The Impact of School Closure for COVID-19 on the US Healthcare Workforce and the Net Mortality Effects
Authors: Bayham Jude , Fenichel Eli P. 
Published: March 2020

AbstractBackgroundCOVID-19 is leading to the implementation of social distancing policies around the world and in the United States, including school closures. The evidence that mandatory school closures reduce cases and ultimately mortality mostly comes from experience with influenza or from models that do not include the impact of school closure on the healthcare labor supply or the role of the healthcare labor force in reducing the per infection mortality from the pathogen. There is considerable uncertainty of the incremental effect of school closures on transmission and lives saved from school closures. The likely, but uncertain, benefits from school closure need to be weighed against uncertain, and seldom quantified, costs of healthcare worker absenteeism associated with additional child care obligations.MethodsWe analyze data from the US Current Population Survey to measure the potential child care obligations for US healthcare workers that will need to be addressed if school closures are employed as a social distancing measure. We account for the occupation within the healthcare sector, state, and household structure to identify the segments of the healthcare labor force that are most exposed to child care obligations from school closures. We use these estimates to identify the critical level for the importance of healthcare labor supply in increasing a patient’s COVID-19 survival probability that would undo the benefits of school closures and ultimately increase cumulative mortality.FindingsThe US healthcare sector has some of the highest child care obligations in the United States. 29% of healthcare provider households must provide care for children 3-12. Assuming non-working adults or a sibling 13 years old or older can provide child care, leaves 15% of healthcare provider households in need of childcare during a school closure, while 7% of healthcare households are single-parent households. We document the substantial variation within the healthcare system. For example, 35% of medical assistants and 31% of nursing, psychiatric, and home health aide households have child care obligations, while only 24% of emergency medical personnel have childcare obligations. Child care obligations can vary between states by over 10 percentage points. A 15% decline in the healthcare labor force, combined with reasonable parameters for COVID-19 such as a 15% case reduction from school closings and 2% baseline mortality rate implies that a 15% loss in the healthcare labor force must decrease the survival probability per percent healthcare worker lost by 17.6% for a school closure to increase cumulative mortality. This means that the per infection mortality rate cannot increase from 2% to 2.35% when the healthcare workforce declines by 15%; otherwise, school closures will lead to a greater number of deaths than they prevent. For school closures to unambiguously provide a net reduction in COVID-19 mortality with these parameters, the school closures must reduce cases by over 25%.ConclusionSchool closures come with many tradeoffs. Setting aside economic costs, school closures implemented to reduce COVID-19 spread create unintended childcare obligations, which are particularly large in healthcare occupations. Detailed data are provided to help public health officials make informed decisions about the tradeoffs associated with closing schools. The results suggest that it is unclear if the potential contagion prevention from school closures justifies the potential loss of healthcare workers from the standpoint of reducing cummulative mortality.FundingNo external funding.Research in ContextEvidence before this studyCOVID-19 is affecting many countries around the world. Multiple countries, states, and school districts are employing school closures as a non-pharmaceutical social distancing strategy. Support for school closures mostly comes from models and experience with influenza. Few studies explicitly consider the tradeoff between case reduction and disease burden with the potential loss of healthcare workers to child care obligations. We found only two studies that attempted to quantify the potential child care burden of school closures for healthcare workers. These analyses were coarse, and no studies have explicitly considered the tradeoff between reduced transmission and healthcare labor’s role in cumulative mortality.Added value of this studyUsing current detailed data from the US Current Population Survey, we quantify the exposure of the US healthcare sector, occupations within the healthcare sector, and individual US states to unmet child care obligations for US healthcare workers in the event of a school closure. These obligations could compromise the ability of the US healthcare system to respond to COVID-19. We identify the parameter space where school closure could lead to a greater number of deaths from COVID-19 through healthcare labor force reductions. We find that the current best estimates of healthcare worker likely absenteeism to provide child care in the event of school closures imply great uncertainty to whether school closures will ultimately reduce COVID-19 mortality.Implication of all the available evidenceTargeted pharmaceutical interventions for COVID-19 are likely months away. However, supportive measures by healthcare providers are important. Social distancing, including school closures, can limit COVID-19 cases. However, the evidence that the potential transmission reduction benefits of mandatory school closures exceed the costs of potentially imposing greater child care obligations on healthcare workers, thereby reducing the healthcare workforce, is not overwhelming. We provide the first explicit analysis of the school closure tradeoff between case reduction and labor force impact on patient survival probability. A 15% decline in the healthcare labor force, combined with reasonable parameters for COVID-19 such as a 15% case reduction from school closings and 2% baseline mortality rate implies that a 15% loss in the healthcare labor force must decrease the survival probability per percent healthcare worker loss by 17.6% for school closures to increase cumulative mortality. This means that the per infection probability of survival cannot increase by more than 2.4%; otherwise, school closures will lead reduce patient survival. Even if the only objective is to save lives, there is still a tradeoff associated with closing schools due to potential losses in healthcare labor force capacity.