The United States remains the only high-income country that does not guarantee workers the right to earn paid sick leave at the national level. The result is a patchwork: as of 2025, fifteen states and the District of Columbia, along with more than a dozen major cities, have enacted paid sick leave laws; the remaining thirty-five states have not, and fourteen of those have enacted preemption laws that prohibit localities from enacting sick leave requirements within their borders. Approximately 23 percent of private-sector workers — and 46 percent of workers in the lowest income quartile — have no access to paid sick leave. The distributional pattern maps consistently onto race, sector, and income: restaurant, retail, home care, and agricultural workers — who are disproportionately workers of color and immigrant workers — have the lowest rates of paid sick leave access.
The public health consequences of this distributional pattern became graphically visible during the COVID-19 pandemic. Workers without paid sick leave reported to work while symptomatic at significantly higher rates than workers with paid sick leave, and counties with lower rates of paid sick leave access showed higher rates of community COVID transmission in the pandemic's early phase. This was not a new finding: pre-pandemic research had documented the relationship between lack of sick leave and influenza transmission — a 2014 study estimated that mandatory paid sick leave would have reduced influenza incidence by approximately 5 percent nationally. The mechanism was direct: workers who cannot afford to miss a shift work sick, and workers who work sick infect coworkers and customers.
The policy design of paid sick leave laws involves several dimensions. Accrual versus immediate availability: most laws require workers to accrue sick leave at a rate of one hour per thirty or forty hours worked, meaning that new hires have limited accrued leave; some jurisdictions provide immediate availability. Covered purposes: laws vary in whether sick leave can be used only for the employee's own illness or also for care of a sick family member, for preventive care, for reasons related to domestic violence or stalking, and for public health emergencies including quarantine orders. Small business exemptions: many laws exempt employers below a threshold number of employees (five, ten, or fifteen) or provide smaller accrual rates for smaller employers. Carryover and use-it-or-lose-it provisions affect how much leave workers can accumulate over time. Annual caps range from twenty-four hours (three days) in some jurisdictions to eighty hours (ten days) in others.
The economic literature on paid sick leave's effects has grown substantially since the Connecticut law (2012) — the first mandatory state paid sick leave law — and particularly since San Francisco's 2007 ordinance (the first local law). Findings are largely consistent: employer costs are smaller than pre-legislation predictions. The primary mechanism is that sick leave reduces presenteeism costs (the productivity loss from workers present but ill) and reduces turnover, both of which offset the direct cost of paid leave days. In food service and retail, where illness transmission to customers is particularly costly, employers in sick-leave jurisdictions have reported reduced customer complaints about employee illness. Worker outcomes show wage benefits beyond the direct value of sick days — workers in covered firms show lower turnover, higher tenure, and slightly higher wages, consistent with the prediction that mandatory benefits improve match quality and worker retention.
The preemption landscape is a consequential political geography. The preemption wave — in which state legislatures controlled by Republican majorities passed laws stripping municipalities of the power to enact worker protections stronger than state minimums — accelerated after 2014, following successful local sick leave ordinances in several Southern cities. The cities of Birmingham, Alabama; Austin, Texas; and multiple Florida cities enacted paid sick leave laws that were subsequently invalidated by state preemption statutes. The political logic of preemption is to protect business interests at the state level against urban majorities that might otherwise enact more protective local regulation, while maintaining the rhetorical position of opposing federal action on the ground of state autonomy. The result is that workers in cities with the political majority to enact sick leave protections are denied those protections by state legislatures representing different geographic and political majorities.
Federal action has been intermittently proposed. The Healthy Families Act, first introduced in 2004, would require employers with fifteen or more employees to provide seven paid sick days annually. It has been reintroduced in every Congress since without advancing. The Emergency Paid Sick Leave Act (2020), enacted as part of the Families First Coronavirus Response Act, was the first federal paid sick leave requirement in American history, providing two weeks of emergency paid sick leave for COVID-related absences at employers with fewer than 500 employees, with a tax credit mechanism for covered employers. Its expiration in December 2020 ended the first (and as of 2025, only) episode of federal paid sick leave coverage in American history.
The demographic distribution of sick leave access is both a cause and a consequence of broader labor market inequality. Workers in professional and managerial occupations have sick leave access rates above 95 percent; workers in food service have access rates below 30 percent. Because professional workers are disproportionately white and food service workers are disproportionately workers of color, the racial distribution of sick leave access reflects and reinforces occupational segregation. The COVID-19 pandemic made this racial dimension visible in terms of infection and mortality rates: Black and Latino workers were disproportionately represented in essential services employment without sick leave, and disproportionately died of COVID-19. The connection between policy design, racial equity, and public health is direct and documented.
The political economy of sick leave legislation reflects a recurring pattern in American labor policy: the states with the lowest rates of worker protection tend to have the strongest employer political mobilization, the weakest union presence, and the largest shares of low-wage service sector employment — the workers whose need for sick leave is greatest. Breaking this political economy requires either federal floor-setting legislation or the kind of cross-jurisdictional competitive pressure that would make sick leave economically rational for employers even absent a mandate. Some evidence suggests that the latter is occurring in tight labor markets, where employers increasingly offer sick leave as a recruitment tool — but this competitive dynamic operates only in high-employment conditions and does not reach workers in monopsony-constrained labor markets.