The US health agency overseeing coronavirus has told Americans that to curb the inevitable spread of the respiratory illness, they only need to take simple steps: wash your hands, stay home from work if you feel sick and speak to a doctor if you have symptoms of the disease.

But in the US healthcare system, things are never as simple as they seem.

From the cost of healthcare to the lack of guaranteed paid sick days in the US, experts say containing the coronavirus requires systemic change beyond more people washing their hands.

“For many Americans who have insurance and have a good job with an understanding employer, and I’m not an expert on the labor market, those recommendations are plausible,” David Blumenthal, president of the global health think tank the Commonwealth Fund, told the Guardian.

“They are not necessarily workable for people who have no health insurance or poor health insurance – so that’s about a fifth of the American population.”

The head of immunization at the US Centers for Disease Control and Prevention (CDC), Nancy Messonnier, said Tuesday that containing coronavirus was a priority because there is no vaccine or medicine to prevent and treat it.

To do this, she said businesses should consider replacing in-person meetings with telework. She recommended school authorities consider ways to limit face-to-face contact, such as using Internet-based learning or even closing schools. People experiencing respiratory illness are advised to seek medical help early.

But Americans, particularly those with expensive health insurance plans or no health insurance at all, are known to avoid medical help because of the cost.

More Americans were afraid of paying for health care if they became seriously ill (40%) than were afraid of getting seriously ill (33%), according to a 2018 poll by the University of Chicago and the West Health Institute.

The study also found that in one year, more than once, about 40% of Americans skipped a medical test or treatment and 44% didn’t go to the doctor when they were sick or injured.

“People with acute illness of all kinds postpone healthcare when they lack health insurance or have high deductibles,” Blumenthal said. “And there’s no reason to expect people with symptoms of an upper respiratory infection would not do the same when coronavirus might present with a cough, with a low-grade fever, but not a completely debilitating illness.”

In countries with universal healthcare, people do not always go to the doctor when they are sick. But the deterrent is never the threat of high medical bills. “This is almost a uniquely American problem when it comes to the developed world,” Blumenthal said.

One American who usually skipped visits to the doctor, Osmel Martinez Azcue, decided to get tested when he developed flu-like symptoms after returning from China in January. While he would normally just go to a drugstore and buy medicine, he went to a hospital out of concern for his community.

Azcue told the Miami Herald he had a limited insurance plan so he attempted to keep the testing to a minimum, fearing the cost of the CT scan clinicians recommended. After doing smaller, less expensive tests, doctors told him he had the flu, not coronavirus. He was charged $3,270. After the hospital was contacted by the Miami Herald, they said he was responsible for $1,400 of the bill.

“How can they expect normal citizens to contribute to eliminating the potential risk of person-to-person spread if hospitals are waiting to charge us $3,270 for a simple blood test and a nasal swab?” he said.

Staying home when sick leave isn’t guaranteed

To contain coronavirus, the CDC emphasized how important it would be to avoid crowds, work from home and even self-quarantine.

In the only wealthy country in the world which does not require employers give workers paid sick days, that guidance is difficult to follow.

At least three in 10 workers did not take time off from work when sick with the H1N1 swine flu in 2009, according to a paper by the Institute for Women’s Policy Research. The paper said this led up to seven million additional infections and may have extended the outbreak.

“There’s a lot of infrastructure that needs to happen before the CDC’s recommendations can be taken seriously,” said Carol Joyner, director of the Labor Project for Working Families, a not-for-profit which advocates for better family workplace policies.

For people in public-facing, low-wage jobs, staying home from work is rarely an option.

The average wage of workers without paid sick leave is $10 per hour, according to a 2012 Center for American Progress report. The report said that while 38% of private-sector workers lack even one paid sick day, the percentage is much lower for part-time workers, with 73% lacking access.

These workers are likely to include people who work with the public, such as food servers and bus drivers, or people who work with vulnerable populations, such as assisted-living home staff and people who work in child care. These are also jobs where telecommuting, which the CDC warned might be needed as the coronavirus outbreak spreads, isn’t an option.

“It will be a population of lower wage earners, people who earn lower wages, who are often people of color, who are often women, who will be hardest hit by the coronavirus,” said Joyner.

These are also the groups studies show over and over again have the worst access to affordable health insurance and to paid family and medical leave.

A 2014 CDC study found one in five food service workers said they worked at least once in the previous year while sick with vomiting or diarrhea. These workers cited fear of job loss and not wanting to leave coworkers short-staffed as significant factors in their decision to go to work ill.

Karen Scott, a PhD student in management at the Massachusetts Institute of Technology, warned in an article for the Conversation that when sick employees head into work “a manageable health crisis can spiral out of control”.

Scott advised consumers to ask about paid sick leave policies at their favorite restaurants, which could impact company culture.

There is also legislation moving to create national paid family and medical leave insurance called the Family Act, and the Healthy Families Act to set a baseline of seven paid sick days each year.

That said, the situation isn’t much better for workers who do have paid leave. Workplace culture in the US does not support taking sick days, even when they are needed. An October 2019 study from the global staffing firm Accountemps found 90% of professionals have gone to work with cold or flu symptoms.

Private sector workers who do have sick days are given an average of seven days of paid sick leave per year, whether they have been at a company for one, five or 10 years, according to the US Bureau of Labor Statistics. At 20 years of service, the average bumps up to eight paid sick days.

This is half the amount of time recommended for a self-quarantine.

Even the most basic recommendation: to wash your hands more frequently with soap and water, was challenged by the writer Talia Jane on Twitter.

“‘Wash your hands’ is great advice to folks who don’t engage with hundreds of people a day,” she said. “i can’t leave the floor to wash my hands after each customer whose money and food i touched while bagging their groceries. we also can’t wear gloves or masks.”