Journal Issue: Work and Family Volume 21 Number 2 Fall 2011
For the past two decades, family leave has been viewed in the United States as one of the core tools in helping parents address their children’s health care needs. The federal Family and Medical Leave Act (FMLA) of 1993 provides unpaid family leave primarily to long-term employees working more than half time for public agencies or large private employers. Several states and the federal government have implemented or are considering implementing expansions that provide pay during leave, reach more employees, or both. Employers, meanwhile, are increasingly introducing greater scheduling flexibility, access to child care, and paid leave. For these governmental and employer policies to be most effective, they must take into account children’s preventive, acute, and chronic health care needs, the associated health care responsibilities of parents, and the costs for employers.
Even the healthiest children have substantial health care needs.1 All children are expected to receive routine preventive care that addresses not only the screening and prevention of disease but also the promotion of healthy development. Virtually all children also need acute intermittent care (at home, in outpatient settings, or in hospitals), often multiple times a year, for illnesses ranging from minor to serious. Moreover, a large and growing subset of children is chronically ill, with ongoing preventive, acute, and chronic health care needs that may be dramatically greater than those of healthy children.2
A distinct feature of health care for children is that parents are expected to perform nearly all of the support roles that make direct services by health care professionals possible. Moreover, parents themselves must provide (free of charge) direct health care services, many of which were once considered to be the responsibility of health care professionals. In general, the number, frequency, and complexity of these parent-provided services increase with the severity of the illness, and health care system reforms that encourage home care over hospital care typically do so with the full expectation that parent responsibilities will increase. It is not an exaggeration to view parents as the linchpin of a shadow health care system without which the formal child health care system would be unable to function. To provide this shadow care, parents or parent surrogates must be present with the child.
Employed parents currently rely on a patchwork system of employment policies and family leave benefits (as well as the informal accommodations of employers and coworkers) to maintain this shadow system of care. Employers, meanwhile, have interests in ensuring that provision of this shadow care does not unduly affect workplace productivity. How federal, state, and employer policies and practices mesh with the child health care needs of families is therefore a central issue in the ongoing national discussion about work and family balance. In this article, we describe the health care needs of children, the essential health care responsibilities of parents, the perspective of employers, and the existing network of benefits that employed parents can access. We also identify gaps in these benefits that may be particularly salient for the types and patterns of care responsibilities that parents shoulder.