Paid Sick Leave

Paid sick leave is earned time off that an employee may take for short-term mental or medical illness, injury, medical treatment, or preventive healthcare for themselves or a family member. Many sick leave mandates also allow employees to use earned sick time when absence is necessary because of domestic violence, sexual assault, harassment, or stalking.

Paid sick leave policies can provide economic security to workers and their families by preventing lost pay and job separation when employees miss work due to sickness. Additionally, paid sick leave policies can mitigate the spread of contagious illnesses by encouraging workers to stay home when sick. Not all employers offer paid sick leave benefits, and of those that do, many exclude part-time workers. Several state and local jurisdictions have enacted paid sick leave mandates to ensure more equitable access to leave-taking. Though mandates vary in requirements, workers typically begin accruing paid sick leave hours on their first day of employment, but usually must wait to use the hours until the end of a probation period. The rate of accrual varies, but most mandates require a minimum of 1 hour of sick leave earned per 30 hours worked.² State mandates allow employers to cap the number of hours earned and many allow employers to choose whether unused hours can carry over to the next year. Most state mandates cover all employees working in the state, though many have exemptions for small businesses or specific industries, such as nonprofit organizations.

The United States has no permanent federal mandate for paid sick leave, which makes the US one of only two countries, including the Republic of Korea, in the Organisation for Economic Co-operation and Development (OECD) without a national paid sick leave policy. The US Family and Medical Leave Act (FMLA) requires employers to offer up to 12 weeks unpaid leave for medical purposes. However, firm size and work history requirements preclude some employees from taking time off through the FMLA. Additionally, the Families First Coronavirus Response Act (FFCRA) temporarily mandates up to two weeks paid time off at the employee’s regular rate of pay for workers who must quarantine due to COVID-19. This act is set to expire December 31, 2020.³

Who Is Affected by Paid Sick Leave?

Although many employers offer paid sick leave benefits in the absence of a state mandate, approximately 24 percent of workers in the US lacked access to paid sick leave in 2019, according to the Bureau of Labor Statistics.⁴ Access varies based on the sector and industry of employment. State and local government workers are more likely to have access than private sector workers.⁴ Workers in the occupations of production, retail, construction, farming, and serviceⁱ are the least likely to have access to paid sick leave.⁵ Hispanic workers are overrepresented in these occupations and are the least likely group across race and ethnicity to have paid sick leave – only 46 percent.^6,8 Among other race and ethnicity groups, the gaps are smaller. 62 percent of Black workers and 53 percent of American Indian or Alaskan Native workers have access to paid sick leave, compared with 63 percent of White workers.⁶

Workers of low socioeconomic status are most likely to benefit from a paid sick leave mandate. Workers in the lower end of the wage distribution are the least likely to have access – only 51 percent of workers in the bottom quarter of earnings and 31 percent in the lowest-earning decile have access.⁴ Because many employers only offer leave benefits to full-time employees, only 43 percent of part-time employees have paid sick leave benefits.⁶ Low-income households have less of a financial buffer when they must take unpaid time off work for well-visits or illness.

Access to paid sick leave among men and women is equal across all ethnic groups when grouped together; however, when the data are broken down by race/ethnicity, differences between gender are present. Women are more likely than men to have paid sick leave access among Hispanic and Black workers. White men are more likely to have access compared with White women.⁶

What Are the Funding Options for Paid Sick Leave?

Paid sick leave benefits are funded by employer payroll contributions and are usually compensated at the normal rate of pay and capped at 5 to 10 days per year.² The federal Families First Coronavirus Response Act provides a tax credit to employers to offset the costs of providing paid sick leave, though no state policy has currently adopted an employer tax credit.³

1. “Service Occupations” includes workers in Food and Beverage Preparation (e.g., hostesses, bartenders, cooks), Health Service (e.g., home health aides, dental assistants), Cleaning and Building Service, and Personal Service (e.g., hairdressers, recreation attendants, child care workers)

Parents play a critical role in the health of their young children. Parents are responsible for ensuring their children receive vaccinations and other preventive health care, as well as timely medical treatment. Children are dependent on parents to provide the support necessary for a healthy recovery as parents are responsible for managing medications and daily care when children are too sick to attend child care or school. Preventive care such as well-child visits are also essential for monitoring growth and getting on-time vaccinations. Parents with access to paid sick leave may be more likely to be healthy themselves, and therefore better able to care for their children.

Parents need time off work to take their children to these critical health appointments, and parents’ ability to make these appointments may depend on workplace factors such as access to paid sick leave. Workers without paid sick leave may avoid taking time off if it means going without pay. Additionally, workers may fear job retaliation by employers for taking unpaid sick leave, such as through job loss or negative performance reviews. Access to paid sick leave provides job protection and a stable income to parents when they need to stay home to care for a sick child or take a child for well-visits.

Historically, most of the research on paid sick leave has focused on employer-based policies and the economic impacts on income and employment.^{9, 10, 11, 12, 13} Very limited research, until the past decade, has examined how state mandated paid sick leave affects access to leave-taking and employee health outcomes. More strong causal studies are needed to show the impact of paid sick leave on access to well-visits and potential health outcomes for parents and children. Because research that focuses on parent and child outcomes is still limited, the strong causal studies included in this review focus on working adults approximately ages 18 to 64, some of whom may be parents. Additionally, many of the studies relied on surveys that gathered self-reported data, which may lead to inaccuracies if respondents do not remember details clearly.

The research discussed here meets our standards of evidence for being methodologically strong and allowing for causal inference, unless otherwise noted. Each strong causal study reviewed has been assigned a letter, and a complete list of causal studies can be found at the end of this review, along with more details about our standards of evidence and review method. The findings from each strong causal study reviewed align with one of our eight policy goals from Table 1. The Evidence of Effectiveness table below displays the findings associated with paid sick leave (beneficial or equivalent, null, or detrimental) for each of the strong studies (A through J) in the causal studies reference list, as well as our conclusions about the overall impact on each studied policy goal.

Outcomes are classified as “beneficial or equivalent” rather than “null” in our table if a better or equivalent outcome between the treatment and control groups was achieved and was an expected outcome in the study’s hypothesis. For example, if the mandate of paid sick leave was hypothesized to produce detrimental outcomes (e.g., on wages) but a study found equivalent outcomes to states without a mandate of paid sick leave, that would be considered a “beneficial or equivalent” outcome. On the other hand, if a paid sick leave mandate was intended to produce better outcomes than states without a paid sick leave but failed to do so, then the finding is classified in our table as “null” rather than “beneficial or equivalent.” The assessment of the overall impact for each studied policy goal weighs the timing of publication and relative strength of each study, as well as the size and direction of all measured indicators.

Table 2: Evidence of Effectiveness for Paid Sick Leave by Policy Goal

 ^ Trending indicates that the evidence is from fewer than two strong causal studies or multiple studies that include only one location, author, or data set.

Access to Needed Services (Leave-Taking)

Because many paid sick leave mandates have exemptions for small businesses and specific industries, research has evaluated whether mandates affect coverage rates of paid sick leave benefits. Three studies found that paid sick leave mandates increased access to paid sick days.^C,D,F A 2020 study found that state-level mandates increased coverage rates of employees by 13 percentage points (from a baseline of 66 percent) in the 4 years following passage.^D A 2020 Washington study found coverage increased 28 percentage points compared to control states.^F A 2020 study that focused on state and local paid sick leave policies compared urban counties with and without mandates and found that mandates increased access by more than 8 percentage points in the treatment counties compared to counties where no mandate existed.^C

Because workers must earn and accrue sick time before they can take it, use of earned days increases linearly in the years post-mandate.^D Three studies found paid sick leave mandates result in a clear increase in leave-taking. The 2020 multi-state mandate study found an increase in leave-taking of approximately 2 additional sick days per year.^D The Washington study found that post-mandate the likelihood of workers working while sick decreased by 8 percentage points compared to control states.^F A 2020 study found mandates increased the likelihood of newly-covered employees using a sick day for themselves or a family member by approximately 3.4 percentage points compared to employees with a high likelihood of pre-mandate coverage.^C

Parents’ Ability to Work

One study found that paid sick leave reduced job separation, including job-to-job turnover as well as job-to-unemployment. A 2013 study of employer-based (not mandated) policies found that paid sick leave decreased the probability of job separation by 2.5 percentage points.^B A subgroup analysis within that study found that the effect of paid sick leave on reducing job separation is greater for workers without paid vacation, parents, and mothers compared to workers with paid vacation, nonparents, and fathers. The coefficient estimate was only significant for mothers and three times larger for mothers than fathers.^B

Because of fears that paid sick leave mandates may negatively impact the labor market by causing employers to decrease hiring or work hours offered,^G null impacts on employment may be considered a positive outcome. Two studies found null outcomes for employment. A 2020 study on the labor market effects of paid sick leave mandates found no evidence that employment significantly decreased or increased post-mandate.^I A 2015 study of Connecticut’s paid sick leave law evaluated the effect of the mandate on labor force participation, employment, and hours worked. Once adjusted for controls, the results were statistically insignificant.^G

Sufficient Household Resources

Some economists have predicted employers will decrease wages in response to increased benefit costs because of paid sick leave mandates. However, one multi-city and state quasi-experimental study of the US labor market effects of paid sick leave mandates did not find significant evidence that wages substantially decreased (or increased) after the enactment of paid sick leave mandates.^I Wage decreases of 3 percent or greater (the amount estimated to offset the costs of the new benefits) in jurisdictions post-mandate were statistically insignificant.^I A lack of change in wages in this case is a positive outcome because employers are not passing on the cost of the new benefit to employees by decreasing wages.

Parental Health and Emotional Wellbeing

Three studies found decreases in rates of illness for workers after enactment of paid sick leave laws.^A,E,J The research in these studies focuses on workers, some of whom are parents, but more research is needed that focuses specifically on parental health. A Connecticut study found the rate of occupational injuries and illnesses decreased by 17.8 percent within the service industry and by 6.8 percent in other occupations after the enactment of a paid sick leave mandate.^A This rate is compared with a 12.9 percent decline in the service industry in New York which did not have a paid sick leave policy at the time of the study and the US overall with a decline of 7.8 percent.^A A 2020 study focusing on positive health externalities found that state paid sick leave mandates decreased influenza-like illness by 28 percent.^E This decrease was based on a baseline rate of 1.9 confirmed cases per 100 patients that decreased by 0.53 cases per 100 patients. A 2020 study on the effect of the emergency sick leave provision of the federal Families First Coronavirus Response Act (FFCRA) found that states where workers newly gained access to paid sick leave saw a 56 percent decrease in COVID-19 cases post-FFCRA compared with states that already had access to paid sick leave.^J

One study found null impacts of paid sick leave policies on work-life conflict. The study measured work-life conflict in three ways: employees having enough flexibility in their schedules to deal with personal and family matters, if the respondent’s work schedule caused stress to themselves or their family, and the combination of those two responses.^F These variables most closely capture the dimension of work–life conflict that paid sick leave might help to mitigate. The outcomes were in the positive direction but not statistically significant.

Optimal Child Health and Development

No strong, causal studies were identified that examined child health outcomes. However, one widely cited study found positive associations between paid sick leave and use of health care services for children.⁷ Because this study relied on cross-sectional surveys with no time distinction between treatment and outcome, it did not meet our standards for causal evidence. However, it does suggest a correlation between children with parental access to paid sick leave and improved preventive care. Children with parental access to paid sick leave were 12.5 percent more likely to receive flu vaccinations and 13.2 percent more likely to receive annual medical checkups than children whose parents lacked paid sick leave.⁷

Parents without access to paid sick leave may delay a child’s care when doctor’s office operating hours do not align with the parent’s hours off work. The correlational study found access to paid sick leave decreased the odds of delaying medical care because of a time mismatch by 13.3 percent and lowered the odds of an emergency room visit by 53.6 percent.⁷

Because paid sick leave mandates may especially benefit workers of low socioeconomic status and workers in production, retail, construction, farming, and service industries, such policies may have the potential to reduce socioeconomic disparities. In the research included in this review, study results were not broken down to show differential effects by race, ethnicity, gender, or socioeconomic status, so further research is needed.

Two studies evaluated the return on investment for paid sick leave and found mixed impacts. One study that focused on paid sick leave mandates across the US found a small increase in costs for employers, but overall aggregate improvements in productivity and employee satisfaction.^D The mandates increased total costs by “10% to $610 per job and year” (pp. 17).^D Overall, sick pay was found to have widespread beneficial effects. A 2018 study that evaluated sick leave mandates in the District of Columbia and Connecticut found that paid sick leave policies decreased the aggregate rate of leave-taking for illness across the workplace. For each percentage point increase in the share of workers with access to paid sick leave, the aggregate illness-related leave-taking rate decreased 0.13 percentage points across the workplace.^H Workers with paid sick leave may be more likely to stay home when sick, and therefore less likely to spread their illness to coworkers or customers. A more comprehensive analysis of the return on investment is forthcoming.

Because most paid sick leave mandates were enacted fairly recently, some research exists on the short-run economic effects, but data on long-term effects is lacking. Additionally, the majority of current studies focus on worker absenteeism and presenteeism (working while sick), resulting in limited evidence on the effect of paid sick leave access on health care utilization and health behaviors. The research in this review focuses on workers, some of whom are parents, but more research is needed that focuses specifically on the effects of work/life stress and child health outcomes.

City and state paid sick leave mandates vary in the amount of paid leave offered – generally employees earn 1 hour for every 30 to 50 hours worked.² More research is needed to determine what threshold is most effective.

The evidence demonstrates that paid sick leave policies are effective for increasing leave-taking and improving adult health. Paid sick leave policies enable workers to take paid sick time without fear of job loss or wage suppression. By allowing workers to stay home when they or their child is sick, rates of illness and injury decrease. State paid sick leave policies are not yet tracked as part of the Prenatal-to-3 State Policy Roadmap because of the need for further study on how paid sick leave affects the prenatal-to-3 period. More research is needed that focuses on how state paid sick leave policies affect parents (not workers in general), infants, and young children.

Since 2011, 13 states and DC have passed legislation to require employees to provide paid sick leave to their employees.² All state mandates require employers to provide paid time off on an accrual basis, but state policies vary in their coverage and benefits.

There is variation in the coverage provided by the mandates by sector, industry, and employer-size. Many states cover both public and private employers; however, some only cover private-sector employers. A few states have exemptions for occupations such as students, non-profit organizations, and day laborers. Connecticut is unique because, rather than exempt one sector, the law is aimed only at service workersⁱⁱ in workplaces with more than 50 employees.² A few states require statewide coverage regardless of employer size but most have exemptions for smaller businesses. The threshold for exempt employer size varies from those with fewer than 10 to fewer than 100 employees.

All states mandate a minimum accrual rate at which employers must provide paid time. The majority of states require 1 hour of earned paid sick time for every 30 hours worked, but the rates vary up to 1 hour per 50 hours worked. The accrual rate can also vary by employer size. Current policies also mandate a minimum amount of earned paid sick leave that an employer is required to pay per year, usually up to 40 hours, but flexibility is given to the employer to offer more generous rates.

Table 3: State Variation in Paid Sick Leave Policies

Policy adoption status data: As of July 16, 2020. Paid sick time laws. (2020). A Better Balance. https://www.abetterbalance.org/paid-sick-time-laws/

2. Defined by state statute as an employee primarily engaged in an occupation with one of the “broad or detailed occupation code numbers and titles, as defined by the federal Bureau of Labor Statistics Standard Occupational Classification system.”

Method of Review

This evidence review began with a broad search of all literature related to the policy and its impacts on child and family wellbeing during the prenatal-to-3 period. First, we identified and collected relevant peer-reviewed academic studies as well as research briefs, government reports, and working papers using The University of Texas at Austin library system and the Google Scholar search engine. These databases allowed us to identify literature from journals such as the American Journal of Public Health, Work and Occupations, the American Journal of Industrial Medicine, and Labour Economics, among others. We used the following key terms to identify literature relevant to paid sick leave in the prenatal-to-3 period:

Paid sick leave and paid sick time paired with: policy, state policy, specific state names and legislative acts, parents, equity, disparities

From this search, we reviewed 70 study abstracts to determine relevance for our population of interest and research questions. We excluded 30 studies from the set of 70 based on geography (outside of the United States) or because the study was clearly qualitative and did not attempt to draw a causal link between paid sick leave and our outcomes of interest. We carefully reviewed the remaining 40 articles and excluded 30 of them for one or more of the following reasons: the study was published prior to 2012 (the effective year of the first state paid sick leave mandate), the study investigated unpaid sick leave or non-mandated leave only, or the study’s methodology was not sufficiently rigorous to allow for a causal inference. We reviewed the 10 remaining quasi-experimental studies to develop our conclusions about policy effectiveness and used the other literature to inform our understanding of paid sick leave policies that warrant further rigorous evaluation. All studies considered to date for this review were released on or before October 15, 2020.

Standards of Strong Causal Evidence

When conducting a policy review, we consider only the strongest studies to be part of the evidence base for accurately assessing policy effectiveness. A strong study has a sufficiently large, representative sample, has been subjected to methodologically rigorous analyses, and has a well-executed research design allowing for causal inference—in other words, it demonstrates that changes in the outcome of interest were likely caused by the policy being studied.

The study design considered most reliable for establishing causality is a randomized control trial (RCT), an approach in which an intervention is applied to a randomly assigned subset of people. This approach is rare in policy evaluation because policies typically affect entire populations; application of a policy only to a subset of people is ethically and logistically prohibitive under most circumstances. However, when available, randomized control trials are an integral part of a policy’s evidence base and an invaluable resource for understanding policy effectiveness.

The strongest designs typically used for studying policy impacts are quasi-experimental designs (QEDs) and longitudinal studies with adequate controls for internal validity (for example, using statistical methods to ensure that the policy, rather than some other variable, is the most likely cause of any changes in the outcomes of interest). Our conclusions are informed largely by these types of studies, which employ sophisticated techniques to identify causal relationships between policies and outcomes. Rigorous meta-analyses with sufficient numbers of studies, when available, also inform our conclusions.

Studies That Meet Standards of Strong Causal Evidence

1. Hawkins, D., & Zhu, J. (2019). 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, 62(10), 859–873. https://doi.org/10.1002/ajim.23028
2. Hill, H. D. (2013). Paid Sick Leave and Job Stability. Work and Occupations, 40(2), 143–173. https://doi.org/10.1177/0730888413480893
3. Callison, K., & Pesko, M. F. (2020). The Effect of Paid Sick Leave Mandates on Coverage, Work Absences, and Presenteeism. Journal of Human Resources, 1017-9124R2. https://doi.org/10.3368/jhr.57.4.1017-9124r2
4. Maclean, J. C., Pichler, S., & Ziebarth, N. R. (2020). Mandated sick pay: Coverage, utilization, and welfare effects (No. w26832). National Bureau of Economic Research. https://www.nber.org/papers/w26832
5. Pichler, S., and Wen, K., and Ziebarth, N.R. (2020). Positive Health Externalities of Mandating Paid Sick Leave. (IZA Discussion Paper No. 13530).Institute of Urban Economics. https://ssrn.com/abstract=3660277
6. Schneider, D. (2020). Paid Sick Leave in Washington State: Evidence on Employee Outcomes, 2016–2018. American Journal of Public Health, 110(4), 499–504. https://doi.org/10.2105/ajph.2019.305481
7. Ahn, T., & Yelowitz, A. (2015). The short-run impacts of Connecticut’s paid sick leave legislation. Applied Economics Letters, 22(15), 1267–1272. https://doi.org/10.1080/13504851.2015.1023934
8. Stearns, J., & White, C. (2018). Can paid sick leave mandates reduce leave-taking? Labour Economics, 51, 227–246. https://doi.org/10.1016/j.labeco.2018.01.002
9. Pichler, S. & Ziebarth, N. R., (2020). Labor market effects of US sick pay mandates. The Journal of Human Resources, 55(2). https://doi.org/10.3368/jhr.55.3.0117-8514R2
10. Pichler, S., Wen, K., & Ziebarth, N.R. (2020). COVID-19 Emergency Sick Leave has helped flatten the curve in the United States. Health Affairs, 39(12), 1-6. https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2020.00863

Other References

1. Shonkoff, J., & Phillips, D. (2000). From neurons to neighborhoods: The science of early childhood development. Washington, DC: The National Academies Press. https://doi.org/10.17226/9824.
2. Paid sick time laws. (2020). A Better Balance. https://www.abetterbalance.org/paid-sick-time-laws/
3. Families First Coronavirus Response Act: Employer Paid Leave Requirements (2020). US Department of Labor. https://www.dol.gov/agencies/whd/pandemic/ffcra-employer-paid-leave
4. Paid sick leave benefits factsheet. (2020, March 16). Bureau of Labor Statistics. https://www.bls.gov/ncs/ebs/factsheet/paid-sick-leave.htm#ref1
5. 94 percent of managers, 56 percent of construction and extraction workers had paid sick leave, 2019. (2020, March 5). The Economics Daily: Bureau of Labor Statistics. https://www.bls.gov/opub/ted/2020/94-percent-of-managers-56-percent-of-construction-and-extraction-workers-had-paid-sick-leave.htm
6. Institute for Women’s Policy Research. (2016). Paid Sick Days Access and Usage Rates Vary by Race/Ethnicity, Occupation, and Earnings (IWPR #B356). https://iwpr.org/wp-content/uploads/2020/08/B356-paid-sick-days.pdf
7. Asfaw, A., & Colopy, M. (2017). Association between parental access to paid sick leave and children’s access to and use of healthcare services. American Journal of Industrial Medicine, 60(3), 276–284. https://doi.org/10.1002/ajim.22692
8. Employed persons by detailed industry, sex, race, and Hispanic or Latino ethnicity. (2020, January 22). Bureau of Labor Statistics. https://www.bls.gov/cps/cpsaat18.htm
9. Gilleskie,D.(2010). Work absences and doctor visits during an illness episode: The differential role of preferences, production, and policies among men and women. Journal of Econometrics 156(1), 148–163.
10. Gilleskie, D. B. (1998). A dynamic stochastic model of medical care use and work absence. Econometrica 66(1), 1–45.
11. Pauly, M.V. (1974).Overinsurance and public provision of insurance: the roles ofmoral hazard and adverse selection. Quarterly Journal of Economics. 88 (1), 44–62.
12. Pauly, M.V., Nicholson, S., Polsky, D., Berger, M.L., Sharda, C., (2008). Valuing reductions in on-the-job illness: ‘presenteeism’ from managerial and economic perspectives. Health Economics. 17 (4), 469–485.
13. Chatterji, M., Tilley, C.J. (2002). Sickness, absenteeism, presenteeism, and sick pay. Oxford Economic Papers. 54, 669–687.