistance to providing for sick days has little to do with the economics of the business and everything to do with the view of the top brass that only employees of at least the managerial level get to exercise control over their time.

By Stefan Pichler, Postdoc, ETH Zurich, KOF Swiss Economic Institute, Katherine Wen, PhD candidate, Department of Policy Analysis and Management, Cornell University, and Nicolas Robert Ziebarth, Associate Professor, Cornell College of Human Ecology. Originally published at VoxEU

By now, it should be clear that presenteeism (going into work when sick) contributes significantly to the transmission of diseases. This column summarises current evidence on sick-pay mandates in the US and the spread of flu-like illnesses and COVID-19. Over the last ten years, states that introduced sick-pay mandates saw a decrease in seasonal flu activity by up to 30% in the first years compared to states that didn’t introduce such mandates. Introducing sick-pay mandates did not result in significant employment or wages decreases. Mandating COVID-19-related emergency sick leave also significantly reduced COVID-19 infection rates in states previously without sick-pay mandates, especially affecting low-income and service-sector employees.

The US is one of the few OECD countries that does not guarantee universal access to paid sick leave. Europeans, by contrast, take this benefit for granted. Nevertheless, more than a third of all European employees go into work when sick at least once a year (European Working Conditions Survey 2015). Moreover, also in Europe, lower sick-pay generosity can increase presenteeism behaviour and trigger relapses of illness, as shown for Spain (Marie and Castello 2020).

Our research shows that presenteeism behaviour, especially during the flu season, increases the spread of diseases. In the current pandemic, the spread of COVID-19 could be reduced if more employees had access to paid sick leave and stayed home when showing symptoms of sickness. The pandemic has highlighted the need to bolster sick leave systems and led to increases in access to paid leave in many countries (OECD 2020, Thewissen et al. 2020).

Reforms in the US

Even in the US, the COVID-19 pandemic encouraged US policymakers to reconsider their positions on paid sick leave. For the first time ever, effective from April 2020, a bipartisan majority enacted a sick-leave mandate at the federal level, as part of the Families First Coronavirus Response Act (FFCRA). Among other benefits, the FFCRA included up to two weeks of Covid-related emergency sick leave. Although the pandemic continues, the main FFCRA sick leave provisions expired at the end of 2020 as Democrats and Republicans could not agree on an extension.

But does paid sick leave really make a difference to the transmission of COVID-19 and other respiratory illnesses such as the flu? We studied this question in several peer-reviewed research articles (we discussed previous findings in an earlier Vox column; Pichler and Ziebarth 2018).  Specifically, we studied the effects of introducing sick-pay mandates in dozens of US states and cities over the past ten years. Using state-of-the-art statistical methods, we estimated the causal effect of improved access to paid sick leave – especially for employees in the service sector and lower-paid occupations – on influenza activity in the population. Most recently, we evaluated whether the FFCRA emergency sick-leave provision was effective in reducing the spread of COVID-19 in the US.

Causal Effects of Better Access to Paid Sick Leave for Low-Income Employees

First, when states mandate employers to provide paid sick leave, employees’ access to paid sick leave significantly improves. Second, because of improved access, sick workers use the new benefit and are more likely to stay home (Maclean et al. 2020). This reduction in presenteeism behaviour lowers the spread of contagious diseases, as reduced social contact reduces transmissions to co-workers, customers and other people, for example, on the way to work (Pichler and Ziebarth 2017).

The findings are consistent when we study influenza-like illnesses, where we find a decrease in seasonal flu activity by up to 30% in the first years after state governments mandate sick-pay access (Pichler and Ziebarth 2017, Pichler et al. 2021). Moreover, we find that COVID-19 infection rates were significantly reduced, with an estimated decrease of 56% in the weeks following the introduction of FFCRA emergency sick leave (Pichler et al. 2020).

Figure 1 illustrates the decline in influenza (Pichler et al. 2021). The figure plots differences in rates of influenza-like illnesses between states that introduced sick-pay mandates (treatment group) and states without sick-pay mandates (control group) in the US. To illustrate the effect of increased access to paid sick leave, the figure normalises the introduction of sick-pay mandates at time 0 on the horizontal axis. This mapping is also normalised so that at time -1, this proportion corresponds exactly to 0. The vertical axis shows the differences in flu cases between states with and without a mandate. We observe flu dynamics in the 36 months before and after the introduction of the mandate.

Figure 1 Mandate effects on influenza


Figure 1 shows that in the 36 months before the introduction of sick-pay mandates, the flu rate differential between the two groups of states is roughly zero. However, after the mandates are enacted, we observe a decrease in the proportion of flu cases, which averages slightly more than five influenza cases per 1,000 doctor visits. As the overall flu case average is 18 cases per 1,000 doctor visits, this represents a decrease of one-third over the 36 post-mandate months, where the public health benefit increases over time. In the first 12 months, we observe an 11% decrease in flu cases.

Figure 2 shows the effects of the FFCRA emergency sick-leave provision on COVID-19 infection rates, following a similar model described in Pichler et al. (2020). As FFCRA was introduced for all states at the same time, we needed a different statistical ‘identification’ strategy to isolate the causal effect of the emergency sick-leave provision. We compare states with existing sick-leave mandates (control group) to states where workers gained access to paid sick leave for the first time thanks to FFCRA (treatment group).

The FFCRA was signed into law on 18 March 2020 (first vertical line) and became effective on 1 April (second vertical line). Here, too, we find a significant decrease in COVID-19 cases as a result of improved access to paid sick leave for low-income and service-sector employees. The decrease is about 400 cases per state and day, which sums to about 15,000 prevented cases per day for the entire US.

Figure 2 Mandate effects on COVID-19


Do Sick-Pay Mandates Harm the Economy?

There will always be critics of sick-pay mandates. Their main arguments are that such mandates harm the economy because they drive up wage costs and incentivise shirking behaviour. We investigated this argument in another research study – again for the US using the introduction of state and city-level mandates. Specifically, we compared wage and employment dynamics in cities and states that introduced mandates to comparable cities and states without a change in the law. The result: we did not find any evidence for significant employment or wages decreases (Pichler and Ziebarth 2020a).


Unfortunately, the evidence presented here was not sufficient to convince the US Congress to mandate sick pay beyond 31 December 2020. However, the new Biden administration is likely to consider such a nationwide law, and the majority of voters (also Republicans) have long supported a federal sick-pay mandate (Pichler and Ziebarth 2020b).

In Europe, there exists basically universal coverage of paid sick leave. However, in Europe as well, to prevent the spread of contagious diseases, employees should more often use sick leave and work-from-home options, especially when they have cold and flu symptoms. Needless to say, this is particularly true during the current pandemic. One of the few positive side effects of this pandemic is that flu cases have plummeted to a level that is not statistically significant from zero (Hills et al. 2020) – which also impressively demonstrates how carelessly we once dragged ourselves to work with symptoms of sickness. Thus, the next time our throats scratch or we sense a fever emerging, we should stay home with a good conscience. It helps us all.

See original post for references

Print Friendly, PDF & Email


  1. PlutoniumKun

    Akira Kurosawa’s great 1952 film Ikiru (to live) is maybe the greatest film ever made about working in an office bureaucracy. The ‘hero’ of the film is a career bureaucrat who is proud of never having missed a day of work in 30 years.

    In one scene a junior clerk comments that the only reason the he has never taken a sick day in his entire career is that he’s terrified that if he took a day off everyone would realise that everything would function fine without him. Things haven’t changed much.

    1. XXYY

      By now, it should be clear that presenteeism (going into work when sick) contributes significantly to the transmission of diseases.

      My understanding is that this is less true for COVID than for other transmissible diseases. Roughly half of COVID infectees never have any overt symptoms, and would thus never stay home “sick”. For those who do eventually become symptomatic, they are shedding virus most furiously during the time when they are not yet showing symptoms, and thus would not yet have stayed home sick.

      This is not to say we shouldn’t have generous sick leave policies in the name of humanity and decency, but as an infection control measure during the current pandemic they may not be all one would wish.

    2. QuicksilverMessenger

      I’ll have to check out that film- I have never seen that one. Yes, I heard something like this from someone (I can’t remember who it was now) who said something like, ‘better be careful when you take a vacation or a few days off- they might realize that they don’t even need you’. I think a situation like this is, indeed, as you say, a kind of ‘terror’ – a pervasive fear. And as the article shows, it leads to all kinds of bad outcomes.

      1. The Rev Kev

        True story here from Oz in the 70s. So this guy worked for the Public Service and took a long holiday. Seeking to get rid of him, his boss re-arranged the office floor, desks, chairs and partitions. When the guy got back, he was seen to wander the floor asking where his desk was and if anybody had seen his desk.

  2. dummy

    Paid sick leave will end up being same as paid holiday.
    I dont know if its good or bad , depends who is footing the bill, (my guess will be some retention from wages the rest by the employer) but let me tell you how it works in european countries that have generous such leaves.
    First they are immediately considered as paid holidays and almost all workers will take them without exception by calling in sick whenever they need to stay home. Some companies in the EU hire their own doctors now to go and check on the worker at his/her home to make sure he/she is really sick.
    The problem of course is that the level of stress/sickness being subjective, no doctor can say you are not sick and must go to work and all sick days are usually taken by the workers.
    I have seen people plan in advance when they will take sick days.

    1. R

      That is a strangely bitter and broadbrush comment, @dummy.

      The way it works in the UK is that the first N days of sickness absence are self certified and beyond this requires a GP’s certificate. N varies by employer and status (wages vs salary), typically 3-5 for white collar jobs.

      My distant impression is that workers on hourly wages suffer fairly fierce policing of this mechanism and because / thus compete quite hard to abuse it but only in some roles / industries / companies.

      I’ve always had a salaried position and I have never needed to produce a sick note. I have rarely been sick – a couple of days off for a broken thumb – and any time off was informally booked with a line manager and usually made up later. I also don’t remember any colleagues calling in sick formally except for major illness (cancer). I also do not recall people coming in to work sick, except with mild colds, although I do remember some people coming down with illnesses during the day. I have tended to go home if I feel I’ll at work to avoid spreading it about.

      The sick note system for white collar workers is really there to identify and eventually manage out malingerers. I think I am entitled to six months on full sick pay in the event of something awful….

      My Italian colleagues have a more bureaucratic process. I think any sick leave requires a doctors note. On the flip side, the employer is not allows to ask the employee back until they are signed back to work and yes, I think there are official labour doctors who deal with this system.

      Most European systems new closer to the Italian model than the British.

      1. dummy

        In Belgium for instance there is no limit as to how many sick days per year one can take, and the employer has to pay you when you stay home. All you have to do is provide a certificate form your doctor which is a formality. If you get lucky and work for the government things get even better. I know of a 32 year old guy working for the SNCB (the national rail company) that was put on retirement as according to their rules if you take a certain number of sick days per year for a number of years, it costs less to put you on retirement as its not possible to fire you. To be fair SNCB is owned by the government, not a private company but private companies cant fire you either unless you really are a moron. Also you can collect unemployment insurance for life if you have 6 months of continuous work. Belgium has a permanent unemployment rate as it pays to collect unemployment and work in the black market especially if your trade is in the construction or retail.

      2. Parker Dooley

        “My distant impression is that workers on hourly wages suffer fairly fierce policing of this mechanism”

        Probably because their presence/work is actually necessary to the enterprise.

    2. Eclair

      Even worse, Sweden mandates paid time off to take care of a sick child. They have a official word for it: VAB. Vård av barn: Care of child. And a newish colloquial verb: att vabba . Meaning ‘to work from home because your kid is sick.’

        1. Arizona Slim

          I can’t speak for Eclair, but I can say that my Remote Sarcasm Detector alarm was warbling.

    3. Anthony G Stegman

      Have you heard of “mental health days”? We all need time off now and again. Mental health is as important as physical health. Having doctors check on employees is an absurdity. If a worker is not up to going to work for a day here and there let it be. We all know when we need a break, so we can at times plan for it in advance. Nothing sinister going on in most cases.

  3. herman_sampson

    Another case of managers/ the elite assuming everybody has the same (low) level of morality as themselves.

  4. floyd

    Fellow workers are a bigger problem, IMO. Some people are never sick (one kid I knew in high school didn’t miss a single day from grade 1-12) while others get everything. HR will be assaulted by all the non-sick people complaining that “Sally” or “Jimmy” are getting extra time off. Early in my career I established and managed HR and ran into this over a woman who left work frequently to help a sick family member. Several women in the office felt the need to inform everyone that once again this lady was leaving early.

    1. Eclair

      This is our problem right there: we can monetize and elevate and reward the making of cheap plastic widget holiday decorations in computerized plants in China, making platoons of executives feel important (and padding their bank accounts), flying around the world, taking meetings in Shanghai and Columbus, (or hanging about the office twelve hours a day filling out forms), all the while adding carbon to the atmosphere and plastic crap to the oceans and endocrine-altering chemicals to everyone’s bloodstreams. To what end? Increasing the national GDP. And, insuring that a steady stream of plastic Santas and Jack O’ Lanterns flowing into Dollar Stores becomes more important than caring for our children or our frail parents.

      Really, some days I think its a blessing that all those endocrine disruptors are reducing human sperm counts. Just pisses me off that the frogs had nothing to do with this debacle and they’re the first to go.

Comments are closed.