Paid sick leave laws

Evidence Rating  
Some Evidence
Evidence rating: Some Evidence

Strategies with this rating are likely to work, but further research is needed to confirm effects. These strategies have been tested more than once and results trend positive overall.

Health Factors  
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? This strategy is rated some evidence.

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).


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1 US DOL-PSL - US Department of Labor (US 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. US 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 US workers. Vaccine. 2018;36(48):7316-7323.

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22 Wilson 2014 - Wilson FA, Wang Y, Stimpson JP. Universal paid leave increases influenza vaccinations among employees in the US. 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 US 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 US workers. American Journal of Preventive Medicine. 2017;53(2):216-224.

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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.

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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.

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51 Hegland 2022 - Hegland TA, Berdahl TA. High job flexibility and paid sick leave increase health care access and use among US 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, DC: Brookings Institution; 2019.

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56 Urban-Marotta 2019 - Marotta J, Greene S. Paid sick days: What does the research tell us about the effectiveness of local action? Washington, DC: 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.

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