Yet the U.S. is entering another COVID holiday season, and federal laws that offered COVID-related paid sick leave to workers have expired. Colorado, Los Angeles and Pittsburgh are among a small number of places that have put in place their own COVID protections, but many sick workers across the country must wrestle with difficult financial and ethical questions when deciding whether to stay home.

“Millions of workers don’t have access to paid sick leave, and we’re still in a pandemic,” said Nicolas Ziebarth, a labor economist at Cornell University.

The U.S. is one of only a few industrialized nations that has no national paid sick leave policy. By contrast, Germany, Ziebarth’s homeland, has had one for nearly 140 years.

The coronavirus pandemic led to short-term change. The Families First Coronavirus Response Act mandated paid sick leave nationally, a first in U.S. history, according to Ziebarth. The law included about two weeks of full pay for employees who were quarantined or seeking medical attention for COVID-like symptoms and additional weeks at partial pay to care for a child stuck at home because of COVID.

But the paid sick leave mandate consistently applied only to employers with 50 to 499 employees and lasted just nine months, expiring at the end of 2020. After that, employers could decide whether they wanted to continue offering paid sick leave in return for tax credits, though those expired at the end of September.

About 5% of U.S. employees used the federal COVID sick leave protection, Ziebarth and his colleagues wrote in the journal PNAS, and it appears to have helped flatten the curve of the pandemic initially. But it wasn’t enough. The number of people who were sick with any kind of illness but couldn’t take time off went from about 5 million per month before the pandemic to 15 million in late 2020—even with the federal leave in place.

People with the lowest incomes are the least likely to be covered by paid sick leave, said Dr. Rita Hamad, a social epidemiologist and family physician at the University of California-San Francisco. “We’re just left with whatever patchwork of employer and state policies that existed before, which leave the most vulnerable people least covered,” she said.

The Build Back Better Act, which is up for a vote in the Senate after passing the House on Nov. 19, may grant some paid medical and family leave so workers can deal with longer-term illnesses or caregiving, but it does not include time off for recovering from short-term illness.

Jared Make, vice president of A Better Balance, a national legal nonprofit advocating for worker rights, has been pushing federal, state and local lawmakers for years to expand paid sick leave and has drafted model legislation. He said 16 states, Washington, D.C., and about 20 localities have permanent paid sick time laws. One of the most generous, New Mexico’s, will take effect in July. Colorado, Massachusetts, Nevada, New York and the District of Columbia provide COVID-specific emergency sick leave, as do Pittsburgh and a few cities in California, such as Los Angeles, Oakland and Long Beach.

In some places, employers are taking the initiative to address the problem. A recent KFF survey of about 1,700 employers from across the nation found that 37% of workers work in a place that expanded or started paid leave, either to recover from an illness or to help a relative recover from one. Meanwhile, 1% of workers had their paid sick leave reduced or eliminated.

Still, calls to A Better Balance’s free legal help line have skyrocketed since the pandemic began, Make said. “Many workers are either risking their job, or they have no choice but to go to work when they’re sick, and it’s a real public health concern.”

In August, local public health departments in California asked state leaders to extend paid sick leave to all workers, saying that failing to do so discouraged people from getting a COVID vaccine and disproportionately affected disadvantaged communities.

Many people who have avoided vaccination are afraid they’ll suffer side effects that will force them to miss work for a day or two, which they can’t afford, Hamad said.

But without federal funds to reimburse employers, California and other states would have to find money to pay for sick leave—and there’s little enthusiasm among lawmakers for passing the costs on to businesses.

“It is a glaring gap, in our opinion, that the federal government hasn’t continued some form of even COVID-19 emergency sick leave,” Make said. “It’s obviously a huge shortcoming given where we are in the pandemic.”

Colorado, which is experiencing a COVID surge, passed last year what Denver-based Make considers the strongest COVID sick leave protections of any state. The law, which allows any employee to earn up to six days of paid sick leave per year and takes effect fully in January, says that when local, state or federal officials declare a public health emergency, employers must supplement workers’ accrued leave so an employee can take up to two weeks of paid sick leave for, in this case, COVID-related reasons. The emergency leave provision won’t expire until at least February.

However, some employers aren’t complying. As of early November, Colorado’s Division of Labor Standards and Statistics was looking into complaints related to the sick leave law that were filed against 71 employers, according to outreach manager Eric Yohe. That represented about 8% of all its wage complaints under investigation. Yohe said his division had already restored paid time off for “a good number” of employees under the new law.

Colorado’s leave law still has limitations. Workers don’t get “refills” of COVID leave if they get sick again or a relative gets sick—just 80 hours total from January 2021 until the public health emergency ends. And the law allows some workplaces to force employees to use their paid time off instead, as long as they notify employees in advance and offer at least two weeks of PTO to full-time employees.

Jamie Bradt, a special-education teacher at a high school in Mead, Colorado, found herself in that situation this month after testing positive for COVID. Bradt, who is fully vaccinated, thought she could tap into state-sanctioned COVID sick leave. But her employer, St. Vrain Valley Schools, told her she would have to use her PTO, which she had been saving up for about decade.

“It is so frustrating that I’m being punished for accruing my leave,” said Bradt, who was isolating at home. The district did not respond to questions.

Policies that push employees to work when they’re sick are counterproductive, said Barbara Holland, an adviser at the Society for Human Resource Management, a national trade group. “It’s a communicable disease,” she said. “You don’t want them showing up in the workplace.”

Since the federal provisions expired, Cristina Cuevas and her colleagues at a Minnesota school have been required to use their accrued sick and vacation time if they come down with COVID.

Recently, a co-worker of Cuevas’ went to work sick, assuming it was a cold. “She actually had COVID the whole time,” Cuevas said. The school had to shut down briefly, Cuevas said, and several students got sick.

California Healthline correspondent Rachel Bluth contributed to this story.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.