Unlock eSignature Legitimacy for Pregnancy Leave Policy in United States

How to eSign a document: e-signature licitness for Pregnancy Leave Policy in United States

(logo chimes) (peaceful orchestral music) - So, first of all, for those of you who are unfamiliar, let me briefly describe what paid family leave is. As the name suggests, the policy provides paid leave either fully or partially replacing an employee's wages while they're out. In some cases, it also guarantees job protection, which means that if an employee is out, their employer can't fire them. And the idea behind it is that it gives people time to care for themselves and their families often due to a health condition. So most people who use it are new parents after the adoption or birth of a child. And it does provide time for infant-parent bonding and social support for the new parents. More generally, it's intended to support families to cope with illness or a health condition more generally. The case studies that I'm gonna cover today are gonna focus on the case where paid family leave is being used for new parents. And as Dr. Kaufman mentioned, these days, there's a lot of talk on the use of this for people who have health conditions or illness. And I'm not gonna get as much into that. Sadly, I've been preparing these slides for a couple of weeks and the situation has changed so quickly. I haven't had time to add anything on this other use of paid leave, but hopefully this should still provide some insight into the effects of these policies. So the reason some of you may not have heard of this policy, if you haven't heard of it, it's because the U.S. actually does not have a national paid family leave policy. It's the only high-income country and one of only a handful of countries worldwide that has no such policy in place. As you can see in this figure, most European countries provide at least six months of leave, if not a year, and currently in not offering paid family leave, we are keeping company with Suriname, Papua New Guinea, and a handful of Pacific islands that don't show up on this map. So we're quite unique in that respect. So what does the U.S. have? The U.S. has what's known as the U.S. Family and Medical Leave Act. And this provides unpaid leave for qualifying workers. It is job-protected, meaning people can't be fired while they're out. It's about 12 weeks of leave. However, more than 40% of employees in the U.S. actually don't qualify. In part because eligibility is determined by the number of hours you work or the size of your employer. So, many people can't actually take advantage of it. And studies have also shown that low-income workers are less likely to take advantage of the leave perhaps because they simply can't afford to take unpaid time off of work. So again, we're gonna focus a little bit more on parents today, but this picture shows the leave arrangements for working mothers in the U.S.. So as a result of the current policy landscape, about half of moms, which is the pink bar, take paid leave. And that's, I said there was no national paid family leave policy, but there are a handful of state policies. And most often people get this benefit through their employers. And then about 10% take disability leave. About 20% quit their jobs. About 40% take unpaid leave. And then about 5% are actually let go from their jobs. So this adds up to more than 100% because some people use more than one of these options. And what we next do is we break this down by educational attainment. So this next group of bars is for those with less than a high school education and this last group of bars is for those with a bachelor's degree or more. So you'll see that those with less than the high school education are much less likely to have paid leave often because their employers don't cover it. They're less likely to take disability leave. They're quite likely to take unpaid leave. If you see about twice as many actually quit their jobs, about 50% and 10% of people are let go from their job when they take leave due to a pregnancy. And then if you look among people with a bachelor's degree or more, the inverse is true. They're more likely to have paid leave and are less likely to quit or be let go from their job. So we're all here today because presumably we're interested in health. So next let's take a look at all the ways that paid family leave policy is hypothesized to affect a family's health. So here on the slide, we have the exposure we're interested in which is paid family leave policy, and here are all the ways that it might affect health. So first of all, compared to unpaid leave, it provides income to families. Again, either through partial or full wage replacement. And so especially for families who are vulnerable, this might enable them to purchase more healthy food or more food. It might improve household resources and housing. It might give them more access to healthcare and the ability to afford medications. The knowledge that you have a more steady stream of income could also improve your mental health. And of course, healthcare access has the potential to improve your mental health. The other thing paid family leave policy does is it gives people time off to seek that social support. And that's especially true for things like mental health after the birth or adoption of the child. And then also for breastfeeding, which for those who have gone through it is a complicated process where the ability to connect with others is really important. The other thing paid family leave does is time for bonding with the new child, with the spouse or partner. And those also have the potential to improve mental health and breastfeeding. All of these pathways together have the potential to improve the child's health. And then also paid family leave policy provides people with the opportunity to take care of themselves instead of brushing back to work, which has the possibility of improving lots of downstream health conditions which we can get into a bit later. So as I mentioned, we're gonna be talking about two case studies today. So the first one is looking at the effects of paid family leave policy on breastfeeding. So why is breastfeeding important? There's been many studies that have shown that breastfeeding is associated with a lower risk of obesity for moms and also less obesity and metabolic problems for children who have been breastfed later in their lives. Breastfeeding also improves infant-parent bonding, so family dynamics, and it's also been shown to reduce behavioral problems in kids. One study, for example, has shown that paid family, sorry, there's been a handful of studies that have shown that people who take paid leave have improvements in breastfeeding. Those are usually people who've taken paid leave because their employer offers it. And so in the U.S. what the American Academy of Pediatrics recommends is that children are exclusively breastfeed for six months, and that there is continued breastfeeding for 12 months with the supplementation of solid. So the problem or the complicating factor here is that 60% of women with small children in the U.S. are employed. And what happens in the U.S. is that a quarter of women return to work after delivering in two weeks and then a third return to work within three months. So just to put this into perspective, in Europe, about 5% of women return to work within three months because of that ability to take longer paid family leave. And it's known that women in full-time employment are less likely to breastfeed than those in part-time employment and that returning to work earlier further reduces breastfeeding rates possibly because of the difficulties in having time to spend with the infant, finding a place to pump, that sort of thing. So these all suggest that strategies to promote early breastfeeding are important. And the disparities that we see in paid family leave, or in taking leave, may be one reason why we see such stark racial disparities in breastfeeding. So here you can see that black women are less likely to initiate breastfeeding in the immediate postpartum period compared to white and Hispanic women. And that at six months postpartum, only a quarter of black women are still breastfeeding relative to about half of white and Hispanic women. But to put these patterns into context, it's helpful to look at employment trends. So while black women make up about 13% of the total labor force, they're disproportionately represented in low-wage jobs. So because of things like discrimination in employment or structural racism and access to education, black women are more likely to work in low-wage jobs that do not qualify for unpaid or paid leave. And that might be a major contributor to the breastfeeding patterns that we see here. So again, putting this into our concept map that we looked at earlier, we think that paid family leave policy is likely to improve rates of breastfeeding by giving people the space to have social support and time for bonding. So I hinted earlier about the latest movements in this policy arena, which are state paid family leave policies. So individual states are passing laws to provide leave to new parents after the birth or adoption of a child. You can see here the color of the bars indicate the number of weeks of leave available and it ranges from four to 12 weeks. And they also vary in the amount of the worker's salary that's replaced while they're out. Most have wage replacement rates that are about half or two thirds of the employee salary, but actually this policy landscape is changing so quickly. I couldn't find a map that had all states that have policies colored in because just in the last year, Washington, DC, Massachusetts and Connecticut have also passed their own paid family leave policies. And these most recent policies actually have higher wage replacement rates up to 95% in Connecticut for low-wage workers. And California, actually just passed changes to its policy. And here in California, we're gonna start offering eight weeks instead of six weeks starting this summer. And there's actually a proposal that would expand this to 12 to 16 weeks starting in 2021. So let's next, take a look at how many people have benefited from this policy. And here we have California in particular. So in orange, we have the number of births per year in California, since when the policy in California was first implemented, which was 2004. And 2005 as the first year that we have complete data on the policy. So you can see that the number of births in California is about half a million, although it's been slowly declining over time. And here you can see in the blue line that this is the total number of paid family leave, or PFL claims that have been paid. And you can see that even as birth rates are declining, the number of claims paid every year is increasing. We should keep in mind though, this doesn't mean that half of births in California are receiving paid family leave. Since claims that are paid can include both parents, including birth parents, or same-sex parents or adoptive or foster parents. And some of these claims may even represent caring for family outside of the context of a new child, although most are related to a new child. But what this does indicate is that this program is increasingly being used by family. So the case study that I'll be presenting here took advantage of the passage of these state policies to examine their question, what are the effects of these state paid family leave policies on breastfeeding practices? So since most of these state policies have been passed very recently, this study focuses on two slightly earlier policies whose effects come more easily measured. As I mentioned, California's policy passed in 2004 and New Jersey's policy passed in 2009. And this study also looked at whether effects are different among different socio-demographic subgroups to see whether these policies affect everybody similarly. It used data from the National Immunization Survey on about 300,000 moms. And the survey just happens to also ask questions about breastfeeding. So in this case, the analytic method we used was a technique called difference-in-differences analysis. And you do not have to understand the slide to understand the results, but I'm gonna share it for those who are interested in how this research is done. So to do that, let's take a look at this figure. So this is sort of stylized for now and not based on the actual study results. This is just to help understand the method itself. So here we have times as the pre-policy period, and this is after the policy has been implemented. And you can put whatever health condition you want here on the Y-axis. So this is breastfeeding. And so during the month before the policy is implemented, ideally, we'd like to see that paid family leave states, California and New Jersey, have similar trends in health to the other states. Importantly, the prevalence of the conditions doesn't have to be the same. The breastfeeding rates don't have to be the same. They just, the trends in them have to be parallel during this period. Then after the policy is implemented, let's say that we observe this pattern for the two groups. So this analysis essentially assumes that the rates in California and New Jersey would have stayed parallel to those in all the other states. And so this difference between the observed and the actual is the treatment effect that's due to the policy implementation. If that didn't make any sense, just forget this slide and you'll still be able to understand the results that I'm about to present. So these are the main results. And this illustrates the effect of the policy on each of the different breastfeeding practices and the ones that we looked at include whether the mother ever breastfed, whether she was still exclusively breastfeeding the child at three months and at six months, whether she was breastfeeding the child at all, even including solid supplementation at six months and 12 months, as well as the total duration of breastfeeding and the duration of exclusive breastfeeding. So if you look at this overall sample, well, let me also explain how to take a look at these graphs. So, the effects that we're looking at are these black dots, and if they're close to this zero line, then that means that we don't really see an effect. So the the breastfeeding practice that we see the biggest effect for, is exclusively breastfeeding at six months. And we see that there's a 1.3 percentage point increase in the likelihood of this breastfeeding practice. And we also see that breastfeeding at six and 12 months is also maybe a little bit more common after these policies passed. We don't see any effects on people ever breastfeeding or on breastfeeding duration. However, when we next looked at the different subgroup effects we saw that these effects in the overall sample mask some important findings among the subgroups. So this is the same graph, but now we're looking at each outcome by itself. So this is ever breastfed. And the groups that we're looking at are comparing married and not married moms, comparing moms of different racial backgrounds, comparing moms with different household incomes, and those have different ages. And so again, being around zero means that this is the reference group. So here we can see that people who are married breastfed at about the same rates of those who are unmarried and again, not much difference by race. We see that these bars sort of overlap with the line zero. Where we do see a difference is that those with higher household income were more likely to increase rates of breastfeeding compared to lower-income moms. And another important thing to note is that if we see a negative value like here among black women, it doesn't mean that black women breastfed less in response to the policy. It just means that they benefited less from the policy compared to the reference group, which is white women. So when we look at exclusive breastfeeding at three months, in this case, we see that married women benefited more than unmarried women. And then again, middle and high-income women were much more likely to benefit than low-income women. Now, this is looking at exclusive breastfeeding at six months. We again see more advantages for married women and this case also for Hispanic women. And then also again, advantages for middle-income women compared to low-income women. Although in this case, not as much for high-income women. When we look at whether women were still breastfeeding at six months, again, we see those benefits for married women. And again those benefits for middle and high-income women. In this case, it looked like maybe black moms were benefiting slightly less than white moms. And then when we look at breastfeeding duration, the biggest effects that we see here, again, that middle and high-income moms were more likely to have longer breastfeeding duration by about 17 to 25 days longer than the reference group of low-income women. And in this case again, black women were less likely to benefit than white women and younger women were less likely to benefit than older women. And when we look again at the duration of exclusive breastfeeding, again, those benefits for married women, and again, those benefits for middle and high-income women. So I just barraged you with a bunch of results. So let me summarize the findings. So first we see that there's increased breastfeeding at six months when we just look at the sample overall. So this is consistent with one other U.S. study that's examined this question as well as a handful of international studies that suggest that paid family leave policies do increase breastfeeding. And while the California and New Jersey policies only provide paid leave for six weeks, the thought is that maybe they're supporting parents in the early weeks of breastfeeding when it's crucial to have time and support to keep up the practice. And that's what allows them to still be breastfeeding at six months. The thing that prior studies haven't done is examined these differential effects among different subgroups. And this study showed consistently larger benefits for high-income women and married women and some inconsistent findings for different racial, ethnic, and age sub groups, depending on the outcome, depending on the breastfeeding practice. So one possible implication of this work is that these policies are actually increasing health disparities by disproportionately benefiting women who are already advantaged. It might be that low-income women are still not able to benefit from the policies because they only covers part of their wages. Again, we said these policies cover 50% to two thirds of women's wages. And so low-income woman would rather get right back to work than take the time off. And importantly, California's policy actually doesn't provide job protection. So women may still be worried that they'll lose their jobs if they take advantage of the benefit and they're not also eligible for that U.S. Family and Medical Leave Act that does protect their jobs. And this study highlights how it's important to be very thoughtful about the design of policies to keep health equity in mind. All right, so now let's move on to the second case study and this one examined how paid family leave policy affects different aspects of parent health. So let's take a look at our concept map again, this time we'll be examining parents' mental health, as well as overall health smoking, alcohol use and obesity, and again, the reason we think paid family leave policy matters for us is the ability to provide people time to get social support and bonding after the birth or adoption of a new child and the ability to take care of themselves instead of getting straight back to work. So thinking just about mental health, the most common mental health conditions for moms in particular after the birth of the baby is postpartum depression. And this debilitating condition actually affects one in seven women. And what a lot of people don't know is that it actually, depression affects one in 12 men after the birth of a new child. So it's common for both parents. We know that postpartum depression is bad for kids. It's associated with worse depression among kids later in life, worse cognition, a greater likelihood of having conduct disorder as well as worse physical health. And then we know in general that having poor mental health among adults is also associated with worse physical health, including higher risks of smoking, alcohol use and obesity. So this suggests that preventing postpartum depression and improving parents' mental health during the postpartum period is important. And lucky for us, there are studies that suggest that each additional week of leave among moms is associated with a reduction in the odds of postpartum depression, so that paid family leave policy might be a good policy to tackle these health issues. So in this study, the research question was what are the effects of these state paid family leave policies on parental health? The same policies I discussed before. In this case, we only examined the California policy since we didn't have enough of a sample size, enough people in our sample to look at New Jersey or other more recent states who've passed these policies. And in this case, we looked at how the effects differed for moms versus dads. And the sample that we used here was 7,000 people from a study known as the Panel Study of Income Dynamics. And we used that same difference-in-differences design that I described earlier. So here are the effects that we observed for this study. So here a positive number means more of something and the negative number means less of something and the star that you see means that this association was strong enough that we think it was statistically significant. So we see that California's Paid Family Leave policy improved overall health, reduced psychological distress, reduced the risk of parents being overweight and reduced alcohol use. Now, we next looked at whether the effects were same for moms versus dads. And here we see that overall health improved for both, although this number is bigger. So the effect was more prominent among moms than it was among dads. The reductions in psychological distress were mostly among moms and not quite as large for dads. Similarly, the reductions in being overweight were larger for moms and for dads. And meanwhile, the reductions in alcohol use, drinking any alcohol or drinking three or four drinks a day, that reduction was bigger among dads. So again, to summarize these findings, we see improved overall health for both parents. And this might be the result of the fact that paid family leave policy provides more money and more time for parents to be at home with their new child. We also see the reduced risk of overweight among moms. We had already seen that paid family leave increases breastfeeding. So it might be that the ability to have more time for breastfeeding reduces the risk of overweight among moms, or it might be that moms have more time to take care of themselves, eating healthy and exercising rather than rushing back to work. And finally, we see this combination of less psychological distress for moms and less alcohol use for dads. And we know that there are gender differences in the experience of stress and mental health and that alcohol use is more common among men. So these both maybe manifestations of improved mental health among parents. So these studies have a couple of limitations that I wanted to touch on to sort of get ahead of some of the questions you might have in this area. So neither of the data sets that we used for either of these studies includes questions on actual leave-taking or eligibility for leaves. Most studies don't ask those kinds of questions. So these results that I showed you might actually be understating. They're underestimating the policy's impact because paid family leave is for working parents only. And the samples that we examined here include ineligible families as well. So those are sort of being mushed in and potentially making the effects look not as strong as they would have been otherwise. Second, this analysis, as I mentioned, doesn't include those states with more recently implemented paid family leave policies, since we don't have data yet on those most recent years. Again, some of these policies were just passed in the last year or two, and this means that the results might not generalize to these other states. And importantly, it may not reflect the effects of policies that have longer leave or more generous wage replacement. A lot of these more recent policies provide eight, 10, 12 weeks of leave, and as we showed up to 95% wage replacement, especially for low-income workers. So the same issues that we saw earlier about health disparities for the California and New Jersey policies might not be the case, although that still needs to be looked at. And finally, the type of analysis that we did assumed that there were no other policy changes that happened right at the same time as the paid family leave policy that would have affected these same health conditions. And we can't totally rule that out. So it's possible that some other policy got passed at the same time as paid family leave. And that's what explaining the differences in breastfeeding or these other mental health outcomes. Although we have sort of ways to test for that that I'm not gonna get into, but we can't ever totally rule out the fact that that's what's explaining the results. So there've been a handful of other studies that have looked at the effects of these paid family leave policies on maternal and paternal health. And I talked a little bit about those as I went along and there've been others that have looked at the health of children whose parents benefited from these policies later in childhood. So this is just a snapshot of those results. These show that there's reductions in abusive head trauma among these kids. Again, the thought is that the parents are less stressed, there's less tension, there's less economic distress to reduce the rates of abusive head trauma. These kids are also less likely to be overweight, less likely to have ADHD, less likely to have hearing problems so that the implementation of these policies may be having downstream positive effects on kids later in life. So, to conclude, what we see is that paid family leave might be an important lever to improve both infant and parent health at the population level. Not just one-on-one. So for clinicians, doctors or other providers, one implication might be to involve a social worker or other team members who can help new parents navigate the benefits for which they're eligible. And for everyone, it means working to ensure the passage of paid leave policies by either employers, cities, states, the federal government. There's a lot of actors here who might benefit from this evidence. There is a possibility that the state policies in California and New Jersey as currently implemented may be exacerbating disparities, especially in that study of breastfeeding practices. And it may be that more disadvantaged groups still can't take advantage of the leave because it's partially paid and that low-income families simply can't get by on just half or two thirds of their salaries. So again, with these latest state policies, it'll be important to look at those and see the effects that those are happening. And especially in the context of the discussions just in the last few days, there's really not much research on how paid family leave policies are used and affect health conditions beyond birth. So people can also take paid family leave to care for an elderly parent or a sick family member. And there's just very little work that's been done in that arena. Just in the last couple of days, I was trying to update these slides to see if there's anything I could find. And there's not a lot of work done in that area. And I think that's something, especially now that a lot of people are gonna be interested in and hopefully this conversation will spur researchers and policy makers to gather that evidence. So I just wanted to acknowledge some of my collaborators on this work at UCSF, San Francisco state and the University of Pennsylvania, as well as the funding for this work. And I wanna thank all of you guys for your attention and your patience with working on this platform on Zoom. And I'm happy to take any questions. So we have one question here. Do any studies show the effects of cultural or attitudinal differences, if any, among white, black and Hispanic women regarding their desire to breastfeed, which would affect the benefit they obtained from the policies or their likelihood to utilize the available benefit? I mean, I think there are, that's not exactly what I study, although I've delved into that a little bit just in writing these papers. And I think there are papers that have tried to look at how people's cultural background affect how they perceive breastfeeding. Although a lot of that is just tied to if your family or people of your racial background, just historically, aren't able to even have the time to access that benefit because many people are in those low-wage jobs. I think that shifts culture so that even the availability of the policy affects the culture and it's certainly possible that people's cultural background also affect their breastfeeding practices. So I'd say that it goes both ways. And I think there's not a great study that teases apart, which is the predominating pathway there. All right, let's see. So another question. Has paid family leave been studied as it relates to benefits to business such as employee retention or returning to work healthier? Does the business world see this mostly as another employment cost they begrudge? So that probably depends a lot on who you talk to. There have definitely been economic studies that show that paid family leave makes women in particular, more likely to go back to work in the year or two after a kid's birth. And you can imagine that that means that you don't have to retrain new workers. That's good for the workforce. And there's certainly, again, this is a conversation we have a lot in this country and depending on where your values lie or how you perceive the evidence, people see the cost of providing the paid leave as outweighing the health benefits or vice versa. Importantly, what happens in a lot of other countries is that employers aren't the one that shoulder the costs. It's most often a government-provided benefit, and that might shift how employers perceive it. So that's part of the conversation we're having in this country. We have another one here. As the crisis unfolds and legislation fundings, big swaths of the workforce, is this essentially the biggest paid family leave event ever? I've actually been reading the news in part to see that. I think that's very likely to be the case that this is the biggest paid family leave policy sort of injection that our country has seen so far. And the other very closely tied policy is paid sick leave. So the idea behind paid family leave is that you're providing care for a family member, either a new child or your sick family member, but then there's also paid sick leave, which is leave for yourself when you're sick. And that, we didn't cover that today and maybe that's a conversation for the future. But there's also that related policy to see how that affects employer health and likelihood to return to work. And these days there's just a lot of talk about that. So yeah, I think we're likely gonna see some of the biggest jumps, the biggest increases in people benefiting from these policies in the coming weeks. And yeah, we'll have to see how that goes. And I think the policies that they're discussing now would provide those benefits for a year. And depending on what kind of evidence we see for those in the coming year, or how people feel about having those benefits, there's a chance that maybe we could start having that conversation in this country about having those policies be in effect in the long term. All right. So then the next question, why is America so far behind? That's a good question. I don't know. (laughs) I think there's people who study policy-making itself rather than the effects of policies. And I think that would be a question for them. But yeah, I mean, I think there's a lot of different hypotheses. The fact that for a lot of these benefits, including things like health insurance, that a lot of time in the U.S. the employers are the one to take that on. And so, and then it's left to the individual employer to sort of balance the benefits of their workers receiving this benefit versus the cost to them. Whereas in a lot of countries, again, it's done at the national level. So then you can sort of take the long view of improving the entire population's health, rather than just thinking about like your handful of workers and if they leave, then you can just replace them. That might be one thought. And there's always a lot of talk about differences in values of individualism versus a more community view of things in other countries. I think there's just a lot of historical reasons that I'm probably not the most qualified person to talk about the why of why the policy landscape is the way it is. So the next question, to what extent is your research and that of other people who study paid family leave being shared with policy makers? That's a great question. So that's a lot of the reason that I do research and that a lot of health researchers and economists do this kind of research is that they are trying to inform policy and there's different ways that we can get that information to policy makers. UCSF, for example, has the media office that communicates these findings to the media. And the idea is that's one way to get to both the public and policymakers to help people understand the effects of these policies. We also have a government relations office. And increasingly in the last year or two, I have been talking to them and they help us put together policy briefs to share with policy makers. And of course we're an academic institution. So the idea is not that we say "You should pass this policy," or, "The policy should contain this." What we say is "We have studied these past policies and we have found that the effects are XYZ," and leave it at that. And just so they can incorporate that information moving forward. And I, this isn't as much of what I do, but there are other researchers who also work with community organizations to inform them in the same way that we would inform policy makers to let them know about how they can take action in their community to improve population health. I'll say though, that for the last, the study that I just presented the results of, that second study, that one actually came out in a journal earlier this week, and I actually contacted our press office to let them know and to see if they wanted to put anything out about this. And they turned me down and they said the entire media office right now is focused on COVID-19. So, it depends on the, sometimes the media office doesn't see the results of being important at a given point in time. So then that often makes it harder to pass along. And then another question, are there tangible things we all can do, especially amidst the current crisis to help decision makers apply these studies to influence the new normal that will likely emerge as our work world gets reinvented? This is sort of more a personal comment, but I think as citizens, it's good to be in touch with your policy makers. I have my house representative and my senators programmed into my phone now. I've done this in the last couple of years to let them know whatever your inclinations are about where the policy landscape should go, we as citizens have that opportunity and almost responsibility really, when it comes to policy. So that's sort of personally and I'd say that's probably one of the most tangible things you can do. I'm open to other suggestions. I think different people have different ideas about community organizing and that sort of thing, depending on what your personal status is in your community, in your workplace. So one question, is there a correlation between the rise of anti-abortion legislation and the rise of paid family leave legislation? So I'm not sure. I think these types of legislation happen in different states. If you think back to that map that I showed you guys of where paid family leave policies have been passed. They tend to be maybe exclusively along the coast. And I don't study anti-abortion legislation, but just from keeping up with policy more generally, my impression is that that tends to happen not along the coast. So I don't think that that is probably affecting policy makers within the same state. But I'll say, there is a lot of work out there by political scientists that does talk about how state policymaking is being increasingly polarized. And especially as the federal government in recent, not just recent couple of years, but in recent decades takes less action on social policies, economic policies, health policies, that a lot of states are filling those gaps. And so that does allow for a lot more polarization in policymaking. Do we have evidence from countries where paid family leave replaces a higher percentage of income that doing so reduces the subgroup differences you found? So there are a handful, probably quite a few more international studies that look at the effects of paid family leave policies, mostly in European countries, to see what those effects are on health. I'm actually not sure that I've seen any of them do subgroup analysis like we did here, where we look at differences by income levels or by race, importantly, policies and other countries especially high-income countries, I'll say most of the other evidence is from high-income countries rather than low and middle-income countries. And in those countries, wages are pretty much uniformly replaced, 100%. So people don't just get part of their salary while they're out, they get their whole salary. And everybody who works is eligible. It's not that it's dependent on where you work or even the California and New Jersey and other state policies, there's still some rules like the size of your employer or how long you've worked, or whether your employer pays into the state disability fund, that sort of thing. And in other countries, essentially, it's a universal benefit. And that might be why researchers in those other countries haven't thought to look for these disparities, just because I think they're less likely to arise in that situation when a benefit is applied universally. But that would certainly be something to look at. And I haven't seen, I mean, I think there's probably very few studies looking at paid family leave policy in low and middle-income countries. Again, you saw on that map, every other country in the world, including low and middle-income countries, have the paid family leave policy at the national level for employees. And I think there's just been very little research done in low and middle-income countries. (peaceful orchestral music)