Paid sick leave laws
Community in Action
Paid sick leave laws require employers in the affected jurisdictions to provide paid time off to employees for use when ill or injured. Sick employees may use the time to care for themselves by seeing a health care provider or stay home until they are healthy enough to work again, without concern for lost wages. In some cases, sick leave can be used to provide care to a sick child, or for instances related to domestic violence. As of 2022, the U.S. Bureau of Labor Statistics estimates that 21% of civilian workers in the U.S. do not have paid sick leave1. Women, Hispanics, low-wage workers, and employees with lower levels of education are less likely to have paid sick leave than their counterparts2, 3, 4. Individuals with paid sick leave also tend to have higher incomes5, 6, 7 while those without it are more likely to have income below the poverty line8 and receive safety net services9. Some local governments cannot enact paid sick leave measures due to state preemption legislation10.
What could this strategy improve?
Expected Benefits
Our evidence rating is based on the likelihood of achieving these outcomes:
Increased access to paid leave
Increased access to health care
Potential Benefits
Our evidence rating is not based on these outcomes, but these benefits may also be possible:
Improved health outcomes
Increased use of parental leave
What does the research say about effectiveness?
There is some evidence that paid sick leave laws increase access to paid sick leave (PSL)11, 12, 13, 14, especially among women without a college education and workers in industries which have historically lacked access12. Access to paid sick leave can increase use of preventive health care services5, 15, 16, 17, 18, 19, 20, 21, 22. However, additional evidence is needed to confirm effects.
Access to paid sick leave can increase use of outpatient preventive care services including cancer and other health care screenings17, 19, flu vaccinations18, 22, and dental care17, as well as decrease emergency room use for children18 and adults15, 23. Workers who receive six days or more of PSL may be more likely to use preventive care services than those with two days or less, and those with ten or more days may be even more likely to16. Parental access to paid sick leave improves children’s access to health care18. Lack of access to paid sick leave appears to lead to lower levels of preventive health care use, including screenings3, 20, and delayed or forgone medical care3, 21, particularly among those with very low incomes21. Workers without access to PSL are more likely to report being in fair or poor health24, may be less able to afford needed health care services and goods (such as dental care and eyeglasses), and are more likely to incur elevated medical expenses8. Lack of PSL is also associated with increased psychological distress25 and financial worry26, while access to paid sick leave is associated with reduced financial hardship and improved quality of life27.
Access to paid sick leave is associated with an increased likelihood that employees stay home when they are ill or injured11, 12, 28, 29, and to care for children who are ill or injured29, particularly among low income parents6. When workers gain access to paid sick leave, flu rates decrease approximately 10%, likely due to fewer employees coming to work while contagious30; PSL mandates in Connecticut and Washington, D.C. appeared to decrease illness-related leave taking by all workers, not just those directly affected by the change31. Lack of access to paid sick leave may increase the risk of illness for individuals and the spread of contagious illness among the wider population32.
Paid sick leave is associated with a decreased risk of mortality from all causes, particularly from heart disease and unintentional injuries33. Access to PSL is also associated with a decrease in nonfatal occupational injuries among private sector workers, particularly in high risk sectors and occupations34. For example, three years after implementation of Connecticut’s PSL law, occupational injuries and illnesses declined in the industries targeted by the law35.
A study of 9 city- and 4 state-level PSL mandates, generally allowing workers to earn one hour of PSL per work week and up to 7 days per year, suggests such laws do not significantly affect employment or wages36, while an initial assessment of Connecticut’s paid sick leave law suggests potential for small decreases in employment concentrated among older workers37. Access to paid sick leave may increase job stability for employees38 and may lead to positive effects for employers such as decreased turnover, increased productivity, and increased employee loyalty and morale4. An early study of Seattle’s Paid Sick and Safe Time Ordinance showed modest and smaller-than-anticipated costs to organizations following implementation39. Following implementation of the law, employer-offered leave increased in Seattle for both full and part-time employees, particularly in the hospitality sector13.
Early assessments of San Francisco’s paid sick leave ordinance suggest variable effects on profits14, 40, and some adjustments to employee benefit packages among employers who had not previously offered paid sick leave, along with some initial challenges in implementation14. One study indicates that six months after the implementation of New York City’s PSL law, workers with part-time jobs and workers without a college degree were least likely to be paid for sick days, least likely to access the benefit, and most likely to work while sick; over 1/3 of those not paid for sick leave worked in retail, food service, or health care41.
Available cost benefit analyses from advocacy organizations suggest that benefits outweigh the costs associated with PSL provision4, 42.
Responses to the Harvard School of Public Health’s 2006 Pandemic Influenza Survey suggest workers without PSL are more likely to believe they would lose their jobs or businesses if forced not to work for 7-10 days; lack of paid sick leave, inability to work remotely, and lower income levels are all associated with perceived ability to comply with stay at home orders during illness outbreaks43.
How could this strategy advance health equity? This strategy is rated potential to decrease disparities: suggested by expert opinion.
Paid sick leave laws are a suggested strategy to reduce disparities in income, health, and access to leave for workers across racial and economic groups, as well as for women44, 46, 47, 48, 49. Paid sick leave laws can increase access to paid sick leave (PSL), especially for women and workers from industries that often lack access12. One study in the U.S. suggests recently passed PSL laws reduce disparities in access to paid sick leave for Hispanic workers and appear to be reversing a trend of declining paid sick leave access for Black workers50.
While 79% of private-sector workers have access to PSL1, only 35% of the lowest paid workers do47. Both full and part-time workers without access to PSL are more likely to work when ill, and those with the lowest incomes were the most likely to delay or forgo needed care for themselves and their families21. However, access to PSL may increase Hispanic29 and low income parents taking needed time off work to care for themselves or others6, 29. It may also increase part-time workers’ use of office-based health care51. It may also reduce disparities in influenza-like illness among Hispanic populations32. Those without PSL are more likely to earn lower incomes and be enrolled in supportive programs, and PSL may decrease the need for use of such benefit programs52.
To create more equitable paid leave, experts suggest programs include job protection and progressive wage replacement, and should cover part-time and gig workers, include all firms no matter their size, and have broad coverage and eligibility requirements47.
What is the relevant historical background?
During the era of Jim Crow, employment laws excluded individuals from racial and ethnic minority groups from collective bargaining and allowed unions to discriminate, effectively barring these individuals from the benefits unions provided, including paid sick leave53. Today, America’s low-wage work force is largely made up of women and people of color54. Structural and historic racial inequities in U.S. economic systems mean that Black, Hispanic, Native American, and immigrant workers are more likely to work in lower-income, part-time jobs47. More than two-thirds of low-wage workers do not have access to paid sick leave55 and less than half of part-time workers do47. People of color, women, immigrants, and members of the LGBTQ community are less likely to be able to take needed sick leave44, 56.
The U.S. is the only industrialized nation without a national paid sick leave policy. The Healthy Families Act would create a minimum standard, providing up to 7 job-protected paid sick days each year for employees of businesses with 15 or more employees. It has been proposed multiple times but has not yet been enacted48. During COVID-19 pandemic, the federal government created a temporary paid sick leave program through the CARES Act, granting 2 weeks of paid leave for workers with COVID-19, but the program expired at the end of 202049.
The COVID-19 pandemic highlighted inequities in paid sick leave availability, as many essential workers are people of color46. Workers from groups marginalized in U.S. society were more likely to miss work, and to go without pay due to the lack of paid leave, including workers with low incomes, people of color, women, and families with children. Additionally, women were disproportionately responsible for child care and other family obligations, and their absences were the least likely to be paid. The lack of universal paid leave combined with the COVID-19 pandemic compounded economic and health disparities between families with high incomes and most other families (Urban-Boyens 2022a).
In recent decades, local paid sick leave laws have been a subject of state-level policy preemption. Lawmakers have used state-level preemptions as a tool of structural racism, preventing the expansion of local policies that could reduce racial inequality57 and excluding low income workers, workers of color, and their communities from the health benefits and opportunities these laws could provide58. However, state or federal preemption can be used to protect and expand local policies that reduce health inequities, as in the case of civil rights laws59.
Equity Considerations
- Who doesn’t have access to paid sick leave in your community? Are there specific groups or industries that are most in need but lacking access?
- How do preemption laws impact your ability to implement paid sick leave?
- Who is opposed to paid sick leave expansion and what is at the root of that opposition? What role can public health play in (re)framing the discussion?"
- What community partners can assist in efforts to expand paid sick leave? Is there a history of labor organizing or labor partners in your community who could be involved?
- If you have paid leave laws in place, do the laws include job protection? Are all types of workers eligible? Are different industries or business sizes exempt from participating?
Implementation Examples
At the end of 2021, 16 states (Connecticut, California, Massachusetts, Oregon, Vermont, Washington, Arizona, Rhode Island, New Jersey, Maryland, Michigan, Nevada, Maine, New York, Colorado, New Mexico) and many municipalities, including Washington, D.C. have enacted paid sick leave laws and ordinances44, covering an estimated 28% of U.S. jobs45. State legislation pre-empts local laws related to leave in 23 states10.
Implementation Resources
‡ Resources with a focus on equity.
ABB-PST campaigns - A Better Balance (ABB). Tools and resources for paid sick time campaigns. 2022.
ChangeLab-Paid sick leave - ChangeLab Solutions. Understanding paid sick leave & preventive cancer screening: Resources to promote public health.
AIC-PSL - All-In Cities, an Initiative of PolicyLink. All-In Cities Policy Toolkit: Paid sick leave.
NPWF-HFA 2022 - National Partnership for Women & Families (NPWF). The Healthy Families Act (HFA). 2022.
LAW-Resources - Legal Aid at Work (LAW). Work & family. San Francisco, CA.
NCSL-PSL - National Conference of State Legislatures (NCSL). Paid sick leave.
SF-PSLO - City & County of San Francisco. Paid sick leave ordinance (PSLO).
Footnotes
* Journal subscription may be required for access.
1 US DOL-PSL - U.S. Department of Labor (U.S. DOL), Bureau of Labor Statistics (BLS). Employee benefits in the United States - March 2017.
2 BLS-Bartel 2019 - Bartel AP, Kim S, Nam J. Racial and ethnic disparities in access to and use of paid family and medical leave: Evidence from four nationally representative datasets. Monthly Labor Review. U.S. Bureau of Labor and Statistics (BLS); 2019.
3 Zhai 2018 - Zhai Y, Santibanez TA, Kahn KE, Black CL, de Perio MA. Paid sick leave benefits, influenza vaccination, and taking sick days due to influenza-like illness among U.S. workers. Vaccine. 2018;36(48):7316-7323.
4 Chen 2016 - Chen ML. The growing costs and burden of family caregiving of older adults: A review of paid sick leave and family leave policies. The Gerontologist. 2016;56(3):391-396.
5 Cook 2011 - Cook WK. Paid sick days and health care use: An analysis of the 2007 National Health Interview Survey data. American Journal of Industrial Medicine. 2011;54(10):771-779.
6 Clemans-Cope 2008 - Clemans-Cope L, Perry CD, Kenney GM, Pelletier JE, Pantell MS. Access to and use of paid sick leave among low-income families with children. Pediatrics. 2008;122(2):e480-6.
7 CWF-Collins 2004 - Collins SR, Davis K, Doty MM, Ho A. Wages, health benefits, and workers’ health. New York: The Commonwealth Fund (CWF); 2004: Issue Brief #788.
8 Stoddard-Dare 2018b - Stoddard-Dare P, DeRigne LA, Mallett C, Quinn L. How does paid sick leave relate to health care affordability and poverty among U.S. workers? Social Work in Health Care. 2018;57(5):376-392.
9 Stoddard-Dare 2018a - Stoddard-Dare P, Quinn L, Mallett C. Paid sick leave status in relation to government sponsored welfare utilization. American Journal of Orthopsychiatry. 2018;88(5):608-615.
10 Grassroots Change - Grassroots Change: Connecting for better health. Preemption Watch.
11 Schneider 2020 - Schneider D. Paid sick leave in Washington state: Evidence on employee outcomes, 2016-2018. American Journal of Public Health. 2020;110(4):499-504.
12 Upjohn-Callison 2017 - Callison K, Pesko MF. The effect of paid sick leave mandates on coverage, work absences, and presenteeism. W.E. Upjohn Institute for Employment Research. 2017: Working Paper 16-265.
13 Romich 2017 - Romich JL. Local mandate improves equity of paid sick leave coverage: Seattle’s experience. BMC Public Health. 2017;17:60.
14 Colla 2014 - Colla CH, Dow WH, Dube A, Lovell V. Early effects of the San Francisco paid sick leave policy. American Journal of Public Health. 2014;104(12):2453-2460.
15 Upjohn-Callison 2016 - Callison K, Pesko MF. The effect of mandatory paid sick leave laws on labor market outcomes, health care utilization, and health behaviors. W.E. Upjohn Institute for Employment Research. 2016: Working Paper 16-265.
16 DeRigne 2018b - DeRigne L, Stoddard-Dare P, Quinn LM, Collins C. How many paid sick days are enough? Journal of Occupational and Environmental Medicine. 2018;60(6):481-489.
17 Hammig 2019 - Hammig B, Bouza B. Paid sick leave benefits and adherence to recommended screening tests among male labor workers in the United States. Journal of Occupational and Environmental Medicine. 2019;61(2):102-106.
18 Asfaw 2017 - Asfaw A, Colopy M. Association between parental access to paid sick leave and children’s access to and use of healthcare services. American Journal of Industrial Medicine. 2017;60(3):276-284.
19 Peipins 2012 - Peipins LA, Soman A, Berkowitz Z, White MC. The lack of paid sick leave as a barrier to cancer screening and medical care-seeking: Results from the National Health Interview Survey. BMC Public Health. 2012;12(1):520.
20 DeRigne 2017 - DeRigne L, Stoddard-Dare P, Collins C, Quinn L. Paid sick leave and preventive health care service use among U.S. working adults. Preventive Medicine. 2017;99:58-62.
21 DeRigne 2016 - DeRigne L, Stoddard-Dare P, Quinn L. Workers without paid sick leave less likely to take time off for illness or injury compared to those with paid sick leave. Health Affairs. 2016;35(3):520-527.
22 Wilson 2014 - Wilson FA, Wang Y, Stimpson JP. Universal paid leave increases influenza vaccinations among employees in the U.S. Vaccine. 2014;32(21):2441-2445.
23 Bhuyan 2016 - Bhuyan SS, Wang Y, Bhatt J, et al. Paid sick leave is associated with fewer ED visits among U.S. private sector working adults. The American Journal of Emergency Medicine. 2016;34(5):784-789.
24 Luckhaupt 2017 - Luckhaupt SE, Alterman T, Li J, Calvert GM. Job characteristics associated with self-rated fair or poor health among U.S. workers. American Journal of Preventive Medicine. 2017;53(2):216-224.
25 Stoddard-Dare 2018c - Stoddard-Dare P, DeRigne LA, Collins CC, Quinn LM, Fuller K. Paid sick leave and psychological distress: An analysis of U.S. workers. American Journal of Orthopsychiatry. 2018;88(1):1-9.
26 DeRigne 2018a - DeRigne LA, Dare PS, Collins C, Quinn LM, Fuller K. Working U.S. adults without paid sick leave report more worries about finances. Journal of Social Service Research. 2019;45(4):570-581.
27 Albelda 2019 - Albelda R, Wiemers E, Hahn T, et al. Relationship between paid leave, financial burden, and patient-reported outcomes among employed patients who have undergone bone marrow transplantation. Quality of Life Research. 2019;28(7):1835-1847.
28 Ahmed 2020 - Ahmed F, Kim S, Nowalk MP, et al. Paid leave and access to telework as work attendance determinants during acute respiratory illness, United States, 2017-2018. Emerging Infectious Diseases. 2020;26(1):26-33.
29 Piper 2017 - Piper K, Youk A, James AE, Kumar S. Paid sick days and stay-at-home behavior for influenza. PLOS ONE. 2017;12(2):e0170698.
30 Upjohn-Pichler 2015 - Pichler S, Ziebarth N. The pros and cons of sick pay schemes: Testing for contagious presenteeism and shirking behavior. W.E. Upjohn Institute for Employment Research. 2015: Working Paper 15-239.
31 Stearns 2018 - Stearns J, White C. Can paid sick leave mandates reduce leave-taking? Labour Economics. 2018;51(May 2016):227-246.
32 Kumar 2012 - Kumar S, Quinn SC, Kim KH, Daniel LH, Freimuth VS. The impact of workplace policies and other social factors on self-reported influenza-like illness incidence during the 2009 H1N1 pandemic. American Journal of Public Health. 2012;102(1):134-40.
33 Kim 2017a - Kim D. Paid sick leave and risks of all-cause and cause-specific mortality among adult workers in the USA. International Journal of Environmental Research and Public Health. 2017;14(10):1-10.
34 Asfaw 2012 - Asfaw A, Pana-Cryan R, Rosa R. Paid sick leave and nonfatal occupational injuries. American Journal of Public Health. 2012;102(9):59-64.
35 Hawkins 2019 - Hawkins D, Zhu J. Decline in the rate of occupational injuries and illnesses following the implementation of a paid sick leave law in Connecticut. American Journal of Industrial Medicine. 2019;62(10):859-873.
36 Pichler 2018 - Pichler S, Ziebarth NR. Labor market effects of U.S. sick pay mandates. Journal of Human Resources. 2020;55(2):611-659.
37 Ahn 2015 - Ahn T, Yelowitz A. The short-run impacts of Connecticut’s paid sick leave legislation. Applied Economics Letters. 2015;22(15):1267-1272.
38 Hill 2013 - Hill HD. Paid sick leave and job stability. Work & Occupations. 2013;40(2):143-73.
39 Romich 2014 - Romich J, Bignell W, Brazg T, et al. Implementation and early outcomes of the City of Seattle paid sick and safe time ordinance final report. University of Washington for City of Seattle, Office of City Auditor; 2014.
40 Urban-Waters Boots 2009 - Waters Boots S, Martinson K, Danziger A. Employers' perspectives on San Francisco's paid sick leave policy. Washington, D.C.: Urban Institute; 2009.
41 Hall 2018 - Hall GS, Walters S, Wimer C, et al. Workers not paid for sick leave after implementation of the New York City paid sick leave law. Journal of Urban Health. 2018;95(1):134-140.
42 Awuor 2011 - Awuor G, Arellano A. Costs and benefits of paid sick leave: Reviewing the research. The Bell Policy Center; 2011.
43 Blake 2010 - Blake KD, Blendon RJ, Viswanath K. Employment and compliance with pandemic influenza mitigation recommendations. Emerging Infectious Diseases. 2010;16(2):212-218.
44 ABB-Lankachandra 2022 - Lankachandra D, Gomez C, Leiwant S, Make J. Sick without a safety net: Now is the time to build on state successes with a federal paid sick time law. New York, NY: A Better Balance (ABB); 2022.
45 Johnson 2020 - Johnson JK, Stewart AL, Acree M, et al. A community choir intervention to promote well-being among diverse older adults: Results from the Community of Voices trial. Journals of Gerontology - Series B Psychological Sciences and Social Sciences. 2020;75(3):549-559.
46 Pomeranz 2022 - Pomeranz JL, Silver D, Lieff SA, Pagán JA. State paid sick leave and paid sick-leave preemption laws across 50 U.S. states, 2009–2020. American Journal of Preventive Medicine. 2022;62(5):688-695.
47 Urban-Boyens 2022a - Boyens C, Raifman J, Werner K. Out sick without pay: Missed wages and worker absences during the COVID-19 pandemic. Washington, D.C.: Urban Institute; 2022.
48 NPWF-HFA 2022 - National Partnership for Women & Families (NPWF). The Healthy Families Act (HFA). 2022.
49 Rauhaus 2021 - Rauhaus BM, Johnson AF. Social inequities highlighted by the prolonged pandemic: Expanding sick leave. Journal of Public and Nonprofit Affairs. 2021;7(1):154-163.
50 Johnson 2022 - Johnson CY, Said K, Price AE, Darcey D, Østbye T. Paid sick leave among U.S. private sector employees. American Journal of Industrial Medicine. 2022;65(9):743-748.
51 Hegland 2022 - Hegland TA, Berdahl TA. High job flexibility and paid sick leave increase health care access and use among U.S. workers. Health Affairs. 2022;41(6):873-882.
52 Stoddard-Dare 2018 - Stoddard-Dare P, DeRigne L, Quinn L, Mallett C. Paid sick leave status in relation to government sponsored welfare utilization. American Journal of Orthopsychiatry. 2018;88(5):608-615.
53 Yearby 2020 - Yearby R. Structural racism and health disparities: Reconfiguring the social determinants of health framework to include the root cause. Law, Medicine & Ethics. 2020;48(3):518-526.
54 Brookings-Ross 2019 - Ross M, Bateman N. Meet the low-wage workforce. Washington, D.C.: Brookings Institution; 2019.
55 CLASP-Maye 2021a - Maye A, Banerjee A. The struggles of low-wage work. Washington, D.C.: Center for Law and Social Policy (CLASP); 2021.
56 Urban-Marotta 2019 - Marotta J, Greene S. Paid sick days: What does the research tell us about the effectiveness of local action? Washington, D.C.: Urban Institute; 2019.
57 Melton-Fant 2022 - Melton-Fant C. New preemption as a tool of structural racism: Implications for racial health inequities. Journal of Law, Medicine & Ethics. 2022;50(1):15-22.
58 ChangeLab-Haddow 2020 - Haddow K, Adler S, de Guia S. Preemption, public health, and equity in the time of COVID-19. ChangeLab Solutions. 2020.
59 Carr 2020 - Carr D, Adler S, Winig BD, Montez JK. Equity first: Conceptualizing a normative framework to assess the role of preemption in public health. Milbank Quarterly. 2020;98(1):131-149.
Related What Works for Health Strategies
To see citations and implementation resources for this strategy, visit:
countyhealthrankings.org/strategies-and-solutions/what-works-for-health/strategies/paid-sick-leave-laws
To see all strategies:
countyhealthrankings.org/whatworks