Sickness cert: Learning from the US
Sickness cert: Learning from the US
The UK Prime Minister announced a review of the fit note system last week. In the UK, the fit note is issued after seven calendar days of sickness absence and can detail that someone is unfit for work altogether, or that they may be fit for work with adjustments or advice. It can be required by employers as evidence of an employee’s health affecting their work. Removing the fit note from the primary care workstream and moving sickness certification to specialist services may better enable early return to work. The current process is likely to be underdelivering in its role as a backstop.
How does fitness for work certification work in the US?
In the US there is no federal route to sick pay. Nor is there a particular sickness absence certification process. The Family and Medical Leave Act (FMLA) allows eligible employees to take up to 12 weeks of unpaid job-protected leave per year for longer term serious health conditions or caring responsibilities for an immediate family member. Employers may have internal policies requiring employees to produce medical certification to substantiate the need for leave under FMLA or access corporate sick pay.
Some states including California and New York have laws mandating employers to provide paid sick leave. The requirements vary by employer size, and while some employers may require a medical certificate this is not ubiquitous.
How does flow out of disability benefits to employment work in the US?
Once people are in the US social security system for ill health affecting ability to work, they are able to access the Ticket To Work programme. This is a voluntary programme, open to individuals of working age receiving Social Security Disiability Insurance (SSDI) or Supplemental Security Income (SSI) benefits due to a disability. The programme connects individuals with specialised career counselling and vocational rehab services. While enrolled in the programme individuals are exempt from undergoing continuing medical disability reviews to determine ongoing eligibility for social security.
In the US, incentives are set up to enable SSDI and SSI recipients move into work while still receiving benefits and healthcare coverage. These include:
Trial work period: SSDI beneficiaries can test their ability to work for at least nine months, regardless of earnings, without losing their social security payments
Extended period of eligibility: Following the trial work period, SSDI beneficiaries have three years where benefits are still accessible to them any month their earnings fall below a threshold of around $1500 per month
Medicaid while working: SSI recipients whose earnings reach a threshold where they are no longer eligible for benefits may still be eligible for Medicaid
Impairment-related work expenses: recipients of social security can have expenses related to their disability deducted from their earnings when determining financial eligibility for benefits
Plan to achieve self-support: SSI recipients can save money towards a work goal without confounding their benefit eligibility
Lara’s take
Comparing fitness for work pathways in the US and the UK is interesting. The lack of protection for employees when it comes to paid sick leave in the US is not a good baseline. It may lead to presenteeism (this is when people show up to work when they aren’t well enough, with negative consequences for themselves and the organisation).
It also means that without a safety net, people can more quickly fall down the socioeconomic ladder. This has a broad range of negative consequences on a personal and broader societal level. On the other hand, the US has some legal provision for unpaid carers’ leave - and the UK is behind in this regard.
In the US, the lack of a ubiquitous sickness certification process likely relates to the lack of a federal sick pay scheme. This deregulation means that employers are left to their own devices when it comes to building communication about employee health into their own polices. Forward thinking employers have the autonomy and initiative to create a culture of openness and require early dialogue around any ill health affecting ability to work. One route to this is employers mandating early sickness certification to open up dialogue as soon as possible.
What is really interesting are the ways the US social security system protects benefits eligibility when supporting people back into work. There is a clear emphasis on voluntary participation and support schemes are built around ensuring earning is not financially punitive. The numerous support schemes allow social security recipients to establish financial security through work before undergoing benefit eligibility reviews. This is a less dynamic stance than how earnings are adjusted for Universal Credit recipients in the UK. In the UK, a ‘taper rate’ removes 55p from benefit payments for every £1 earned once the threshold above a protected ‘work allowance’ is met. The Universal Credit work allowance depends on conditions including children and capability for work. Recipients in the UK are assessed for eligibility for benefits according to what they earn on a month-to-month basis. Once recipients earn enough for them to become ineligible for Universal Credit for five months in a row, they need to reapply altogether if their income falls again.
In the context of UK fit note reform, there is potential to learn from the US in encouraging employers to take the initiative to consider how sickness certification fits into their own organisations. Ideally, inspiring early dialogue within organisational policies.
When the UK thinks about encouraging flow of benefits recipients into economic activity, there is something to learn from the US when it comes to emphasis on initial stability of social security income and support. This may help create a psychosocial climate more conducive to unidirectional return to work.