Editor’s Note: This interview first appeared in Path Finders, an email newsletter from the Daily Yonder. Each week, Path Finders features a Q&A with a rural thinker, creator, or doer. Like what you see here? You can join the mailing list at the bottom of this article and receive more conversations like this in your inbox each week.


Vicki Shabo and Hannah Friedman are the authors of a recent report for New America called “Health, Work, and Care in Rural America,” which advocates for better access to paid time off for rural workers.

Enjoy our conversation about surprising points of left-right consensus, the heterogeneity of rural healthcare access, and the way rural America is left out by the Family and Medical Leave Act, below.


Vicki Shabo, Senior Fellow, Paid Leave Policy and Strategy, Better Life Lab. (Photo provided.)
Hannah Friedman, Doctoral candidate in the Department of Health Policy and Management at the University of North Carolina, Chapel Hill. (Photo provided.)

Olivia Weeks, The Daily Yonder: What led you both to studying rural access to paid time off? How did you come to this?

Vicki Shabo: So I actually was part of some focus group work that happened in 2017, when I was at a different organization, and we were talking to people who had voted for Trump in the 2016 election in various places across the country. One of those places was Steelville, Missouri, in a focus group facility where the power literally went off in the middle of the focus groups – and apparently this happened weekly in this town – all of these voters who had conservative political views and had voted for Donald Trump were talking about the challenges that they had getting access to health care and the precarity that they faced in their jobs when they needed to take time off. There was a man who really stuck with me who said that his mother had a stroke and she needed to be in the hospital 90 minutes away and his boss told him, if he left, he shouldn’t come back. There was a mom who had a kid with autism who needed, on a pretty regular basis, to take her kid 90 minutes away to get evaluations and treatments. And she had a really hard time getting paid time off and flexibility to be able to be with her child and to get the child the services that they needed. And there was a dad whose wife had recently given birth, and they had several other children, and his wife barely had any maternity leave. And he didn’t have paid parental leave to be able to take care of the other kids and make sure that his spouse was recovering.

All of these folks saw that there was a role for more investment in paid leave programs and in standards related to paid leave. And they all thought that it would be better to do it at the federal level, because their experience with state programs had not been good. They all knew about problems with Missouri’s unemployment insurance program, for example. So I thought that intersections there were interesting, and cut through what we perceive to be political cleavages in ways that really show how universal the need for paid leave is and how support transcends party lines. There’s some data that I know we included in the report which shows that support for paid family medical leave and support for standards around paid sick time poll at 70 or 80 percent of the public. That’s true in rural areas, as well as in metropolitan areas. We’re thinking about this political moment, rebuilding from a pandemic, and moving forward into a time where we maybe can find more bipartisanship than we’ve seen. This seemed like an important time to dig deeper into the intersections between access to paid time off for family and medical purposes and sick leave, and distances to hospitals in a time where there’s been a lot of media around rural hospital closures, where there’s attention to health disparities, where there’s been more attention to poverty. So that’s the genesis of the report.

DY: Hannah, can you speak about the more striking statistical findings from the report?

Hanna Friedman: I think among the findings, the most striking one to me was about the distance to hospitals that provide neonatal care or neonatal ICUs. Those distances were among the largest, and that’s a situation where typically, if an infant is in the NICU, they’re there for months. Obviously, new parents who are very stressed probably want to be there every day, and so if you have to travel more than 90 minutes just to see your newborn infant, that’s incredibly stressful. It’s incredibly difficult to take the time off.

DY: I’m wondering if you can explain in a little bit more detail how the demographics of rural America increase the salience of this issue.

HF: If you just look at the overall rural population in the U.S. it is whiter, on average, than populations in urban and suburban areas. But rural America is not homogenous. It’s not the same in the northeast as in the south, or the midwest or the west. When we talk about hospital closures, those are most frequently in the south. When we talk about populations that are affected by things happening in rural America, it’s often helpful to be more specific about location. For hospital closures, they’re more likely to affect Black Americans. When we talk about the really long distances people travel to work, those are often in the west, and so you’ll have more people who are Latinx affected.

VS: The other thing I would add is, to me, what was very interesting was sort of the overlay between the distances and the pockets of population. To expand on what Hannah was saying, what we found is that Latino populations, in particular, have less access to paid leave and less access to paid sick time and much further distances to travel. The same is true for people who live in areas of persistent poverty. And so if you think about the implications, these are folks with lower incomes and certainly fewer resources to fall back on. Precarity in their jobs and longer distances to travel, those exacerbate health disparities. So the overlap of these things on specific populations is something to pay a lot of attention to. Similarly to Hannah’s point, for Black Americans who are concentrated in the south, the distances are still quite far and further than a similar metropolitan area. And you have systemic racism built into the health system. So think about Black maternal health, particularly in light of the Dobbs decision, where access to reproductive health services and abortion has been reduced, on top of longer distances to obstetrics care, or God forbid, you know, the need for a NICU that’s very far away. These are inequities that compound on each other.

I think the other piece of demographics that really stood out to me was the caregiving burdens that exist in rural populations, like when people live outside of a rural area but are the primary caregiver or a significant family caregiver for somebody who is living in a rural community. We used the National Alliance for Caregiving and AARP survey to look at caregiving among rural people, and looked at expectations about caregiving going forward. Again, if you have less access to paid sick time and paid family and medical leave, but are caring for, or expect you’ll be caring for somebody going forward, that has significant implications, particularly for women. And then lastly, we looked at some of the data from the Bipartisan Policy Center on moms during Covid, and some of the rural data there and how that all overlaps with these conversations that are happening about workforce shortages, and companies not able to find workers, and also the lower share of working age population in the labor force and rural communities. So this is all related and sort of points to the need for paid leave as a health, economic and labor force issue as well as related to individual families’ health and well being.

DY: At the end of the day, what are the policy steps you’re proposing?

VS: We’ve focused our policy recommendations on the need for a national paid family and medical leave program, or for state policies in rural states. Currently none of the states with high shares of rural populations have a state paid family and medical leave program. All of the 11 states, and DC, that have paid family and medical leave have lower percentages of rural people, although some of them have quite substantial numbers of rural people – like California, for example. But we focused on the need for an equitable program that provides wage replacement high enough for lower income people to be able to take leave in all of the major circumstances like caring for a new child, a seriously ill loved one, your own serious health issue, making sure that that leave is job protected.

Comparison of rural and urban access to paid sick days via Health, Work, and Care in Rural America.

We know that the Family and Medical Leave Act, which turns 30 next year, does a poorer job covering people in rural America than in other places because of smaller business sizes and the lower number of hours per week that rural folks are working. So looking at a comprehensive national paid family medical leave program, looking at guaranteed access to paid sick days, which is something that’s been very much in the news this week with respect to railroad workers. But the reality is that about a quarter of American workers and more in rural communities don’t have access to paid sick time. And that’s particularly true for lower wage workers. We’re the only developed country that doesn’t have a national paid leave policy. And it’s time to change that. Traditionally the support from policymakers has come from urban areas. But I think what this report shows is that this is a rural issue as well.

DY: Have you guys been able to look into, for instance in California, where there are such high numbers of rural people, how higher paid leave protections have played out in rural locations?

VS: No, this is actually a huge untapped area for future research. Much of the research in California has focused statewide in the aggregate in places where there have been public opinion surveys, and on particular populations. For example, in California, this program has contributed to longer leave-taking among moms, greater economic security, and higher wages over time. It’s contributed to family caregivers being more likely to return to the workforce, or stay in the workforce in both the medium and long term. But in terms of particularly deep research, in particular pockets of the state, we haven’t seen that and I think it’s a huge area of need, particularly in a state like California, which has just improved its program with higher wage replacement that will go into effect in 2025. I actually think it’s quite critically important to understand the needs for outreach and education and making sure that rural Californians know that this policy exists for them going forward.


This interview first appeared in Path Finders, a weekly email newsletter from the Daily Yonder. Each Monday, Path Finders features a Q&A with a rural thinker, creator, or doer. Join the mailing list today, to have these illuminating conversations delivered straight to your inbox.


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