By Anwesha Majumder and Jessica Mason

Introduction and Executive Summary

About 5.5 percent of people in the United States – more than 20 million people nationwide – have been diagnosed with heart disease.Centers for Disease Control and Prevent National Center for Health Statistics. (2023, June). Heart Disease Prevalence. Retrieved 23 January 2025, from https://www.cdc.gov/nchs/hus/topics/heart-disease-prevalence.htm Heart disease already ranks as the leading cause of death for U.S. women, according to the CDC.American Heart Association and American Stroke Association. (2017). Cardiovascular Disease: A Costly Burden for America Projections Through 2035. Retrieved 23 January 2025, from https://www.heart.org/-/media/Files/About-Us/Policy-Research/Fact-Sheets/Public-Health-Advocacy-and-Research/CVD-A-Costly-Burden-for-America-Projections-Through-2035.pdf More than one out of every six people in the United States have had a diagnosis of depression at some point in their lives.Lee, B., Wang, Y., Carlson, S. A., Greenlund, K. J., Lu, H., . . . Thomas,C. (2023, June). National, State-Level, and County-Level Prevalence Estimates of Adults Aged ≥18 Years Self-Reporting a Lifetime Diagnosis of Depression — United States, 2020. Morbidity and Mortality Weekly Report (MMWR), 72(24): 644-650. doi: 10.15585/mmwr.mm7224a1 Many chronic health conditions – including depression and heart disease – disproportionately affect women and people of color, in part due to the impacts of persistent racism, sexism and ableism, and their compounding effects.Federal data show higher rates of depression and hypertension – a risk factor for heart disease – among women than among men. (Ibid.) Additionally, women’s health outcomes for a given condition may be worse due to systemic flaws in our health research and health care systems. Medical research has too often not included women as participants, and has neglected to fully examine how factors that tend to vary along the spectrum of sex differences (such as the effects of hormones such as estrogen and progesterone), as well as sociocultural factors like sexism and racism, affect the prevalence and etiology of health conditions and how patients respond to treatments. (Temkin, S. M., Barr, E., Moore, H., Caviston, J. P., Regensteiner, J.G., Clayton, J. A. (2023, April 6). Chronic conditions in women: the development of a National Institutes of health framework. BMC Women’s Health, 23(1), 162. doi: 10.1186/s12905-023-02319-x). In addition, medical discrimination is a common experience, particularly for women of color and disabled women. (See for example National Council on Disability. (2019) Bioethics and Disability Report Series. Retrieved 23 January 2025, from https://www.ncd.gov/report/bioethics-and-disability-report-series/; Gonzalez, D., Kenney, G. M., Karpman, M., & Morriss, S. (2023, October 11). Four in Ten Adults with Disabilities Experienced Unfair Treatment in Health Care Settings, at Work, or When Applying for Public Benefits in 2022. Retrieved 23 January 2025, from Urban Institute website: https://www.urban.org/research/publication/four-ten-adults-disabilities-experienced-unfair-treatment-health-care-settings; Fernandez, H., Ayo-Vaughan, M., Zephyrin, L. C., & Block Jr., R. (2024, February). Revealing Disparities: Health Care Workers’ Observations of Discrimination Against Patients. Retrieved 23 January 2025, from the CommonWealth Fund website: https://www.commonwealthfund.org/publications/issue-briefs/2024/feb/revealing-disparities-health-care-workers-observations Improving the lives of people with chronic illness is essential to advancing racial and gender justice. What’s more, without adequate supports, these conditions also undermine people’s ability to fully participate in our society and economy, including as workers, with costs to themselves, businesses and our country as a whole.

In a country without a national guarantee of paid family and medical leave, workers with chronic illnesses such as heart disease or depression may struggle to take time away from work to seek treatment, care, support and rest when they most need it. They may also be burdened by financial and psychological stress due to loss of income while on unpaid leave, or the prospect of having to choose between keeping their job and caring for their health, which can in turn worsen health in a vicious cycle.

To help address this need, 14 states, including the District of Columbia, have now enacted paid family and medical leave programs for people who work in-state. Ten of those are already providing benefits to workers, making the case that paid leave works and revealing how it benefits workers and their families. Research has documented significant benefits to infant and child health, maternal health (including mental health), family economic security, and labor force outcomes for mothers and family caregivers.National Partnership for Women & Families. (2023, November). Paid Leave Works: Evidence from State Programs. Retrieved 23 January 2025, from National Partnership for Women & Families website: https://nationalpartnership.org/wp-content/uploads/2023/02/paid-leave-works-evidence-from-state-programs.pdf But few researchers have yet to examine the effects of paid leave on workers’ health outside the context of pregnancy and childbirth.

This brief shares findings from a new analysis of the impact of paid family and medical leave on workers with depression or coronary heart disease.Each condition is analyzed separately. Some individuals may have had both. It examines whether the implementation of paid leave in MassachusettsSee Detailed Methodology for more information about the case selection and design of the analysis. had an effect on the frequency of “poor health” days of these workers – the number of days per month that “poor physical or mental health [kept them] from doing [their] usual activities, such as self-care, work, or recreation.” The brief offers strong evidence that paid leave not only supports workers’ health, but also improves productivity.

In the sections below, this brief shows how:

1. States are increasingly moving to expand access to paid leave
2. Paid family and medical leave could support the health of workers with coronary heart disease and depression
3. Lack of support for workers with coronary heart disease costs workers and families, employers and the economy
4. Lack of support for workers with depression costs workers and families, employers and the economy
5. Massachusetts paid leave led to fewer poor health days for workers with depression and workers with heart disease
6. Fewer poor health days could mean more than $1 billion in improved productivity annually

Paid family and medical leave is an essential support for people with coronary heart disease and those with depression, enabling them to experience better health more often. For those who are in the workforce, improved health also stands to improve their ability to succeed at their jobs, strengthening their own financial security and ability to provide for themselves and their loved ones and contributing to their employers’ bottom lines as well.

States Are Increasingly Moving to Expand Access to Paid Leave

Lack of access to leave harms health outcomes. In 2024 about 11.1 million workers needed leave but did not take it, and two-thirds – nearly 7.3 million – reported that it was because they could not afford unpaid leave.National Partnership for Women & Families. (2025, February). Key Facts: The Family and Medical Leave Act. Retrieved 5 February 2025, from https://nationalpartnership.org/report/fmla-key-facts Rates of unmet need for leave are particularly high among women, Black workers, Latino workers, and those who are Native American, Pacific Islander, and multi-racial.National Partnership for Women & Families. (2025, February). Key Facts: The Family and Medical Leave Act. Retrieved 5 February 2025, from https://nationalpartnership.org/report/fmla-key-facts Inadequate paid leave is also a barrier to employment and health care access for workers with disabilities.Ditkowsky, M. (2022, July). Systems Transformation Guide to Economic Justice for Disabled People: Jobs and Employment. Retrieved 23 January 2025, from National Partnership for Women & Families website: https://nationalpartnership.org/report/disability-economic-justice-systems-transformation/ Among workers with unmet need for leave, close to half said that they or their family member put off the health care they needed.Weston Williamson, M. (2024, May 22). Lack of Paid Leave Hurts Americans’ Health. Retrieved 23 January 2025, from Center for American Progress website: https://www.americanprogress.org/article/lack-of-paid-leave-hurts-americans-health/ Delayed or forgone health care can lead to significantly worse outcomes, higher health care expenses in the long term and even increase the risk of death.Weston Williamson, M. (2024, May 22). Lack of Paid Leave Hurts Americans’ Health. Retrieved 23 January 2025, from Center for American Progress website: https://www.americanprogress.org/article/lack-of-paid-leave-hurts-americans-health/

Fourteen states, however, do or will soon provide paid family and medical leave to people who work in state.National Partnership for Women & Families. (2024, July). State Paid Family & Medical Leave Insurance Laws. Retrieved 23 January 2025, from https://nationalpartnership.org/wp-content/uploads/2023/02/state-paid-family-leave-laws.pdf The earliest programs provided only temporary disability insurance (in essence, paid medical leave) for workers experiencing a serious health condition, starting with Rhode Island (1942), California (1946), New Jersey (1948) and New York (1949).Mitchell, S. M. (2024, March). History of Paid Leave in the United States. Women’s Bureau of the U.S. Department of Labor Publication. Retrieved 23 January 2025, from https://www.dol.gov/sites/dolgov/files/WB/paid-leave/HistoryOfPaidLeaveUS.pdf (The relative age of the earliest medical leave programs – older than surveys commonly used to test policy impacts on health outcomes such as BRFSS – may be one reason why there has been less research evaluating the impacts of paid leave programs on a wider range of health conditions.) The Pregnancy Discrimination Act of 1978 ensured that conditions related to pregnancy and childbirth were also covered by these programs,Mitchell, S. M. (2024, March). History of Paid Leave in the United States. Women’s Bureau of the U.S. Department of Labor Publication. Retrieved 23 January 2025, from https://www.dol.gov/sites/dolgov/files/WB/paid-leave/HistoryOfPaidLeaveUS.pdf (The relative age of the earliest medical leave programs – older than surveys commonly used to test policy impacts on health outcomes such as BRFSS – may be one reason why there has been less research evaluating the impacts of paid leave programs on a wider range of health conditions.); see also Lenhoff, D. R., & Bell, L. (n.d.) Government Support for Working Families and for Communities: Family and Medical Leave as a Case Study. Retrieved 23 January 2025, from National Partnership for Women & Families website: https://nationalpartnership.org/wp-content/uploads/2023/02/fmla-case-study-lenhoff-bell.pdf and starting in the early 2000s these states began to expand their programs by adding dedicated time for all parents to bond with new children and for workers to care for family members with serious health conditions.Mitchell, S. M. (2024, March). History of Paid Leave in the United States. Women’s Bureau of the U.S. Department of Labor Publication. Retrieved 23 January 2025, from https://www.dol.gov/sites/dolgov/files/WB/paid-leave/HistoryOfPaidLeaveUS.pdf; Parental and family leave components of these state programs went fully into effect for California in 2004, New Jersey in 2009, Rhode Island in 2014, and New York in 2016. It was not until 2020 that new state programs, with no pre-existing temporary disability insurance infrastructure, were implemented, providing new opportunities to evaluate whether and how workers’ health is affected by the implementation of a new paid leave program.

Programs in the District of Columbia and Washington state began providing benefits in 2020, amid the disruptions of the COVID-19 pandemic. Massachusetts’ program, the third to start without a prior temporary disability insurance system, began providing benefits in January 2021. It offers up to 20 weeks of leave for a worker’s own health condition (more than Washington or D.C.) and 12 weeks for parental or family caregiving leave (the same as Washington and more than D.C. initially offered), and provided up to 80 percent of usual wages for the lowest-paid workers (compared to 90 percent in Washington and D.C.) Notably, leave is job-protected, meaning that workers have a right to return to their same or a similar position;For example, Arora and Wolf (2024) found that paid family leave programs increased the provision of elder care only when job protection was offered. Arora, K., & Wolf, D. A. (2024, June). Paid Leave Mandates and Care for Older Parents. The Milbank Quarterly, 102(3), 0621. doi: 10.1111/1468-0009.12708 the greater availability of job protection in Massachusetts is likely to strengthen any potential benefits of paid leave relative to other states’ programs.National Partnership for Women & Families. (2024, July). State Paid Family & Medical Leave Insurance Laws. Retrieved 23 January 2025, from https://nationalpartnership.org/wp-content/uploads/2023/02/state-paid-family-leave-laws.pdf Because it would be difficult to disentangle pandemic-related effects on initial program rollout, the makeup of the employed workforce, and workers’ mental health in 2020, Washington and D.C. were excluded from this analysis.

How Paid Family and Medical Leave Could Support Workers with Heart Disease or Depression

A substantial, and growing, body of research has identified numerous health benefits of state paid leave programs for children and new mothers. For new mothers, paid leave is linked to improved physical health and reduced odds of experiencing postpartum depression, and greater likelihood of attending at least one postpartum visit.Heshmati, A., Honkaniemi, H., Chatterji, P., & Juárez, S. P. (2023, January). The effect of parental leave on parents’ mental health: a systematic review. The Lancet Public Health, 8(1), E57-E75. doi: 10.1016/S2468-2667(22)00311-5; Sara Markowitz, S. (2008, July). Family Leave After Childbirth and the Health of New Mothers. Retrieved 23 January 2025, from National Bureau of Economic Research website: http://www.nber.org/papers/w14156; Kornfeind, K. R., & Sipsma, H. L. (2018). Exploring the Link between Maternity Leave and Postpartum Depression. Women’s Health Issues, 28(4), 321-326. doi: 10.1016/j.whi.2018.03.00; Pal, I. (2016). Work, Family and Social Policy in the United States – Implications for Women’s Wages and Wellbeing. Doctoral thesis, Columbia University. Retrieved 23 January 2025, from https://academiccommons.columbia.edu/doi/10.7916/D87W6C74; Perry, M. F., Trasatti, E., Yee, L. M., & Feinglass, J. M. (2023). State paid family and medical leave and postpartum outcomes. American Journal of Obstetrics and Gynecology, 228(1). doi: 10.1016/j.ajog.2022.11.054 Paid leave is also associated with reduced hospital admissions among infants for respiratory and gastrointestinal conditions, lower likelihood of recurrent ear infections, and greater likelihood of on-time vaccination.Pihl, A. M., & Basso, G. (2019). Did California Paid Family Leave Impact Infant Health? Journal of Policy Analysis and Management. 38(1), 155-180. doi: 10.1002/pam.22101; Lichtman-Sadot, S., & Pillay Bell, N. (2017). Child Health in Elementary School Following California’s Paid Family Leave Program. Journal of Policy Analysis and Management, 36(4), 790-827. doi: 10.1002/pam.22012; Choudhury, A. R., & Polachek, S. W. (2019, July). The Impact of Paid Family Leave on the Timing of Infant Vaccinations. I. Z. A. Institute of Labor Economics, No. 12483. Retrieved 23 January 2025, from http://ftp.iza.org/dp12483.pdf In addition, while not all new mothers want or are able to breastfeed, paid leave supports those who decide to do so, and the research shows that paid leave programs increase likelihood of breastfeeding.Hamad, R., Modrek, S., & White, J. S. (2019, January). Paid Family Leave Effects on Breastfeeding: A Quasi-Experimental Study of US Policies. American Journal of Public Health, 109(1), 164-166. doi: 10.2105/AJPH.2018.304693 But relatively little research has investigated the impacts of state paid family and medical leave programs on the health of workers, outside of the context of pregnancy and birth.Smalligan, J., & Boyens, C. (2020, April 30). Paid medical leave research. Washington Center for Equitable Growth publication. Retrieved 23 January 2025, from https://equitablegrowth.org/research-paper/paid-medical-leave-research/; Bartel, A., Rossin-Slater, M., Ruhm, C., Slopen, M. & Waldfogel, J. (2023). The Impacts of Paid Family and Medical Leave on Worker Health, Family Well-Being, and Employer Outcomes. Annual Review of Public Health. 44, 429-443. doi: 10.1146/annurev-publhealth-071521-025257 Findings related to child and maternal health are nonetheless promising for paid leave’s potential to support people with other health conditions, particularly workers with depression.

In addition, research on the impacts of paid sick days policies points to ways that paid leave has the potential to facilitate improved health outcomes.Washington Center for Equitable Growth. (2020, March). What is paid medical leave and how does it support U.S. workers’ health and the U.S. economy? Retrieved 23 January 2025, from https://equitablegrowth.org/what-is-paid-medical-leave-and-how-does-it-support-u-s-workers-health-and-the-u-s-economy/ Beyond reducing the spread of infectious diseases such as influenza and COVID-19, paid sick days laws have also been linked to increased use of preventive health careDeRigne, L., Stoddard-Dare, P., Collins, C., & Quinn, L. (2017, June). Paid sick leave and preventive health care service use among U.S. working adults. Preventive Medicine, 99, 58-62. doi: 10.1016/j.ypmed.2017.01.020 and improved mental health.Song, S., Calhoun, B. H., Kucik, J. E., Konnyu, K. J., & Hilson, R. (2023, March). Exploring the association of paid sick leave with healthcare utilization and health outcomes in the United States: a rapid evidence review. Global Health Journal, 7(1), 9-17. doi: 10.1016/j.glohj.2023.01.002 Improvements to mental health could be related to improved financial security and reduced financial stress: access to paid sick days is associated with a reduction in food insecurity and reduced odds of being in poverty.Stoddard-Dare, P., DeRigne, L., Mallett, C., & Quinn, L. (2018, March). How does paid sick leave relate to health care affordability and poverty among US workers? Social Work in Health Care, 57(5): 376-392. doi: 10.1080/00981389.2018.1447532 Paid sick days may also directly impact mental health by enabling more workers to access health care, diagnosis and treatment: among people covered by Medicaid, state paid sick days laws are associated with an increase in medications provided for mental health conditions, suggesting higher levels of mental health management and care.Maclean, J. C., Golberstein, E., & Stein, B. (2024, May). State paid sick leave mandates associated with increased mental health disorder prescriptions among Medicaid enrollees. Health Affairs Scholar, 2(5), qxae045. doi: 10.1093/haschl/qxae045/7656766

Evidence from paid sick leave policies also illustrates how expanding access to these types of programs addresses racial and gender health inequities. Workers of color and women are less likely than white workers and men, respectively, to have access to paid sick daysHawkins, D. (2023, May). Disparities in Access to Paid Sick Leave During the First Year of the COVID-19 Pandemic. Journal of Occupational and Environmental Medicine, 65(5), 370-377. doi: 10.1097/JOM.0000000000002784; Goodman, J. M., & Schneider, D. (2023, November). Racial/Ethnic and gender inequities in the sufficiency of paid leave during the COVID-19 pandemic: Evidence from the service sector.. American Journal of Industrial Medicine, 66(11), 928-937. doi: 10.1002/ajim.23533 or paid family and medical leave.Bartel, A. P., Kim, S., Nam, J., Rossin-Slater, M., Ruhm, C.J., Waldfogel, J. (2019, January) Racial and ethnic disparities in access to and use of paid family and medical leave: evidence from four nationally representative datasets. Monthly Labor Review. Retrieved 23 January 2025, from U.S. Bureau of Labor Statistics website: https://www.bls.gov/opub/mlr/2019/article/racial-and-ethnic-disparities-in-access-to-and-use-of-paid-family-and-medical-leave.htm The benefits of these policies may be especially pronounced for those who currently have the least access. For example, one study has found that while Black workers reported elevated levels of psychological distress overall, having access to paid sick days was linked to lower distress for Black workers. After controlling for other relevant factors such as income. Alang, S. M., Harris, L. K., & Carter, C. R. (2023, December). Psychological distress and life satisfaction among black working adults in the U.S. during the COVID-19 pandemic. SSM – Mental Health, 4(15), 100267. doi: 10.1016/j.ssmmh.2023.100267 Another study has found that state paid leave laws reduced the share of women reporting that their health was “fair” or “poor,” and a reduction in the number of days that women reported their mental health and their physical health were not good – with stronger effects among women of color. Slopen, M. (2023, April). The impact of paid sick leave mandates on women’s health. Social Science & Medicine, 323, 115839. doi: 10.1016/j.socscimed.2023.115839

These findings on the positive impacts of paid sick leave support the idea that paid family and medical leave could also have similar benefits (although because of differences in policy design, not all of the benefits documented for one form of leave should be expected to follow for the other). However, it is plausible that paid leave could improve mental health by improving financial security, providing workers time to access ongoing treatment and allowing workers to take intermittent time off to address a flare in symptoms, as well as to care for loved ones with chronic illnesses. There may also be a “peace of mind” benefit from knowing that time will be available if needed, whether or not a worker takes additional time off.

Similarly, paid leave would enable a worker with heart disease to attend appointments for ongoing treatment, or to undergo and recover from surgery and attend follow-up appointments, and would enable family caregivers to support their loved one. Because heart disease is linked to stress, individuals may also experience physical benefits from reduced financial stress and greater peace of mind. Given that 94 percent of the lowest paid workers lack access to paid leave,National Partnership for Women & Families. (2023, November). Key Facts: Paid Family and Medical Leave. Retrieved 23 January 2025, from https://nationalpartnership.org/wp-content/uploads/key-facts-paid-family-and-medical-leave.pdf those that are most likely to endure chronic stressors that exacerbate cardiovascular conditionsAmerican Psychological Association. (2023, March). Stress effects on the body. Retrieved 23 January 2025, from https://www.apa.org/topics/stress/body are the least likely to be able to take time to rest, recover and heal. Providing paid leave is a critical step in ensuring workers with health conditions like CAD can maintain their financial security and employment, while reducing the stress that can intensify their life-threatening symptoms.

Workers with Coronary Heart Disease Need Supports to Thrive at Work

In 2015, upwards of 40 percent of the U.S. population (more than 100 million Americans) reported suffering from some form of cardiovascular disease – a total reached almost 15 years sooner than the American Heart Association’s (AHA) predictions had anticipated.American Heart Association. (2017). Cardiovascular Disease: A Costly Burden for America. Projections Through 2035. Retrieved 23 January 2025, from https://www.heart.org/-/media/Files/About-Us/Policy-Research/Fact-Sheets/Public-Health-Advocacy-and-Research/CVD-A-Costly-Burden-for-America-Projections-Through-2035.pdf Heart disease takes a serious toll on health, wellbeing, and economic security, particularly within communities that face intersecting inequities due to racism, sexism and ableism.Javed, Z., Maqsood, M. H., Yahya, T., Amin, Z., Acquah, I., et al. (2022, January 18). Race, Racism, and Cardiovascular Health: Applying a Social Determinants of Health Framework to Racial/Ethnic Disparities in Cardiovascular Disease. Circulation: Cardiovascular Quality and Outcomes,15(1). doi: 10.1161/CIRCOUTCOMES.121.007917; see below for discussion of health inequities related to sexism and ableism. Several risk factors for heart disease are more common among non-Hispanic Black adults and Hispanic adults who report Mexican ancestry, compared to the population overall.Lopez-Neyman, S. M., Davis, K., Zohoori, M., Broughton, K. S., Moore, C. E., Miketinas, D. (2022, November). Racial disparities and prevalence of cardiovascular disease risk factors, cardiometabolic risk factors, and cardiovascular health metrics among US adults: NHANES 2011–2018. Scientific Reports, 12(1): 19475. doi: 10.1038/s41598-022-21878-x Cardiovascular disease, including coronary heart disease, is also disproportionately common among American Indian and Alaska Native adults, although data are limited. Eberly, L. A., Shultz, K., Merino, M., Brueckner, M., Benally, E., Tennison, A., et al. (2023, September). Cardiovascular Disease Burden and Outcomes Among American Indian and Alaska Native Medicare Beneficiaries. JAMA Network Open, 6(9), e2334923. doi: 10.1001/jamanetworkopen.2023.34923 Compared with their non-Hispanic, white counterparts, Black men and Black women are more than 30 percent more likely to die of heart disease.Listed as “diseases of the heart.” Kochanek, K. D., Murphy, S. L., Xu, J. & Arias, E. (2023, September ) Deaths: Final Data for 2020 (Table 10). National Vital Statistics Reports, 70(8). Retrieved 23 January 2025, from Centers for Disease Control and Prevention website: https://www.cdc.gov/nchs/data/nvsr/nvsr72/nvsr72-10.pdf When it comes to disability status, disabled adults are nearly three times as likely to have heart disease as nondisabled adults.Centers for Disease Control and Prevention. (2024, July). Disability Impacts All of Us. Retrieved 23 January 2025, from https://www.cdc.gov/disability-and-health/articles-documents/disability-impacts-all-of-us-infographic.html

The most common cardiovascular disease in the United States is coronary heart disease (CHD), a buildup of plaque in the arteries of the heart that reduces blood flow and can lead to a heart attack.Also commonly called “coronary artery disease.” We use “coronary heart disease” in this brief to follow the language used in the BRFFS questionnaire. Centers for Disease Control and Prevention. (2024, May ). About Coronary Artery Disease (CAD). Retrieved 23 January 2025, from https://www.cdc.gov/heart-disease/about/coronary-artery-disease.html; American Heart Association. (2017). Cardiovascular Disease: A Costly Burden for America.Projections Through 2035. Retrieved 23 January 2025, from https://www.heart.org/-/media/Files/About-Us/Policy-Research/Fact-Sheets/Public-Health-Advocacy-and-Research/CVD-A-Costly-Burden-for-America-Projections-Through-2035.pdf It is most prevalent among older adults, affecting nearly one-quarter of adults aged 75 and older, but it also impacts working-age adults: 1 percent of those aged 18 to 44, 3.6 percent of those aged 45 to 54, and 9 percent of those aged 55 to 64.Centers for Disease Control and Prevention National Center for Health Statistics. (2024, August). Heart Disease Prevalence. Retrieved 23 January 2025, from: https://www.cdc.gov/nchs/hus/topics/heart-disease-prevalence.htm The AHA projects that by 2035, 24 million people will have CHD, an increase of more than 40 percent from 2015.American Heart Association. (2017). Cardiovascular Disease: A Costly Burden for America. Projections Through 2035. Retrieved 23 January 2025, from: https://www.heart.org/-/media/Files/About-Us/Policy-Research/Fact-Sheets/Public-Health-Advocacy-and-Research/CVD-A-Costly-Burden-for-America-Projections-Through-2035.pdf The potential for a rapid rise of CHD can be attributed to the fact that nearly half of the people in the United States (47 percent) already have at least one of the three main risk factors – high blood pressure, high blood cholesterol or a history of smoking.Centers for Disease Control and Prevention. (2024, May). About Heart Disease. Retrieved 23 January 2025, from https://www.cdc.gov/heart-disease/about/index.html However, it is often undiagnosed until a person experiences signs or symptoms of a heart attack, heart failure or an arrhythmia.Centers for Disease Control and Prevention. (2024, May). About Heart Disease. Retrieved 23 January 2025, from https://www.cdc.gov/heart-disease/about/index.html

Economic and health inequities borne from structural racism play an outsized role in shaping which communities are most likely to suffer from cardiovascular diseases like CHD, shaping social drivers of health such as education, household income, residential environment and health care access.Javed, Z., Maqsood, M. H., Yahya, T., Amin, Z., et al. (2022, January). Race, Racism, and Cardiovascular Health: Applying a Social Determinants of Health Framework to Racial/Ethnic Disparities in Cardiovascular Disease. Circulation: Cardiovascular Quality and Outcomes, 15(1). doi:10.1161/CIRCOUTCOMES.121.007917 For example, a recent study found that women who experience job discrimination are 14 percent more likely to have hypertension – and Black women and women with low incomes were more likely than others to report experiencing job discrimination.Coates, M. M., Arah, O. A., Matthews T. A., Sandler, D. P., Jackson, C. L., Li, J. (2024, July). Multiple forms of perceived job discrimination and hypertension risk among employed women: Findings from the Sister Study. American Journal of Industrial Medicine, 67(9), 844-865. doi: 10.1002/ajim.23634 Workers of colorU.S. Bureau of Labor Statistics. (2024, December). Labor force characteristics by race and ethnicity, 2023. Retrieved 23 January 2025, from https://www.bls.gov/opub/reports/race-and-ethnicity/2023/home.htm and disabled workersU.S. Bureau of Labor Statistics. (2024, February). Persons with a Disability: Labor Force Characteristics – 2023 (Table 3 and Table 4). Retrieved 23 January 2025, from https://www.bls.gov/news.release/pdf/disabl.pdf are overrepresented in occupational groups with some of the poorest cardiovascular health measuresCenters for Disease Control and Prevention. (2024, January). About Work-related Heart Disease. Retrieved 23 January 2025, from: https://www.cdc.gov/niosh/heartdisease/about/?CDC_AAref_Val=https://www.cdc.gov/niosh/topics/heartdisease/default.html – including workers in the transportation, food service, personal care and agricultural sectors. In addition to offering low wages, these jobs are less likely to provideBoyens, C., Karpman, M., & Smalligan, J. (2022, July ). Access to Paid Leave Is Lowest among Workers with the Greatest Needs. Retrieved 23 January 2025, from Urban Institute website: https://www.urban.org/research/publication/access-paid-leave-lowest-among-workers-greatest-needs benefits that enable workers to access preventive health care, treatment and caregiving support, including health insurance, paid family and medical leave, and paid sick time.

The costs of cardiovascular diseases – including not only direct medical costs but also the indirect impacts of lost productivity at work and in people’s personal lives, lost income and premature death – are substantial for individuals, employers and our healthcare system. Direct medical costs for cardiovascular health care for U.S. adults was estimated at $320 billion in 2016, including $89 billion for CHD, and are projected to increase to $749 billion by 2035 ($215 billion of which will be for CHD).Birger, M., Kaldjian, A. S., Roth, G. A., Moran, A, E., Dieleman, J.L., Bellows, B.K., (2021, April). Spending on Cardiovascular Disease and Cardiovascular Risk Factors in the United States: 1996 to 2016. Circulation, 144(4), 271-282. doi: 10.1161/CIRCULATIONAHA.120.053216; American Heart Association. (2017). Cardiovascular Disease: A Costly Burden for America. Projections Through 2035. Retrieved 23 January 2025, from: https://www.heart.org/-/media/Files/About-Us/Policy-Research/Fact-Sheets/Public-Health-Advocacy-and-Research/CVD-A-Costly-Burden-for-America-Projections-Through-2035.pdf These costs are rising even more rapidly for Black and Hispanic Americans due to population growth and projected prevalence of cardiovascular disease: direct medical costs will likely triple over the next 20 years for Hispanic individuals and more than double among Black individuals, and indirect costs are projected to rise the most among Hispanic individuals.American Heart Association. (2017). Cardiovascular Disease: A Costly Burden for America. Projections Through 2035. Retrieved 23 January 2025, from: https://www.heart.org/-/media/Files/About-Us/Policy-Research/Fact-Sheets/Public-Health-Advocacy-and-Research/CVD-A-Costly-Burden-for-America-Projections-Through-2035.pdf Adults with plaque buildup in arteries (atherosclerotic cardiovascular disease)CHD is one type of atherosclerosis, in which plaque builds up in the heart. are even more likely to have difficulty paying medical bills, not take medication as directed due to cost, report food insecurity, and delay or forgo care due to cost, compared to either those with cancer, or those with neither condition.Valero-Elizondo, J., Chouairi, F., Khera, R., Grandhi, G. R., Saxena, A., et al. (2021, June). Atherosclerotic Cardiovascular Disease, Cancer, and Financial Toxicity Among Adults in the United States. JACC: CardioOncology, 3(2), 236-246. doi: 10.1016/j.jaccao.2021.02.006 Close to half of adults with atherosclerotic cardiovascular disease report experiencing financial hardship due to medical bills, and nearly one in five say that they cannot pay medical bills at all. American College of Cardiology. (2019). Medical Bills Financially Burden Almost Half of Cardiovascular Disease Patients [Press release]. Retrieved 23 January 2025, from https://www.acc.org/About-ACC/Press-Releases/2019/02/12/10/14/Medical-Bills-Financially-Burden-Almost-Half-of-Cardiovascular-Disease-Patients

Meanwhile, Black, Native Hawaiian and Pacific Islander, Hispanic, and American Indian and Alaska Native people in the United States are more likely to be uninsured than white people, and most groups of adults of color are more likely than white adults to avoid seeing a doctor due to cost.Ndugga, N., Hill, L, & Artiga, S. (2024, June). Key Data on Health and Health Care by Race and Ethnicity. Retrieved 23 January 2025 from KFF website: https://www.kff.org/key-data-on-health-and-health-care-by-race-and-ethnicity/ More than one-third of adults (37 percent), half of Latinx adults (51 percent) and over half of Black adults (55 percent) – would have difficulty paying for an unexpected $400 expense, for example.Share who would not cover a $400 emergency expense completely using cash or cash equivalents. Board of Governors of the Federal Reserve System. (2024, May). Report on the Economic Well-Being of U.S. Households (Table: Adults who would cover a $400 emergency expense using cash or its equivalent). Retrieved 23 January 2025, from: https://www.federalreserve.gov/consumerscommunities/sheddataviz/unexpectedexpenses-table.html For the workers of color and low-wage workers least likely to have access to paid leave,Mason, J. (2023, September). When We Fight, We Win – Paid Sick Days and Paid Family Leave. Retrieved 23 January 2025 from National Partnership for Women & Families website: https://nationalpartnership.org/when-we-fight-we-win-paid-sick-days-and-paid-family-leave/; Bartel, A., P., Kim, S., Nam, J., Rossin-Slater, M., Ruhm, C. J., Waldfogel, J. (2019, January). Racial and ethnic disparities in access to and use of paid family and medical leave: evidence from four nationally representative datasets. Monthly Labor Review. Retrieved 23 January 2025, from U.S. Bureau of Labor Statistics website: https://www.bls.gov/opub/mlr/2019/article/racial-and-ethnic-disparities-in-access-to-and-use-of-paid-family-and-medical-leave.htm taking time away to treat or recover from a cardiovascular disease or emergency would mean going without the pay critical to affording their care while also maintaining their overall financial stability.

In addition to the individual cost of treating a cardiovascular disease, letting conditions like CHD go unchecked and untreated creates major costs for businesses and the economy.Referred to as angina. Goetzel, R. Z., Hawkins, K., Ozminkowski, R. J., & Wang, S. (2003, January). The health and productivity cost burden of the “top 10” physical and mental health conditions affecting six large U.S. employers in 1999. Journal of Occupational and Environmental Medicine, 45(1): 5-14. doi: 10.1097/00043764-200301000-00007 When employees continue to work through a condition instead of focusing on treatment and prevention, their functional decline leads to missed workdays, reduced work hours, slower work performance and missed employment opportunities.

Failing to Support Workers with Depression Harms Working Families and Our Economy

Depression is defined by the National Institute of Mental Health as “a common but serious mood disorder” characterized by “depressed mood or loss of interest,” generally lasting two weeks or more, and its symptoms affect a person’s ability to manage everyday activities as well as their thoughts and feelings.National Institute of Mental Health. (2024, March). Depression. Retrieved 23 January 2025, from: https://www.nimh.nih.gov/health/topics/depression Nearly three in 10 adults (29 percent) have been diagnosed with depression at some point in their lives and about 18 percent currently experience depression.American Psychiatric Association. (2024, April). What Is Depression? Retrieved 23 January 2025, from: https://www.psychiatry.org/patients-families/depression/what-is-depression

Similar to cardiovascular disease, the accumulated stress of systemic racism and oppression disproportionately harms the mental health of people of color.Mason, J., & Molina Acosta, P. (2021, March). Called to Care: A Racially Just Recovery Demands Paid Family and Medical Leave. Retrieved 23 January 2025, from National Partnership for Women & Families website: https://nationalpartnership.org/report/called-to-care-a-racially-just-demands-paid-family-and-medical-leave/ While rates of diagnosed depression are lower in Black and Hispanic communities than in white communities,Lee, B., Wang, Y., Carlson, S. A., Greenlund, K. J. et al. (2023, June 16). National, State-Level, and County-Level Prevalence Estimates of Adults Aged ≥18 Years Self-Reporting a Lifetime Diagnosis of Depression – United States, 2020. Morbidity and Mortality Weekly Report, 72(24): 644-650. doi: 10.15585/mmwr.mm7224a1 some survey data indicates that Black, Hispanic, Asian and multiracial respondents report experiencing the symptoms of depression at similar or even higher rates than white respondentsBlueCross BlueShield. (2022, May 31). Racial disparities in diagnosis and treatment of major depression. Retrieved 23 January 2025, from: https://www.bcbs.com/dA/e09e583ba5/fileAsset/HOA-Racial-Disparities-Depression_2023.pdf; Nguyen, L. H., Anyane-Yeboa, A., Klaser, K., Merino, J. et al. (2022, August 10). The mental health burden of racial and ethnic minorities during the COVID-19 pandemic. PLoS ONE, 17(8): e0271661. doi: 10.1371/journal.pone.0271661 – suggesting that inequitable access to diagnosis and other mental health care services is a barrier, as well as other factors such as stigma or perception of stigma. Among people who have received a diagnosis of major depression, people in Black and Hispanic communities were less likely to be receiving pharmaceutical treatment, and received counseling or therapy less frequently, compared to those in white communities.In this analysis, a community was coded based on whether more than 50 percent of the households in the patient’s ZIP code identified as Black, Hispanic, or white in the 2019 American Community Survey. BlueCross BlueShield. (2022, May 31). Racial disparities in diagnosis and treatment of major depression. Retrieved 23 January 2025, from: https://www.bcbs.com/dA/e09e583ba5/fileAsset/HOA-Racial-Disparities-Depression_2023.pdf

The prevalence of depression also varies by gender.Sex and gender are linked to social, cultural, environmental, anatomical, biological and other factors that shape health. But how sex and gender affect health is complex because sex and gender are themselves dynamic and multifaceted (not binary), and include characteristics that vary along multiple spectra. Furthermore, these relationships are poorly understood due not only to their complexity, but also due to a long history of bias in scientific research. See Ritz, S. A., & Greaves, L. (2024, May 1). We need more-nuanced approaches to exploring sex and gender in research. Science, 629: 34-36. doi: 10.1038/d41586-024-01204-3 About twice as many women as men experience depression, likely due to a range of complex factors that disproportionately affect women, including stress from dual work and caregiving responsibilities; experiences of discrimination, harassment and abuse; greater economic insecurity and lower social status and power; and experiences related to significant physical changes like pregnancy, birth and menopause.Mayo Clinic. (2019, January 29). Depression in women: Understanding the gender gap. Retrieved 23 January 2025, from: https://www.mayoclinic.org/diseases-conditions/depression/in-depth/depression/art-20047725 The likelihood of experiencing depression may be particularly high for Black and Asian American women, and for women overall, the likelihood appears to increase in their 30s.Hargrove, T. W., Halpern, C. T., Gaydosh, L, Hussey, J. M. et al. (2020, August). Race/Ethnicity, Gender, and Trajectories of Depressive Symptoms across Early- and Mid-Life among the Add Health Cohort. Journal of Racial and Ethnic Health Disparities, 7(4), 619-629. doi: 10.1007/s40615-019-00692-8 LGBTQ individuals – especially youth – are also at an elevated risk for depression due to the harmful impacts of stigma and discrimination.The Trevor Project. (2022.) 2022 National Survey on LGBTQ Youth Mental Health. Retrieved 23 January 2025, from: https://www.thetrevorproject.org/survey-2022/; Bruss, K., V., Seth, P., & Zhao, G. (2024, June 20). Loneliness, Lack of Social and Emotional Support, and Mental Health Issues – United States, 2022. Morbidity and Mortality Weekly Report, 73(24): 539-545. doi: 10.15585/mmwr.mm7324a1

The cost of treating mental health conditions like depression is high. Depression is the sixth-most-costly health condition to treat – costing Americans a total of $71 billion a year as of 2017, including public and private health insurance expenditures and out-of-pocket expenses.Winerman, L. (2017, March). By the numbers: The cost of treatment. Monitor on Psychology, 48(3): 80. Retrieved 23 January 2025, from: https://www.apa.org/monitor/2017/03/numbers Not only do brand-name antidepressants cost hundreds for a 30-day supply for those without insurance,Cherney, K. (2024, August 5). How Much Does Depression Cost? Retrieved 23 January 2025, from Healthline website: https://www.healthline.com/health/depression/how-much-does-depression-cost#medication-cost but therapy sessions can cost $100 or more per hour.Anxiety & Depression Association of America. (2022, August 8). Low-Cost Treatment. Retrieved 23 January 2025, from: https://adaa.org/finding-help/treatment/low-cost-treatment For working people already experiencing financial insecurity, who as noted above are disproportionately people of color, the prospect of losing income or a job would make taking unpaid or unprotected leave prohibitive.

Employers and the economy also have a lot to lose when it comes to the cost of untreated depression and of workers and their families not having the resources to manage depression. Based on employers’ reports, depression is one of the top 10 most costly mental health conditions in terms of lost productivity while on the job, in addition to health care expenditures and time out of work.Goetzel, R. Z., Hawkins, K., Ozminkowski, R. J., & Wang, S. (2003, January). The health and productivity cost burden of the “top 10” physical and mental health conditions affecting six large U.S. employers in 1999. Journal of Occupational and Environmental Medicine, 45(1): 5-14. doi: 10.1097/00043764-200301000-00007 Employers thus stand to gain substantially from investments in supports that help their employees manage and improve their health, including paid leave.

Employers also lose out on talented employees when those with depression do not have the resources or support to participate in the labor market and economy. The unemployment rate among U.S. adults with mental illness is significantly higher compared to those without a mental illness.7.4 percent for people with mental illness compared to 4.6 percent for those without mental illness, according to National Alliance on Mental Illness analysis of 2021 National Survey on Drug Use and Health. National Alliance on Mental Illness. (2023, April). Mental Health by the Numbers. Retrieved 23 January 2025, from: https://www.nami.org/mhstats While the relationship between depression and employment is likely complex – in some cases, the experience of losing a job can worsen a person’s mental health – some research has found that experiencing severe symptoms of depression increases the odds that a person will not be employed in the future.Bubonya, M., Cobb-Clark, D. A., & Ribar, D. C. (2019, December). The reciprocal relationship between depressive symptoms and employment status. Economics & Human Biology, 35: 96-106. doi: 10.1016/j.ehb.2019.05.002 Ensuring greater access to support and treatment for depression and other mental health conditions could help people better manage their conditions, reduce the frequency and/or severity of severe symptoms, and improve their ability to participate in the workforce and succeed on the job.

Massachusetts Paid Leave Led to Fewer Poor Health Days for People with Depression and with Heart Disease

This analysis asks whether the implementation of paid family and medical leave in Massachusetts was associated with better health for workers with depression or with heart disease. To test this question, we assessed the change in monthly “poor health days” using data from the Behavioral Risk Factor Surveillance System, an annual survey conducted by the CDC. We used a difference-in-difference analysis to assess how poor health days changed in Massachusetts and other states in the periods of time before and after Massachusetts’ paid leave program was implemented (2015-2019 and 2021-2022). This analytic design allowed us to compare changes in poor health days in Massachusetts before and after the implementation of paid leave to those changes in a set of control states, while also controlling for other demographic factors and health seeking behaviors that are associated with health status.These variables include sex, race, income, insurance status, marital status, age, education and whether someone had not gone to the doctor in the past 12 months because they couldn’t afford it. (See Detailed Methodology below for more information.)

Our analysis focused on people who were employed and had ever been told that they had a depressive disorder (including depression, major depression, dysthymia, or minor depression),Referred to in this brief as “depression.” or coronary heart disease (CHD) or angina,Referred to in this brief as “CHD.” analyzing depression and CHD separately. To measure health impacts, we looked at the self-reported number of days in the last month that an individual reported experiencing poor health, defined as days during which poor physical or mental health kept an individual “from doing their usual activities, such as self-care, work or recreation.” We refer to these as “poor health days.”

For the employed people this analysis focused on, a poor health day that fell on a usual workday would mean either that the individual felt so poorly that they stayed home from work, or that it significantly interfered with their ability to perform on the job.Stewart, W. F., Ricci, J. A., Chee, E., & Morganstein, D. (2003). Lost Productive Work Time Costs From Health Conditions in the United States: Results From the American Productivity Audit. Journal of Occupational and Environmental Medicine, 45(12): 1234-1246. doi: 10.1097/01.jom.0000099999.27348.78 Outside the workplace, poor health days can mean a person is less able to care for themselves or their loved ones, engage in hobbies or volunteer activities that enrich their life, or take on the many other unpaid forms of work that help our communities thrive.

The results of the analysis show that paid leave supported the health of people with each condition. After the implementation of paid family and medical leave in Massachusetts:

• Workers with depression reported an average of 0.94 fewer poor health days in the past month than they would have without the program, or 11 fewer days per year.
• Workers with CHD reported 2.5 fewer poor health days in the past month, on average, or 30 fewer days per year.The findings for depression are significant at a 0.05 level and for CHD at a 0.10 level. See Detailed Methodology for more information about the analysis.

The gains to overall well-being are substantial. Fewer days impacted by poor health means that individuals with depression or with CHD are better able to care for themselves and their loved ones, to manage essential tasks like household chores or grocery shopping, and to take part in family and community life. Individuals and our health care system may also see lower health care costs thanks to improved health, although this possible outcome was outside the scope of our analysis.

Fewer Poor Health Days Could Mean More than $1 Billion in Improved Productivity Annually

Improved health and well-being alone are worth the investment in paid family and medical leave. Even beyond that, improvements to health can benefit businesses and the economy. Disabled people are a growing share of the workforce,Ditkowsky, M., & Majumder, A. (2024, February 22). Disabled employment is at a record high, but disparities remain. Retrieved 23 January 2025, from National Partnership for Women & Families website: https://nationalpartnership.org/disabled-employment-record-high-but-disparities-remain/ and workers with chronic illnesses and other disabilities are creative, skilled employees. Reducing the barriers that prevent disabled people from equitable participation in jobs and the economy would help employers attract and retain more talented employees, support disabled entrepreneurs and business leaders, and improve the economic security of disabled people.Ditkowsky, M. (2022, July). Systems Transformation Guide to Economic Justice for Disabled People: Jobs and Employment. Retrieved 23 January 2025, from National Partnership for Women & Families website: https://nationalpartnership.org/report/disability-economic-justice-systems-transformation/ Supportive policies, including paid family and medical leave, enable disabled workers to succeed at their jobs while managing their health and caregiving needs.

For an employed person, a poor health day means either that they felt so poor they stayed home from work – absenteeism – or that their ability to work was impacted even if they clocked in at their job, known as presenteeism.Presenteeism can include experiences such as difficulty concentrating, having to repeat tasks, and fatigue while at work. Stewart, W. F., Ricci, J. A., Chee, E., & Morganstein, D. (2003). Lost Productive Work Time Costs From Health Conditions in the United States: Results From the American Productivity Audit. Journal of Occupational and Environmental Medicine, 45(12): 1234-1246. doi: 10.1097/01.jom.0000099999.27348.78 In either case, productivity is affected. Lost productivity due to health-related causes was estimated to cost employers $225.8 billion nationally in 2003 (equivalent to nearly $400 billion in 2024 dollars).Stewart, W. F., Ricci, J. A., Chee, E., & Morganstein, D. (2003). Lost Productive Work Time Costs From Health Conditions in the United States: Results From the American Productivity Audit. Journal of Occupational and Environmental Medicine, 45(12): 1234-1246. doi: 10.1097/01.jom.0000099999.27348.78; U.S. Bureau of Labor Statistics. (n.d.) CPI Inflation Calculator. Retrieved 9 September 2024, from https://data.bls.gov/cgi-bin/cpicalc.pl?cost1=225.80&year1=200301&year2=202406 Notably, it has been estimated that more than 80 percent of the total loss to productivity due to depression is due to worse productivity while at work.Stewart, W. F., Ricci, J. A., Chee, E., & Morganstein, D. (2003). Lost Productive Work Time Costs From Health Conditions in the United States: Results From the American Productivity Audit. Journal of Occupational and Environmental Medicine, 45(12): 1234-1246. doi: 10.1097/01.jom.0000099999.27348.78 But our analysis of Massachusetts’ paid leave program suggests that the availability of paid leave may be associated with fewer poor health days.

Reducing the number of poor health days experienced by workers with chronic illness would mean reducing the number of days on which they either had to stay home from work or their health was so poor it interfered with their work while on the job, thereby improving their productivity on days they were scheduled to work. While our data source did not allow us to identify whether a person was absent or present at work during a poor health day, we estimated the overall potential productivity gain from fewer poor health days for Massachusetts workers with depression and those with heart disease.Each estimate was calculated separately, and so workers with both conditions could be counted twice. We conservatively estimate that four out of every seven poor health days occur on workdays, based on the average hours worked per week by employed people in Massachusetts, and use the average hourly earnings of employees in Massachusetts as a measure of their average hourly productivity. (See Detailed Methodology for more information.)

We estimate that the reduction in poor health days is equivalent to:

• At least $565.4 million and up to $1.2 billion in productivity for Massachusetts workers with depression annually.
• At least $65.7 million and up to $330.4 million in productivity for Massachusetts workers with coronary heart disease annually.

Compared to the modest, shared costs employers and employees pay to fund Massachusetts paid leave, these benefits are sizeable.

• On average, employers would have paid about $258 annually per employee in premiums for Massachusetts Paid Family and Medical Leave in 2021 and 2022.Calculation based on average weekly earnings in Massachusetts in 2021 and 2022, according to American Community Survey data, and assuming a 52-week working year. Historical employer contribution rates for 2021 and 2022 can be found via the Internet Archive at https://web.archive.org/web/20211224090330/https://www.mass.gov/info-details/paid-family-and-medical-leave-employer-contribution-rates-and-calculator#calendar-year-2021-;
• Based on our low-end estimates, the productivity benefit per employee with depression amounts to $880 per year, and per employee with CHD, $1,004 per year.

America Needs Paid Family and Medical Leave to Help Workers with Chronic Health Conditions Thrive

Millions of workers nationwide are already being supported by state paid family and medical leave programs in Massachusetts and nine other states, with more state programs set to be implemented in the next few years. Workers and families in those states are feeling the benefits to their health, financial stability and peace of mind. Employers are experiencing reduced employee turnover and improved productivity and morale. Our research adds health benefits to workers with depression and heart disease to the long list of positive outcomes of paid leave programs.

Yet still, the majority of working people in the United States are not covered by a state paid leave program and have no national guarantee of paid leave. It is past time for state and federal governments to act and finally ensure that every worker in the United States can access paid leave when they need it most.

---

Detailed Methodology

Impact of paid leave implementation

This analysis uses 2015 to 2019 data and 2021 to 2022 data from the Behavioral Risk Factor Surveillance System (BRFSS), a national survey conducted annually by the Centers for Disease Control and Prevention. The analysis excluded data from 2020 due to the likelihood of significant state-level variation in pandemic-related health outcomes, policies and data collection. The analysis focuses on Massachusetts because it was one of the first states to newly implement paid medical leave in a period of time for which BRFSS data was available and had at least two years of data available pre- and post-treatment. Washington and the District of Columbia were excluded due to initial implementation occurring during 2020, due to the likelihood of pandemic-related confounders. In addition, the greater availability of medical leave with job protection in Massachusetts, compared to D.C. or Washington state, is likely to strengthen any potential benefits of paid leave relative to other states’ programs.Arora, K., & Wolf, D. A. (2024, June). Paid Leave Mandates and Care for Older Parents. The Milbank Quarterly. Online first. doi: 10.1111/1468-0009.12708; National Partnership for Women & Families. (2024, July). State Paid Family & Medical Leave Insurance Laws. Retrieved 23 January 2025, from https://nationalpartnership.org/wp-content/uploads/2023/02/state-paid-family-leave-laws.pdf

The control group includes states that, like Massachusetts, had expanded Medicaid prior to the study period, had at least some paid sick days coverage and no change in permanent paid sick days law during the study period, and no paid family and medical leave program during the study period. Six states met these requirements: Vermont, Maryland, Arizona, Illinois, Oregon and Pennsylvania. All analyses were limited to those respondents who were employed and controlled for binary sex, race, household income, insurance status (whether they had “some form of [health] insurance” or not), marital status, age, education and whether someone had not gone to the doctor in the past 12 months because they couldn’t afford it. A standard difference-in-differences approach was used. The model includes the binary variable of interest (treatment with paid leave program/no treatment), the control variables and both individual state and year fixed effects, which control for both time- and location-invariant exogenous effects. All analyses were run in Stata 18.0 and R. For more details on the model formula and results, contact Anwesha Majumder or Jessica Mason.

Estimate of improved productivity due to fewer poor health days

This analysis is based on an estimate of 3.6 million total employed Massachusetts residents 18 and older, average weekly hours of 38.6 and average hourly earnings of $36.26. These estimates are based on 1-year samples of the American Community Survey for 2021 and 2022 (average values across both years), accessed via IPUMS USA, University of Minnesota, www.ipums.org. We value workers’ productivity at the equivalent of the average wage for workers in Massachusetts in 2021 and 2022, averaged across both years. We estimate the prevalence of depressive disorders in Massachusetts at 17.74 percent and the prevalence of coronary heart disease at 1.8 percent, based on BRFSS data for 2021 and 2022 (average value across both years). Because average weekly hours of all Massachusetts workers are slightly less than 40 (38.6), we conservatively assume that 4/7 of poor health days take place on scheduled workdays. The underlying BRFSS data does not distinguish between a poor health day resulting in missed work and a poor health day resulting in presenteeism, and studies attempting to measure how specific health conditions affect workers’ productivity offer a range of approaches and estimates. To account for the range of potential impacts, we include both an upper-bound estimate and a lower-bound estimate for each condition. The upper-bound estimate assumes all poor health days that fall on workdays represent a 100 percent loss of productivity (either due to absence from work or 100 percent loss of productivity while at work).

For the lower-bound estimate, we conservatively assume that every poor health day on a workday represents a day on which the employee did report to work, but experienced a typical level of productivity impairment for someone with their condition.

• For depression, we draw on a recent meta-analysis reviewing relevant research over the previous decade. Based on four studies using a standard validated questionnaire, asking respondents’ work impairment over the previous two weeks, the median impairment impact of depression on work was 47.1 percent. See Rojanasarot, S., Bhattacharyya, S. K., & Edwards, N. (2023). Productivity loss and productivity loss costs to United States employers due to priority conditions: a systematic review. Journal of Medical Economics, 26(1), 262-270. doi: 10.1080/13696998.2023.2172282
• For heart disease, several more recent studies only provided estimates of the impact of broader categories combining multiple conditions (such as hypertension and diabetes) whose impact on work likely differs from coronary heart disease, or estimated productivity impacts averaged over a full year, which would understate the impairment during the kind of acute episodes captured by the poor health day measure in our analysis. To more closely match the health experience targeted in our analysis, we draw on a 2005 study of full-time employees at Dow Chemical, which includes a measure specific to employees with heart and circulatory problems. Asking what level of work impairment was experienced over the previous four weeks, they find a work impairment impact of 19.9 percent. See Collins, J. J., Baase, C. M., Sharda, C. E., Ozminkowski, R. J., Nicholson, S., Billotti, G. M., et al. (2005). The assessment of chronic health conditions on work performance, absence, and total economic impact for employers. Journal of Occupational and Environmental Medicine, 47: 547–557. doi: 10.1097/01.jom.0000166864.58664.29

Back to Paid Leave