Paid family and medical leave is receiving increased attention in the United States by policymakers, employers, media, and the public. Former President Barack Obama discussed the issue at his 2015 State of the Union Address, and the 2016 presidential election broke new ground with candidates from both major parties (Democratic candidate and former Secretary of State Hillary Clinton and Republican candidates Sen. Marco Rubio (R-FL) and now-President Donald Trump) including proposals for paid leave in their campaigns. Employer initiatives to introduce and expand leave coverage have also been widely reported in the media, and recent polls also indicate widespread public support.¹

Paid family and medical leave includes several distinct types of leave. Medical leave is taken from work to care for one’s own serious illness, but family leave encompasses several distinct types of leave, including leave to care for a newborn or newly adopted child (generally referred to as parental leave), as well as leave to care for a family member with a serious illness, whether that be a spouse, domestic partner, child, parent, or other relative. This latter type of leave is our definition of family care leave—the focus of this report.

In contrast to other types of leave—in particular, parental leave, which has been studied extensively—family care leave receives much less attention in existing research. Its inclusion in policy proposals is also uneven. While each of the paid family and medical leave laws at the state level includes family care leave, national proposals diverge on this point. Unlike those proposed by President Obama and Secretary Clinton, the family leave provisions proposed by President Trump and Sen. Rubio focus exclusively on parental leave and do not include benefits for employees who need leave to care for a seriously ill family member.

Yet the unmet need for leave to care for a family member with a serious illness is actually more widespread and more frequent than it is for the other types of family leave.² This is why its relative neglect in research and its uneven treatment by policymakers is all the more striking. For these reasons, this paper focuses on reviewing what we know and do not know about family care leave. In particular, this paper contributes to an understanding of the need for paid leave to care for a seriously ill family member and the current state of policy and research. In doing so, we draw on the best available research on family care leave where available, but because such research is often lacking, we also draw on evidence about family and medical leave more generally when necessary.

We begin this report with a discussion of why paid family care leave is important. We then review the evidence on who needs this type of leave and the current policy situation in the United States. We next turn to a discussion of the consequences of the lack of paid family care leave coverage, potential policy responses, and potential costs. We then conclude with a summary and implications for policy and future research. We also include an appendix on what other countries do for family care leave.

Employees often face the challenge of balancing work and family responsibilities. In the United States, federal workplace policies were first established based on 1930s-era expectations of stay-at-home mothers, which still limit family leave options today and exacerbate the challenge of balancing work and family.³

Today’s two-parent families are more likely to have two wage earners at their helm than a breadwinner and a stay-at-home caregiver, and more families are headed by single parents.⁴ But federal policy has yet to account for the gaps created by these transitions. As a result, employees whose family members develop serious health conditions often must choose between taking time off from work to care for their loved ones or keeping their jobs. Such situations pose a dilemma for employers as well because providing paid leave would be costly but could also yield benefits in terms of employee retention and productivity.

The Family and Medical Leave Act of 1993 is the only piece of federal legislation in the United States to confront this type of work-family conflict. FMLA entitles employees to unpaid time off from work for approved family and medical reasons, including the need to care for a seriously ill family member.⁵ But because the law does not provide paid leave (and because of other limitations that will be discussed later in this report), FMLA leaves many employees with no viable solution when their family members become seriously ill.

Who needs leave to care for a seriously ill family member?

It is difficult to determine the exact number of working Americans who might need paid family care leave, but existing evidence suggests that such need is quite prevalent. The most recent nationally representative survey on leave, conducted by the Pew Research Center in 2017, found that almost half of working adults ages 18 to 70 in the United States expressed the need for leave to care for a seriously ill family member, with 23 percent saying they had taken leave of this kind during their employment tenure and 25 percent saying they had not yet taken leave of this kind but believed they would do so in the future.⁶

The Pew Research survey suggests that many members of the U.S. workforce who need to take family care leave have been unable to do so. This study and many others refer to workers’ inability to take leave when needed as unmet need. Unmet need for family care leave is particularly prevalent. While during the 2 years prior to the Pew 2017 survey only 4 percent of respondents experienced unmet need for parental leave, 10 percent of respondents said they needed to take leave to care for a seriously ill family member but were unable to do so.⁷

There is also considerable evidence of racial and economic disparities in leave-needing and leave-taking. Looking at all types of family and medical leave combined,⁸ the Pew Research study finds that 26 percent of black workers and 23 percent of Hispanic workers experienced unmet need for leave during the 2 years prior to the survey, compared with 13 percent of white workers.⁹ Disparities by income are also striking: 30 percent of respondents with annual incomes less than $30,000 report unmet need for leave of all types, compared to only 14 percent of respondents with incomes more than $30,000.¹⁰

These findings are particularly salient, given that people of color and low-income people are more likely to suffer from serious medical conditions.¹¹ Moreover, limited access to adequate nutrition or healthcare and increased contact with unsafe environments or workplaces—all of which often accompany low-income work-life experiences—lead to a heightened risk of illness.¹² As a result, those needing leave to care for a seriously ill family member are more likely themselves to be low-income people or people of color and are more likely to experience unmet need for leave.

In the United States, the only federal law that addresses the need for leave is the Family and Medical Leave Act. FMLA offers up to 12 weeks of unpaid leave during any 12-month period for employees who need time off to give birth to a child, bond with a new child (whether it be a biological, adopted, or foster child), care for a family member’s military-related issue, care for their own serious health condition, or care for the serious health condition of a spouse, child, or parent.¹³ The law defines a serious health condition as one that requires ongoing treatment or inpatient care.¹⁴

Employees claiming leave through FMLA are guaranteed job protection, meaning that they must be given the same job (or a position that is comparable in terms of pay and benefits, deemed an “equivalent job”) when they return from leave.¹⁵ The law additionally entitles employees to the same health insurance coverage that they received prior to their leave, assuming that the employee continues to pay his or her regular contributions during leave.¹⁶ As noted above, FMLA leave is unpaid (unless an employee has access to payment through another source such as an employer-provided policy or a state paid leave policy).

Although passage of the Family and Medical Leave Act represented a major advance relative to the status quo prior to its implementation, its usefulness for employees needing to care for a seriously ill family member is restricted by three major shortcomings, each discussed below.

Lack of coverage and eligibility under the Family and Medical Leave Act

The Family and Medical Leave Act exclusively covers employees who work at firms with 50 or more employees within a 75-mile radius. Moreover, employees must have worked at a covered firm for at least 12 months and have logged at least 1,250 hours during the year preceding their request in order to be eligible to claim leave through FMLA.¹⁷ As a result, only 55.9 percent of the private-sector workforce is eligible for leave under the law.¹⁸

Ineligibility under FMLA has a considerable effect on employee leave-taking, especially for employees needing family care leave. Since the enactment of the law in 1993, three nationally representative surveys of employees and employers have been carried out to assess the share of the working population needing and taking leave under it. Echoing results from the previous surveys, the most recent FMLA survey found that in the 12 months preceding the study, 22.4 percent of eligible leave-takers took leave to care for a seriously ill family member, while only 14.2 percent of ineligible leave-takers took leave of this kind.¹⁹ Employees who took leave to care for their own serious illness, however, did so at similar rates regardless of their eligibility status, and employees who took leave to attend to a new child were actually more likely than not to be ineligible for FMLA leave.²⁰ These findings suggest that eligibility status disproportionately obstructs leave-taking among those needing family care leave.

Ineligibility under FMLA additionally disproportionately affects those who need leave to care for a seriously ill family member because of the relationship between low-income status and serious illness. People who are young, Hispanic, low paid, or lack a high school degree are all less likely to be eligible for FMLA than are their counterparts because they frequently work at small firms and are often unable to maintain the same job for a year.²¹

Low-income women are even more likely to face ineligibility under the law, as they are particularly likely to be employed in part-time, unstable, or low-paying positions. Although women are less likely to voluntarily work part time than are men, they do so at far higher rates, with 25 percent of employed women and 10 percent of employed men in the United States working part time.²² The eligibility provisions of the law regarding firm size and employment tenure, therefore, prevent many low-income workers—and, in turn, many employees needing leave to care for a seriously ill family member—from accessing job-protected leave.

Reason for leave not covered by the Family and Medical Leave Act

Another important contributor to unmet need for leave, and one that primarily affects employees who need family care leave, is the law’s narrowly defined qualifying reasons. It permits employees to take unpaid leave to care for a “spouse, son, daughter, or parent who has a serious health condition,” designating a spouse as “a husband or wife as defined or recognized in the state where the individual was married.”²³ As such, the law bars employees from taking job-protected leave to care for other close family members such as siblings, grandparents, grandchildren, or even domestic partners.

Many individuals rely on extended family members for care when they are ill. Approximately 85 million Americans live with extended family members.²⁴ Additionally, increasing numbers of Americans are opting not to marry the domestic partners with whom they live and raise children.²⁵ Leave coverage limited to the traditionally defined nuclear family does not account for these American families.

Moreover, for many families, considerations such as who lives nearest to ill family members, who has the closest personal relationship to them, and who would do the best job of providing them with care all factor in heavily to care-delegation decisions.²⁶ Relatives who meet these considerations, perhaps a cousin or an aunt, may be the family’s first choice for a care provider but may not qualify under the law.

As a result, many employees likely experience barriers to caring for nonqualifying family members. While disaggregated data on the types of family members that employees need to take time off to care for is slim, there is evidence that this FMLA restriction prevents eligible individuals from taking leave or claiming the benefits of the law during their leave. The 2012 FMLA survey found that for all employees, both eligible and ineligible, 18.2 percent of people who took leave in the 12 months prior to the survey did so to care for a covered family member, including a parent, spouse, or child, while 3.3 percent did so to care for a person who did not warrant FMLA coverage.²⁷ Among employees who were covered by the law, 9.9 percent of respondents reported unmet need to take leave to care for a nonqualifying person’s health condition (5.5 percent to care for a nonqualifying relative, 2.3 percent to care for a nonqualifying nonrelative, and 1.2 percent to care for a domestic partner).²⁸

Lack of paid leave

While the above shortcomings are important, the lack of any provision for paid leave is a larger challenge. Simply put, lack of paid leave means that eligible employees often do not take leave because they are unable to forgo pay. The 2012 FMLA study found that nearly half (45.7 percent) of eligible employees who expressed an unmet need for time off did not take leave because they could not afford to do so.²⁹

While some FMLA leave-takers are paid during their time off, it is mostly those employees with banked paid sick or vacation days who receive compensation. Of those in the United States in the lowest two household income quintiles—with incomes up to about $47,000—only 15.2 percent and 43.9 percent, respectively, have access to paid sick days, and only 19.4 percent and 49.2 percent, respectively, have access to paid vacation days. This compares with 78.5 percent and 78.6 percent of employees in the top U.S. household income quintile—with incomes more than $127,000—who have paid sick days and paid vacation days, respectively.³⁰

As a result, low-income employees are more likely to be uncompensated during leave-taking despite their greater need for continued wages. Fifty-three percent of employees with income below the median family income of $62,000 in the United States who took leave received no pay during their leave, compared with 17.7 percent of those who took leave with incomes at or above the median.³¹

Indeed, a recent analysis found that even controlling for a host of differences in demographics, geography, industry, and occupation, workers who are less educated, Hispanic, and employed part time are significantly less likely than their counterparts to have access to paid leave.³² Thus, relying on employers to voluntarily provide paid leave is unlikely to address the overall shortfall in this type of leave coverage and the disparities in coverage.

The absence of paid family care leave, as well as paid family and medical leave more generally, results in numerous consequences for employees and their family members. It can contribute to an increase in employee debt and a decrease in well-being for employees and for their seriously ill family members. Moreover, the lack of paid leave may also impose costs on employers.

Without paid leave coverage, leave-needing employees may need to restructure their lives and careers around caregiving, reducing their work hours, switching to less demanding jobs, working part time, or even retiring early in order to accommodate their familial responsibilities. Needless to say, any reduction in work time due to lack of paid leave leads to a reduction in wages, employee benefits, and career advancement prospects, while early retirement reduces earnings and future Social Security benefits.³³ While such losses can pose challenges for any family, they are likely to be especially difficult for low-income families. Given that many families with seriously ill members are low income, noncovered workers who need to take unpaid leave to care for a family member’s health condition are particularly likely to experience financial strain.³⁴

Even for those covered by the Family and Medical Leave Act, leave-taking can be financially burdensome. Healthcare is expensive and can cause financial pressure, especially for families supporting a member with a serious or ongoing medical condition. As mentioned above, while some employers provide some paid leave even though the FMLA does not require it, many employees do not receive full pay during their leave, some of whom may fall below the poverty line and/or incur debt. The 2012 FMLA survey found that among FMLA-eligible employees who received partial or no pay during their time off, 32.1 percent fell behind on bills, 28.1 percent borrowed money, and 9.8 percent went on public assistance.³⁵

Predictably, workers with lower incomes are even more likely to take these actions. The 2017 Pew Research study found that 57 percent of employees with household incomes of less than $30,000 took on debt after a partially compensated or uncompensated leave period. Nearly half (48 percent) of this low-income group went onto public assistance during their leave, while 46 percent put off paying bills, and 45 percent borrowed money from family or friends.³⁶ These high rates of hardship and debt demonstrate the economic consequences of the lack of paid leave entitlements, especially for lower-income Americans.

In addition to economic hardship, employees who take unpaid time off to care for a seriously ill family member may themselves suffer health consequences. Studies find that depending on the level of social and material support that a leave-taking employee receives, caring for a family member with a serious health condition can be either very rewarding or very taxing.³⁷ A study analyzing data from the 2011 Work, Family and Community Nexus Survey suggested that compensation during leave mitigated some of the stressors of caregiving. The survey found that leave-takers who had access to compensation were less likely to experience both mental and physical health problems, compared to those without paid leave options.³⁸

Lack of paid leave coverage also can elevate risks for those in need of care. Likely in anticipation of the financial strain that a reduction in hours or early retirement might generate, many noncovered employees with seriously ill family members shorten leave periods. The FMLA survey and Pew Research study reported that 38 percent of leave-takers who received partial or no pay cut their leave short because of financial issues, while 43.3 percent reported that they would have taken more leave if they had received some pay or additional pay.³⁹ These actions can lead to adverse health consequences for seriously ill individuals.

The negative consequences of lack of paid leave coverage may extend to employers as well. While 97 percent of leave-taking employees who received full pay during their leave returned to the same job they had held prior to their leave, only 85 percent of those who received partial pay and 74 percent of those who received no pay returned to their jobs.⁴⁰ This suggests that paid leave options affect employees’ choices to stay at their jobs following time off and that employers experience less turnover when their employees are covered by paid leave benefits.

Paid leave benefits also influence where employees choose to work. When polled on enticing job benefits, more than 25 percent of Americans who are currently in the workforce or are looking to join the workforce cited paid leave as the benefit that would help them the most. This percentage shot up to 38 percent among workers who have either needed or taken leave in the past.⁴¹ These figures suggest that paid leave coverage is a powerful tool for attracting employees.

Employees also may be more productive when they are offered paid leave entitlements. When employees in the midst of family health crises come to work, they may be stressed and preoccupied. Some, as mentioned above, may even be struggling with mental health issues due to their overlapping responsibilities.⁴² This can be costly for firms, which may lose more money on employees who are not fully healthy at work than they would by covering for leave-taking employees.⁴³ Without paid leave coverage, employers may be less likely to keep their employees loyal, satisfied, and productive—all of which could lead to adverse financial consequences.

In the decades since the passage of the Family and Medical Leave Act in 1993, there have been a number of attempts to provide compensation to leave-takers, whether by expanding the law’s provisions or adopting new policies altogether.⁴⁴ In 2010, legislators suggested amendments to the law with the Family Leave Insurance Act and the Family Income to Respond to Significant Transitions Act. The former proposed establishing an insurance program that would use employee and employer payroll taxes to provide FMLA-covered employees with up to 12 weeks of compensated leave.⁴⁵ The latter proposed supplementing the law by offering federal grants to states to cover some of the costs associated with leave compensation. Neither act passed in Congress.

Since 2013, Sen. Kirsten Gillibrand (D-NY) and Rep. Rosa DeLauro (D-CT) have proposed the Family and Medical Insurance Leave, or FAMILY Act, which would, through incremental employee and employer contributions, compensate employees with 66 percent of their wages for leaves of up to 12 weeks.⁴⁶ Although the FAMILY Act does not include job protection, it does propose to expand upon FMLA eligibility by offering the paid-leave benefit to any employee who has paid into Social Security for 1 year. This act also has thus far failed in Congress.

Despite the stall in national legislation, six states and the District of Columbia have passed legislation to create paid family leave programs, which include paid family care leave, as well as paid parental leave, and four of those states have operational programs.⁴⁷ California, which passed the first such law in 2002 and implemented it in 2004, built its program into its existing State Disability Insurance system, which has long provided income support for workers on short-term medical leave. Following in California’s footsteps, New Jersey, Rhode Island, and New York implemented paid family leave programs in 2009, 2014, and 2018, respectively, each tacking the program onto their states’ disability insurance programs, called Temporary Disability Insurance.⁴⁸ These paid family leave programs in California, New Jersey, Rhode Island, and New York are completely funded by employee payroll taxes.⁴⁹

These state programs also respond to gaps in FMLA eligibility by relaxing the law’s firm-size and eligibility provisions and expanding the qualifying reasons for leave. Like the federal unpaid leave law, each state paid leave program requires that employees earn a certain amount of income during a base period prior to their leave. Unlike the federal stipulations, however, state paid leave programs do not expect employees to have earned the money through employment with one firm. The state laws also generally cover all employees regardless of firm size. As a result, state paid leave programs cover nearly all employees in their states.⁵⁰

Moreover, unlike the federal law, which limits family care leave to employees taking leave to care for a seriously ill spouse, child, or parent, under the state programs, employees can claim paid family leave to care for a seriously ill domestic partner, grandparent, and even, in certain cases, a sibling or grandchild. Given that approximately 10 percent of FMLA-eligible workers are unable to take leave because the person for whom they need to care does not qualify under the law, expanded eligibility provisions help to achieve more comprehensive leave coverage.⁵¹

The evidence thus far suggests that the state programs are popular.⁵² As of 2015, after 11 years of operation, California’s paid family leave program had served approximately 2.1 million leave-needing individuals, 200,000 of whom took leave to care for a seriously ill family member. The numbers of leave claims filed under New Jersey and Rhode Island’s programs, which were established later, are significantly lower but continue to rise annually. As of 2015, these states’ programs had served 217,000 and 13,000 employees across 7 years and 1 year, respectively.⁵³

As mentioned above, the largest body of family leave research focuses on parental leave. Results from this research suggest that the existing state paid leave programs are effective at addressing the negative consequences associated with the lack of paid leave. Studies measuring the effect of state paid parental leave programs in the United States have found that 24 percent of women who took unpaid leave used public assistance during their leave period, while only 10 percent of women on paid leave did the same. Moreover, women who were able to take paid leave were 40 percent less likely to report using food stamps than those who were unable to take paid leave.⁵⁴ While these results focus on women who took leave to care for a new child, it is likely that paid leave also reduces public assistance use among those taking leave for family care reasons.

There also is evidence from parental leave studies to suggest that state paid leave programs improve caregiver mental health. One study found that California’s paid family leave program was significantly associated with a decreased incidence of pediatric abusive head trauma, an injury that has long been linked to mental instability among new parents.⁵⁵ This finding suggests that when some of the financial stressors of leave-taking are neutralized, care providers experience better mental health outcomes, which would be expected to lead to better health outcomes for the care-needing family member.

Moreover, caregivers from California, New Jersey, and Rhode Island who were surveyed about their attitude toward their state’s paid leave options indicated that receiving monetary assistance improved their health, causing them to feel mentally and physically relieved.⁵⁶ While these results are promising, they are by no means exhaustive. More comprehensive research is needed to establish that state paid leave provisions improve mental health outcomes for leave-takers across the board.

Employer responses to paid family leave programs in California, New Jersey, and Rhode Island have been predominantly neutral or positive.⁵⁷ Although there had been some concerns before the laws came into effect about the potential costs associated with paid leave entitlements—such as increased administrative burdens or the need for firms to hire temporary replacements—the majority of employers across all states with operational paid leave programs and across all firm sizes have reported neutral or positive attitudes toward the laws.⁵⁸ In a 2011 survey analyzing the California paid family leave program, 90 percent of employers reported that the program had a neutral or positive effect on profitability, and 8.8 percent reported that the paid family leave program had saved their firm money.⁵⁹

Similarly, a study of New Jersey’s paid family leave program found that 10 perent of employers felt that the program had a negative effect on the firm’s profitability, with 80 percent reporting neutral experiences and another 10 percent reporting that the program increased profitability.⁶⁰ Research comparing employer responses before and after Rhode Island’s law came into effect found that the law had no overall impact on employers, and that two-thirds of employers were somewhat or very supportive of the law.⁶¹ A similar survey also found that two-thirds of employers in New Jersey were supportive of the law.⁶²

The lack of negative responses on the part of employers in California, New Jersey, and Rhode Island likely is because many employers are able to avoid hiring a new employee during the leave period of the absent employee and instead can distribute that leave-taker’s work to other employees.⁶³ In addition, for employers who previously relied on their own paid leave provisions, paid leave programs could potentially decrease costs by allowing the state payroll tax to foot the bill rather than paying employees themselves.

Moreover, paid leave programs seem to have had little adverse impact on productivity. The California and New Jersey surveys reported that 89 percent and 80 percent of employers felt that paid family leave had no noticeable effect or a positive effect on productivity, respectively.⁶⁴

There also is evidence that state paid leave programs improve employee retention rates. Studies find that in California, more than 80 percent of those who used the paid family leave program returned to their same position following leave. The effect on retention was particularly substantial for people in so-called low-quality jobs, who returned to their jobs nearly 10 percent more frequently than those who did not receive compensation during leave, with 82.7 percent of those who used paid family leave returning to their jobs, compared to 73.9 percent of noncompensated leave-takers.⁶⁵

There are, of course, still kinks in the state paid family leave programs that remain to be ironed out. The most glaring problem seems to be employee awareness. In California, as of 2011, more than half of those who experienced a qualifying event for leave-taking were unaware of the state’s paid family leave options.⁶⁶ Moreover, awareness is less common among those who need it most. In California, those who earn less than $15 per hour are nearly 30 percent less likely than those who earn more than $15 per hour to know about the state’s paid family leave program. Further, immigrants, Latinos, those who do not have paid sick or vacation days, those who have received less education, and those who make less than $80,000 annually are all less likely than their counterparts to be aware of California’s paid leave options.⁶⁷ Similar patterns have been noted in New Jersey.⁶⁸

Lack of awareness for these programs can perhaps be attributed to a lack of effective public outreach and education. California now has a built-in funding stream for public outreach ($6.5 million across state Fiscal Years 2014 through 2017), yet awareness levels remain low.⁶⁹ Additionally, many state paid leave programs lack advertising funds, and therefore promotion of the programs often falls to employers.⁷⁰ While some employers offer comprehensive explanations of their paid leave programs, others simply abide by the minimum legislative requirements and post informational posters in their Human Resources offices.⁷¹ Without further efforts to publicize the availability of paid leave options in California, New Jersey, Rhode Island, and New York, the programs will likely not reach all eligible employees.

Paid leave to care for a seriously ill family member is, of course, not costless. The most immediate cost are the money to cover all or part of the employee’s pay while he or she is on leave and the cost of the arrangements to cover the employee’s work. There could also be indirect costs to the employee or other employees if employers become less willing to hire workers that are likely to take leave or restrict them to particular positions or segments of the labor market.

When employers offer paid leave as an employee benefit, the employer pays the cost of that leave. Yet economic theory suggests and empirical evidence shows that if the benefits are valued by employees, then their wages can be reduced to pay for them, meaning that employees end up bearing part or all of the costs.⁷²

In contrast, when paid leave is provided through a social insurance model, as it is in the four states that have operational paid family leave programs thus far, the funding for a given employee’s leave comes from the social insurance fund rather than from the employer. Social insurance funds may be funded in a variety of ways, most typically through shared employer and employee contributions through payroll deductions. Yet in each of the states with paid family leave programs in effect to date, the contributions to state social insurance funds come from employees only. Thus, to date, such programs have not involved increased taxes on employers.

The contributions to state social insurance funds do involve increased taxes on employees, but the amounts are quite low. California’s law, for example, requires a contribution of 1 percent of the employee’s yearly taxable income up to a maximum contribution of $1,149.67 per year.⁷³ Nevertheless, some analysts argue against providing paid family leave through a social insurance model on the grounds that it risks crowding out private provisions with public provisions and that employees might lose out if public benefits replace a lower share of wages than private employer leave policies would do.⁷⁴

As more states follow in the footsteps of California, New Jersey, Rhode Island, and New York, they may need to consider alternative methods to fund family leave programs. Washington state, Massachusetts, and the District of Columbia—which passed paid leave legislation in 2017, 2018, and 2017, respectively, and plan to roll out their programs in 2020, 2021, and 2020 respectively—do not have State Disability Insurance or Temporary Disability Insurance systems onto which to graft paid leave entitlement systems. Instead, they will fund their leave programs through a mix of employer and employee contributions.⁷⁵ While the employer contribution is not high in Washington state (only 0.15 percent of employees’ wages) and is waived for small firms in Massachusetts, the District of Columbia requires employers to pay 0.63 percent of employees’ wages.⁷⁶

The experiences of Washington state, Massachusetts, and especially the District of Columbia will have important implications for the future of state-based and federal paid leave programs, as only five states and Puerto Rico currently have a State Disability Insurance or Temporary Disability Insurance program in place, and four of those states—California, New Jersey, Rhode Island, and New York—have already adopted a paid family leave program.

Regardless of who funds the compensation for employees’ paid leave, employers still have to make arrangements to cover work while employees are on leave. While some employees already take leave under FMLA or other firm policies, providing additional paid leave coverage through state programs or a federal program would be expected to increase the number of employees taking leave, as well as the lengths of leave taken. Thus, to the extent that covering leave is a burden, that burden would become heavier. To date, however, employers have not reported major problems in covering work while employees are on leave. As noted earlier, with regard to leaves taken both under FMLA and under state paid leave programs, the most common arrangement is assigning work to other employees, with only a small share of firms hiring replacement workers.⁷⁷

Finally, there also is the issue of possible employer discrimination against workers thought to be most likely to take paid family care leave, through reduced hiring or restrictions to particular positions or segments of the labor market. Research on parental leave in Europe has raised the concern that very lengthy leave periods—leave of a year or more—may have adverse effects on the employment and wages of the group (women) thought to be most likely to take it.⁷⁸ This seems less likely to be an issue in the United States because of much shorter periods of leave (4 weeks to 6 weeks under the first three state laws, 8 weeks to 12 weeks under the new New York, Washington state, and Massachusetts laws), particularly because leaves to care for ill family members tend to be short, but this is nevertheless an issue to keep an eye on in future research.

While the topic of paid family care leave—leave to care for a seriously ill family member—has received less attention than other types of paid family and medical leave, this review suggests that there is substantial unmet need for such leave and also substantial scope for policy expansion to address that need. There is also a clear need for further research.

Statistics on the need for leave to care for a seriously ill family member are striking. Although fewer than 5 percent of U.S. workers take such leave in a given year, fully one-quarter of the U.S. workforce has taken such leave during the course of their working lives and a similar share expect to do so in future. Moreover, 10 percent of the U.S. workforce says they have needed such leave in the past 2 years but were not able to take it.

The Family and Medical Leave Act only partially addresses this need due to its limited coverage, restrictive qualifying conditions, and most importantly, lack of provision for paid leave. In the absence of comprehensive paid leave options in the United States, employees who need to take leave to care for their seriously ill family members are at risk of negative outcomes related to income, mental health, and physical health. The challenges for people who are low income, less educated, and nonwhite are likely to be particularly consequential, as they are all currently less likely to have access to paid family care leave and more likely to have family members who may face serious health challenges.

The state paid family leave programs in California, New Jersey, Rhode Island, and New York (and soon in Washington state, Massachusetts, and the District of Columbia) have begun to address the shortcomings of FMLA. Thus far, the effects of the state laws look to be primarily neutral or indeed positive. This is an important finding, given the shortcomings of voluntary employer coverage, which reaches fewer than half of all employees and does so unevenly, with the most disadvantaged workers least likely to be covered.

While there is much to be learned from current research, this review also revealed several gaps in knowledge that it would be prudent to address to better understand the current policy framework for family care leave and the optimal design for future policy. There is a clear need for more nuanced research about coverage and usage of paid family care leave for those who need to care for a seriously ill family member, exploring both leave to care for a seriously ill child and leave to care for a seriously ill adult relative (of various kinds). How prevalent is caregiving for ill children versus ill adults (of various kinds), and what is the nature of that caregiving in terms of frequency, duration, intensity, and so on? What are employers’ perspectives on these various types of leave and what challenges do they see raised by them? How might the needs of employees, their family members, and employers be best addressed?

Additionally, existing research rarely considers demographic and economic heterogeneity associated with the need for and use of different types of leave. In order to determine how race, ethnicity, and income play into the need for and use of leave to care for a seriously ill family member, it is necessary for studies to report data in this specific manner. It is also important for future research to consider heterogeneity among employers by firm size, sector, type of employee, and so on.

Ultimately, it would be extremely useful to understand the impact of existing laws—in particular, the new state paid family leave laws—on leave to care for a seriously ill family member. Has the availability of paid family care leave to care for a seriously ill family member improved the health and well-being of family members and of the employees who care for them? What are the effects from the perspective of employers? While this is a large research agenda, it is also a crucial one to provide the evidence base for a better-informed set of paid family and medical leave policies.

Jane Waldfogel is the Compton Foundation Centennial Professor for the Prevention of Children’s and Youth Problems at the Columbia University School of Social Work and co-director of the Columbia Population Research Center. She also is a visiting professor at the Centre for Analysis of Social Exclusion at the London School of Economics. She received her Ph.D. in public policy from the Kennedy School of Government at Harvard University in 1994. Her current research is focused on paid family and medical leave, poverty and social policy, and inequalities in children’s and youth development and health in the United States and peer countries.

Emma Liebman is pursuing an M.P.H. at the Columbia Mailman School of Public Health. She received her Bachelor of Arts degree in history at Yale University in 2017. She currently works at the New York City Department of Health and Mental Hygiene, where she focuses on opioid overdose prevention and control. Beyond substance use, her interests include criminal justice and family and medical leave.

The authors gratefully acknowledge support for this research from Pivotal Ventures, as well as support to the Columbia Population Research Center from the Eunice Kennedy Shriver National Institute of Child Health and Human Development.

What other countries do

An examination of paid family leave provisions in other countries can offer insight into potential options for expanding paid family leave programs in the United States. The majority of the member nations of the Organisation for Economic Co-operation and Development offer paid leave entitlements for employees who need leave to care for their seriously ill family members. In fact, the United States falls into the bottom 25 percent of OECD nations that lack paid family leave provisions.⁷⁹

Similar to the few paid family leave programs that do exist in the United States, international paid leave programs largely rely on a contribution fund made up of tax revenue. These programs are usually operated on a social insurance model, meaning that costs are pooled and employers are not charged for their own employees’ leave periods.⁸⁰ OECD member country paid family leave programs typically rely on employee and employer contributions, unlike most existing state paid family leave programs in the United States but in line with the approach described in the proposed FAMILY Act.⁸¹

One point of difference between the approach taken by other countries and that taken by the United States has to do with the treatment of different types of leave. The U.S. government enacted family and medical leave quite late compared to other countries, and the Family and Medical Leave Act, although lacking paid leave and limited in other respects, is relatively comprehensive with regard to the types of leave covered. Many other countries, in contrast, built their policies on a platform of longstanding maternity leave and sick leave provisions, adding other types of leave, such as paternity and family care, as separate programs. For that reason, among the OECD nations that offer paid family care leave, 40 percent offer compensation at varying monetary rates and for varying intervals of time, depending on who is ill and the severity of their medical condition.

Provisions also differ in these nations based on whether the family member is a child or an adult, and whether the condition is short term, long term, or terminal. Durations range from 3 days to 3 months per year to care for an ill child, 3 months to unlimited for a child’s long-term health condition, 1 week to 2 weeks for an ill adult, 1 month to 2 years for an adult’s long-term health condition, and 2 weeks to 1 year for a terminally ill child or adult. These benefits are in addition to the 10 days to 30 days of annual leave and more specific provisions for permanently disabled relatives.

In Germany and several other countries—among them Estonia, Poland, and Slovenia—employees who need leave to care for a seriously ill family member are allowed more compensated time off if the ill family member is a child than if the ill family member is an adult.⁸² Moreover, some countries—including Finland, Greece, Hungary, Ireland, Israel, Luxemburg, Portugal, and Romania—only offer compensated leave for seriously ill children but not for seriously ill adults.

Many OECD countries also distinguish between leave needed for short-term health conditions, long-term health conditions, and terminal illnesses. Each of these categories comes with a unique paid leave provision. Germany, for example, provides paid leave for employees who need leave to care for a family members’ short term illness for up to 2 weeks per year for a child and over the family member’s lifetime for an adult, but provides paid leave for employees who need to take leave to care for a family member’s long-term health condition for up 6 months.⁸³ Along a similar vein, Belgium and France provide paid leave for 1 year and 3 years of leave, respectively, for a family member’s long-term health condition, but only 2 months and 3 months, respectively, for leave to care for a terminally ill family member.⁸⁴

As in the United States, some employers in other countries provide leave beyond that mandated by their countries’ laws. Likely appreciating the merits of increased morale and productivity, many employers across the world choose to offer paid family leave benefits beyond the legal requirements of their nation or state. One study, conducted in 2011, studied the practices of 50 such firms, finding that some companies offered additional compensated leave days, allowed employees to take leave to care for extended relatives, friends, and neighbors, and facilitated changes to leave plans when necessary.⁸⁵ Moreover, certain companies made an effort to keep in contact with employees during leave, and one company even hired a full-time “leave and reintegration” coordinator to handle leave-taking.