State-paid family leave policies and cancer mortality among older adults: Implications for working-age informal family caregivers.

100 Background: Home care for older adults with cancer often is performed by informal family caregivers, a responsibility that can be time-consuming, physically taxing, emotionally burdensome, and require substantial time away from work. Over the past 2 decades, several states have implemented mandatory paid family leave policies, whereby qualified working individuals gain several weeks of paid time off to tend for family members requiring medical care. We hypothesized that mandatory state paid family leave laws would facilitate caregiving capacity of working individuals and thereby improve outcomes for their older family members with cancer. Methods: State-level cancer mortality data from 2003-2021 for adults ages ≥75 years were obtained by age and year through the National Vital Statistics System. We focused on adults ≥75 years as they are more likely to require assistance and not work. Difference-in-differences (DID) analyses were utilized to compare changes in cancer mortality rates from pre- to post-policy implementation between states that did (DC, NJ, NY, RI, WA) and did not (AL, CO, FL, KY, MD, NH, OR, TN, TX, VT, VA) enact mandatory paid family leave policies during the study period. Analyses accounted for state and year fixed effects; Medicaid expansion; age at death; and state-level % unemployment, % high school completion, % poverty, % insured, and % non-Hispanic White. Generalized estimating equations with clustering by state were utilized to account for correlations in mortality rates over time within states. Event-study analyses evaluated the plausibility of the parallel trends assumption. To mitigate non-parallel trends, data from California were omitted from the group of four states (and DC) enacting paid family leave policies by 2020, and comparison states without paid family leave policies were limited to the eleven states that eventually enacted (or plan to enact) paid family leave policies after 2021. Results: A total of 2,507,561 cancer deaths were included, 551,947 and 1,955,614 in states with and without paid leave policies, respectively. From pre- to post-policy introduction, cancer mortality rates decreased from 1372 to 1214 deaths per 100,000 in states with mandatory paid family leave, compared to a decrease from 1397 to 1262 deaths per 100,000 in non-policy states. In adjusted DID analyses, state mandatory paid family leave was associated with a modest decrease in cancer mortality (OR 0.954, 95% CI = 0.932– 0.975, P<.001), translating to 2975 fewer cancer deaths. Results were similar in sensitivity analyses excluding data from 2020-2021. Conclusions: State mandatory paid family leave was associated with decreased cancer mortality among older adults. State or federal expansion of policies supporting working caregivers’ ability to devote time to care for older family members with cancer may improve cancer outcomes and save thousands of lives.