By Adam Z. Kawalek, MD, and founder, SickSlip
LinkedIn: Adam Z. Kawalek, MD
LinkedIn: SickSlip
It’s flu season in America. On a Tuesday morning, two workers are hit with the same virus. One is a salaried engineer at a tech start-up, and the other is a sorter in a fulfillment warehouse. The engineer drops a message on Slack to her manager: “Feeling rough, won’t be able to make it today”, and goes back to bed. Her manager tells her to rest. Nobody asks for anything further. The warehouse worker, on the other hand, is on an attendance policy that deducts points for undocumented absences. He has 24 hours, until his next shift, to produce a doctor’s note, or the absence counts against his job. Same illness, same city, same conservative management at home. The administrative difference, however, is profound and can cost one of them a paycheck and eventually a job.
Emergency physicians know the second worker well. He arrives at 4 a.m. with a phone in hand, with the attendance policy open. The average emergency department visit, which now runs $2,453, with $646 of it out of pocket, is more than a week’s wages for him. The clinical evaluation takes only a few minutes, but the paperwork is the entire reason for his visit. It also pulls healthcare workers away from patients who need their time more urgently.
The numbers show how common this story is. The Bureau of Labor Statistics reports that 80 percent of private-sector workers now have paid sick leave. The average hides a steep gradient: among the lowest-paid tenth of workers, access is 41 percent compared to 96 percent at the top. The workers most likely to be asked for proof of illness are the least likely to be paid while sick, and the least able to afford the proof.
Where would they even get it? More than 100 million Americans have no usual source of primary care, and only 11 percent of that group is uninsured. Coverage is not the barrier; belonging to a practice is. For patients who do have a doctor, the average wait for a physician appointment reached 31 days this year, up 19 percent since 2022. A note due by tomorrow plus a month-long wait leaves exactly one door open, the expensive one, which costs time, money, and healthcare resources the system can’t spare.
Policy researchers have long studied the broader problem under the name administrative burden. Medicine has mostly ignored it. Call it administrative equity: who can produce the paperwork the system demands, and what producing it costs them.
This spring, federal regulators put a stamp on the pattern. In April, the Equal Employment Opportunity Commission (EEOC) determined that the nation’s second-largest private employer had engaged in systemic, nationwide violations of disability law for more than six years, citing, among other practices, excessive demands for medical documentation.
Investigative reporters had already documented leave paperwork vanishing into administrative black holes and workers being terminated by automated systems while on approved leave. That is not one company’s dysfunction. It is what a documentation-first policy produces at scale. None of this requires new science. Employers could require doctor’s notes only for longer absences and accept telehealth documentation when they do. Requiring a signed note for a 24-hour stomach bug is theater, not risk management. And the distribution problem is already solved: a licensed physician can review a routine case remotely and deliver a signed, verifiable note the same day, for less than most copays.
The missing piece is not technology. It is the decision to count paperwork as part of care. Two workers, one virus. One sent a Slack message and recuperated. The other spent hours securing a document.
Health equity work usually begins with access to treatment, as it should. But for millions of low-wage workers, the most consequential healthcare document of the year is the note that says they were sick. Until getting one is as easy as being believed, this disparity will keep growing.