This piece is the first in a three-part series examining the economic and social conditions that impact health outcomes in Southern states, and how these conditions leave communities underprepared to protect frontline workers and communities during the pandemic.

U.S. federal lawmakers are poised to pass a stimulus package to combat the coronavirus pandemic’s public health and economic damage. In a recent post, we laid out the critical steps that state and local lawmakers should take to protect workers and families, slow the spread of the virus, and mitigate its economic toll. This piece will highlight how state and local policymakers in the Southern states are responding to the crisis, and what more is needed.

Health organizations broadly recognize that where we live and work impacts health risks and health outcomes. By recognizing the economic and social conditions that influence health equity for people living in Southern states, policymakers can provide more targeted solutions to protect public health and support families already struggling to make ends meet.

Health care

The countries around the world that have fared best in the wake of the pandemic took quick measures to identify cases through extensive testing and treatment of the virus. In the United States, however, delayed testing and treatment of the virus has been compounded by the lack of accessible and affordable health care for many, particularly in the South. Of the 14 states that have still not expanded Medicaid, nine states are situated in the South. This is especially problematic because several of these states, including Alabama, Florida, Oklahoma, and West Virginia, are among the states with the greatest share of adults with a higher risk of serious illness if infected by the coronavirus. These states should expand Medicaid coverage and streamline enrollment without introducing additional barriers such as premiums or work requirements.

Paid leave

The absence of paid sick leave policies in Southern states also puts communities at greater risk. Even as many nonessential businesses continue to operate in the South, both nonessential and essential workers are forced to choose between going to work so they can pay their bills or staying at home without pay to care for themselves or a loved one. The recently passed federal legislation leaves behind workers employed by private employers with more than 500 employees and also allows exemptions for small businesses.

Studies show that paid leave programs measurably reduce virus transmission, but too few workers in the South, especially workers in low-wage jobs, have access to paid sick leave. No states in the South require all employers to provide paid sick leave, and recent attempts to pass legislation in Kentucky, Louisiana, Virginia, and West Virginia have not yet advanced.

Mississippi is the first state in the South to enact paid leave for state employees in response to the coronavirus. State action to implement emergency paid sick time is particularly important in Southern states where jobs have lower wages and are less likely to be in financial activities, information industries, and education and health services, which have the highest access to paid leave. Southern states also stick out like a sore thumb in the breadth of worker rights policies for which state governments restrict local control. At a time when the importance of paid leave has been laid bare, Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, Oklahoma, South Carolina, and Tennessee all prohibit local governments from providing paid leave to their constituents. Texas voters passed paid sick leave policies locally in Austin, Dallas, and San Antonio, but legal challenges threaten their implementation. State policymakers should provide at least 14 days of emergency paid sick days to all workers in businesses of all sizes that are immediately available regardless of accrued time, in order to reduce community spread of the coronavirus.

Public health resources

By declaring states of emergency and activating the National Guard, most Southern states have joined others across the country and opened up resources for adequate testing, preparation, and prevention. Alabama, Georgia, and South Carolina have also appropriated dedicated funds for public health preparedness and response to the virus. More states should take similar steps and use whatever funding they have saved in state “rainy day funds.”

Thus far, North Carolina is the only Southern state to request a major disaster declaration which, if approved, would open states up to a broader range of federal assistance. Currently, Southern state and local governments tend to rank low in terms of per capita revenue. And since state and local governments must largely balance their budgets, this means that state and local expenditures also tend to be low in Southern states. This low spending extends to health care, where Southern states tend to spend less. And while many Southern states don’t have adequate fiscal reserves heading into this recession, those that do shouldn’t hesitate to spend on pressing public health needs.

Social distancing

Stopping the pandemic will require social distancing, closing schools and nonessential businesses, and limiting public gatherings, while also providing unemployment insurance for workers and interest-free loans to small businesses. As of March 23, all Southern states have closed schools, but not all have instituted strong limits on public gatherings or nonessential businesses. Louisiana is the only Southern state which has issued a statewide stay-at-home order, requiring residents to avoid going out in public unless their job is considered to be an essential service or they need to pick up groceries, food, or medicine.

There is more that state and local policymakers in Southern states must do to effectively combat the coronavirus pandemic. In subsequent pieces, we will address what is especially needed in these states to protect frontline workers and communities and also strengthen democracy while protecting voter health.