The Classism of Doctor’s Notes in the United States

A lot of times, social media can be a dumpster fire. But sometimes, there are people on social media who make interesting points, and such was the case with one quote I came across:

“Requiring doctor’s notes to excuse absences due to illness is inherently classist in a country w/o universal healthcare and I really wish we talked about it more.”[1]

Upon thinking about this tweet, the person who tweeted it was right: requiring a doctor’s note to excuse absences due to illness is classist in the United States, a country that unfortunately lacks universal healthcare. So, let’s talk about it more.

Many schools and workplaces require someone who’s been out sick, and particularly someone who has been out sick for more than a certain period of time, to give a doctor’s note explaining the person’s absence upon their return to school or work. For many of us, in the cases of a multitude of illnesses (though not all illnesses), it’s simple enough: you go to a doctor, you get something checked out, you find that you are ill with something that keeps you out of school or work for several days or a couple of weeks (like strep throat, an ear infection, etc.), the doctor gives you a note to present to a teacher or employer showing that you were indeed sick with something, you give the note to your teacher or employer, and then you move on.[2]

In the United States, where there is not universal healthcare, not everyone has health insurance because not everyone has a job with insurance or afford to buy insurance if they lack it through their job. Due to how a lack of health insurance can make it prohibitively expensive to visit a doctor (which seems to cost in the $300-$600 range for those who don’t have insurance to cover the visit, per what I looked up online) or even an urgent care clinic (which is less expensive than seeing a doctor without insurance, but still can be in the $100-$200 range apparently), some Americans have a difficult time affording the requisite visit to get that doctor’s note upon their return to work or their kid’s return to school. What are those people to do?

This problem should be especially noteworthy for employers that do all they can in order to avoid paying for health insurance for employees, or employers (oftentimes small businesses) who struggle to afford to pay for adequate health insurance for their employees. As a result, some employees are unable to afford doctor’s visits in general—an injustice in and of itself that prevents people from getting requisite doctor’s notes and has personal and public health ramifications that go well beyond doctor’s notes.

So what is the solution to this doctor’s note classism in the United States?

The long-term solution is universal, affordable health care of some sort so that every single American can be able to go to the doctor when they are unwell. This addresses the issue of being unable to afford a doctor’s visit—which enables someone to get a doctor’s note when they need it. But it has personal and public health benefits that go well beyond the ability to get a doctor’s note. However, to be completely realistic, Congress barely got Obamacare passed and signed into law in the United States (inadequate as it may be in terms of providing truly universal care), and the political situation in the United States is somehow even more toxic now than it was then. In other words, my pessimistic realism is telling me that it may be some time before we get truly universal healthcare. I hope I am wrong.

In the interim, I think that many bosses with uninsured or underinsured employees need to be sensitive to the fact that for some employees, all they can do to get better is to simply rest. As such, sick leave policies should reflect that fact. Admittedly, such an approach requires a certain level of trust in employees that some employers lack (and there are unfortunately some people in this world who give reason for having low trust in employees, but there are also many deserving of that trust). However, the alternative is worse: forcing a poor, uninsured person to come into work sick because they cannot afford to get the doctor’s note necessary to show that they are sick.


[2] However, it is worth noting that there are some illnesses where things like rest and fluids are needed far more than a visit to the doctor. Asking for a doctor’s note is problematic in those sorts of situations as well, albeit such situations are not the focus of my post here.

Obamacare and Race

One of the signature issues for both major political parties is health care. Many Republicans want to repeal the Affordable Care Act, also known as Obamacare, that passed in 2010. President-elect Joe Biden, who was Vice President in the administration under which Obamacare was passed, says he wants to expand it. These are two wildly differing views on what to do with our health care system.

However, given the current climate of racial unrest in the United States, as well as the potential repeal of the law being considered by the United States Supreme Court, it seems timely to talk about Obamacare from a racial justice standpoint.

So, where does Obamacare stand from a racial justice standpoint? Well, I have some good news for proponents of Obamacare, and some not-as-good news:

Reductions in uninsured rates were significant among minorities.

Among the highlights of those gains:

  • 21.8% of American Indians and Alaska Natives were uninsured as of 2018, down from 32% in 2010.
  • 19% of Hispanics were uninsured as of 2018, down from 32.6% in 2010.
  • 11.5% of Blacks were uninsured as of 2018, down from 19.9% in 2010.
  • 9.3% of Native Hawaiians or Other Pacific Islanders were uninsured as of 2018, down from 17.9% in 2010.
  • 6.8% of Asians were uninsured as of 2018, down from 16.7% in 2010.[1]

These are undoubtedly significant gains. However…

The aforementioned gains I mentioned have stalled out.

Most of the gains that occurred were between 2014, when important provisions of Obamacare were implemented, and 2016. Those gains have stalled since then, and for Blacks the rate of those uninsured has started to tick up in recent years. The Kaiser Family Foundation, which focuses on health care issues, attributes this to certain policy changes in the Trump Administration “that affected the availability of and enrollment in coverage.”[2] But whatever the reason for this stall, it has happened, and this stalling trend is one that a President Biden will need to address (assuming the Supreme Court doesn’t repeal the law).

However, the gaps in insurance by race are about more than just what’s coming out of Washington, DC. It’s also because of policies at the state level.

Many states with large Black populations have refused to expand Medicaid under Obamacare.

As a result of this, even though there appear to be modest gains in racial disparities among the uninsured overall as a result of Obamacare, the gains are not as big as many might like. Additionally, the result of this is that about half of the remaining uninsured Americans are people of color.[3] This goes to show that elections have consequences—not just federal elections, but state ones too. This is worth keeping in mind for future elections at the state level.

In spite of the issues I’ve mentioned, the racial gap among the uninsured has closed somewhat.

The rate of those without insurance has dropped among whites too, but as there were fewer uninsured whites than uninsured people of any minority group to begin with, the rate among whites of those lacking insurance dropped more slowly than among any other racial group. As such, the racial gap among the uninsured has closed somewhat, even if there are disparities that still exist.[4]

In spite of all this data I’ve shared, there are some unanswered questions.

So far, I have painted a mixed picture of what Obamacare has been like for minority groups, particularly from an insurance coverage standpoint. But there are some unanswered questions about the true impacts of the health care law, too. Here are a few such questions:

  • While the number of uninsured Americans has decreased significantly since Obamacare was passed in 2010, the number of underinsured Americans has also increased.[5] To what extent does this underinsurance issue affect people of color?
  • Is there anything about Obamacare that might, even unintentionally, contribute to the continued (if somewhat decreased) gap in the uninsured between some minorities and whites?
  • There are mixed messages about how Obamacare affected health care costs—out-of-pocket health care spending decreased, while premiums increased.[6] To what extent are people of color getting the benefit of reduced health care spending, or the drain of increased premiums?

The unanswered questions are so numerous that I may need to republish this post at some point, as a version that hopefully answers some of the questions that I’m asking here.

Over the last several hundred words, I have painted a rather mixed message on the question of Obamacare and racial justice. But where does this leave us?

For those in the United States who care about American health care, this raises some questions. For the Republicans, who are proponents of repealing and replacing the law, how does the law get repealed and replaced without erasing all the gains that people of all races, particularly minorities, have seen as a result of Obamacare? For Biden and his supporters, how can we continue making progress in increasing the number of insured Americans, and how might the issues with underinsurance and health care premiums be addressed (assuming, once again, that the Supreme Court doesn’t strike down the whole law)? And for all sides of the debate on this law, how can we ensure that every American is insured?

The last question is maybe the most important one of all, because access to affordable health care should be a human right, not just a privilege to those fortunate enough to access it.


[2] Ibid.