Bill Thompson’s wife had never seen him smile with confidence. For the first 20 years of their relationship, an infection in his mouth robbed him of his teeth, one by one.

“I didn’t have any teeth to smile with,” the 53-year-old resident of Independence, Missouri, recalled.

For years, Thompson said, he dealt with throbbing toothaches and painful swelling in his face from abscesses while working as a cook at Burger King. He desperately needed to see a dentist but said he couldn’t afford to take time off without pay. Missouri is one of many states that do not require employers to provide paid sick leave.

So, Thompson would swallow Tylenol and push through the pain as he worked over the hot grill.

“Either we go to work, have a paycheck,” Thompson said, “or we take care of ourselves. We can’t take care of ourselves because, well, this vicious circle that we’re stuck in.”

In a nation that was sharply divided about government health mandates during the COVID-19 pandemic, the public has been warming to the idea of government rules providing for paid sick leave.

Before the pandemic, 10 states and the District of Columbia had laws requiring employers to provide paid sick leave. Since then, Colorado, New York, New Mexico, Illinois and Minnesota have passed laws offering some kind of paid time off for illness, while Oregon and California expanded previous paid leave laws. In Missouri, Alaska and Nebraska, advocates are pushing ballot initiatives to put the issue before voters this fall.

The U.S. is one of nine countries that does not guarantee paid sick leave, according to data compiled by the World Policy Analysis Center.

In response to the pandemic, Congress passed the Emergency Paid Sick Leave and the Emergency Family and Medical Leave Expansion acts. These temporary measures allowed employees to take up to two weeks of paid sick leave for COVID-related illness and caregiving, but the provisions expired in 2021.

“When the pandemic hit, we finally saw some real political will to solve the problem of not having federal paid sick leave,” said economist Hilary Wething.

Wething co-authored a recent Economic Policy Institute report on the state of sick leave in the United States. It found that 61% of the lowest-paid workers can’t get time off for an illness.

“I was really surprised by how quickly losing pay — because you’re sick — can translate into immediate and devastating cuts to a family’s household budget,” she said.

Wething noted that even a day or two of lost wages can be equivalent to a month’s worth of gasoline a worker would need to get to their job or the choice between paying an electric bill or buying food. Showing up to work sick poses a risk to co-workers and customers alike, Wething said. Many low-paying jobs that often lack paid sick leave — like cashiers, nail technicians, home health aides and fast-food workers — involve lots of face-to-face interactions.

“So paid sick leave is about both protecting the public health of a community and providing the workers the economic security that they desperately need when they need to take time away from work,” she said.

The National Federation of Independent Business has opposed mandatory sick leave rules at the state level, arguing that workplaces should have the flexibility to work something out with their employees when they get sick. The group said the cost of paying workers for time off, extra paperwork and lost productivity burdens small employers.

According to a report by the National Bureau of Economic Research, once these mandates go into effect, employees take, on average, two more sick days a year compared with before a law took effect.

Illinois’ paid time off rules went into effect this year. Lauren Pattan is co-owner of the Old Bakery Beer Co. there. Before this year, the craft brewery did not offer paid time off for its hourly employees. Pattan said she supports Illinois’ new law, but she has to figure out how to pay for it.

“We really try to be respectful of our employees and be a good place to work, and, at the same time, we get worried about not being able to afford things,” she said.

That could mean customers have to pay more to cover the cost, Pattan said.

As for Bill Thompson, he wrote an op-ed for The Kansas City Star newspaper about his dental struggles.

“Despite working nearly 40 hours a week, many of my co-workers are homeless,” he wrote. “Without health care, none of us can afford a doctor or a dentist.”

That op-ed generated attention locally and, in 2018, a dentist in his community donated his time and labor to remove Thompson’s remaining teeth and replace them with dentures. This allowed his mouth to recover from the infections he’d been dealing with for years. Today, Thompson has a new smile and a job — with paid sick leave — working in food service at a hotel.

In his free time, he’s been collecting signatures to put an initiative on the November ballot that would guarantee at least five days of earned paid sick leave a year for Missouri workers. Organizers behind the petition said they have enough signatures to take it before the voters.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.