The COVID-19 pandemic laid bare the devastating economic and personal costs of the nation’s failure to prioritize care policies. During the pandemic, schools and child care programs closed or reduced their hours and services; people brought their loved ones home from nursing homes out of fear for their well-being; it became a health risk to rely on family, friends, and neighbors for care; and many families—especially mothers—were required to spend unexpected time doing unpaid caregiving and providing support for remote learning while also managing work. The results have been devastating for families and communities and has led to an inequitable economic recovery.

For too long, the United States has treated managing both care and work as an individual responsibility and failed to enact common-sense care policies such as paid family and medical leave; paid sick days; high quality, affordable child care and early education; home and community-based services; and livable wages for care workers. While, at some point, everyone will need to receive or provide care, in the United States, a household’s wealth and income determines whether it will have access to more and better care options. This reality exacerbates and perpetuates structural racism and sexism, which have caused people of color and women to have less wealth and lower earning power throughout their lives.

The nation’s failure to provide the resources necessary for high quality child care and home and community-based services or to establish paid leave policies before the pandemic has exacerbated care challenges and deepened the pandemic’s racial- and gender-specific impacts. Throughout the pandemic, Black, Indigenous, Latinx, and immigrant women in particular were disproportionately providing care to children, family members with disabilities, or aging family members, while also either serving as essential workers (including as members of the care workforce) or losing their jobs and being forced to look for new ones.

The Biden administration, champions in Congress, moms, dads, grandparents, early educators, seniors, people with disabilities, and members of the sandwich generation have all recognized the need for comprehensive public policies to address these challenges. In September 2021, committees in the House of Representatives voted to pass President Biden’s care economy proposals that include paid family and medical leave, comprehensive child care, universal preschool, and significant funding for home and community-based services.1 With the promise of these proposed policies, enacting a robust, transformative national care agenda is finally within reach.

For decades, state advocates and elected officials have been pushing for these types of care-related policies. But passing state-level care policies requires a challenging combination of significant funding and political will. Despite the challenges, states have made progress. Ten states have paid family and medical leave laws in place,2 fourteen have paid sick days,3 and ten have Domestic Workers Bills of Rights.4 Forty-four states have some form of pre-K in place.5 Washington, D.C.6 and Washington State7 have adopted innovative models for child care and long-term care policies respectively. But for most states, there is still a long way to go to get from where they are today to where children and families need them to be.

Grading of State Policies

This report grades states on their existing care infrastructure. The grades should not be taken as a reflection on the desire of state experts, advocates, organizers, and political leaders to make change, but rather a reflection of how well the combination of complex factors that lead to policy change have come together to lead to positive results. It also accentuates why it is critical for Congress to act this year to provide the significant funding and parameters needed to support states in making these policies a reality.

This report looks at five major policy areas to measure each state’s progress toward the goal of enacting the ideal care policies that support children, families, and communities. The policy areas are:

  • child care and early learning;
  • home and community-based services/long-term care;
  • paid family and medical leave;
  • paid sick and safe days; and
  • fair working conditions for care workers.

The grading system in this report assigns states grades of A, B+, B, B-, C+, C, C-, D+, D, D-, or F. The grades assigned were based on a fifteen-point system, in which states earned up to three points for success in each of the five major policy areas. Within each policy area, the points were divided and subdivided based on the specifics of the issue. States received extra credit for having pregnant worker fairness laws, fair scheduling laws, and family-supporting tax policies, one point for each. The grades assigned were based on the following grading scale:

A = 13.5 or more points
B+ = 12.5-13.49 points
B = 10.5–12.49 points
B- = 9.5–10.49 points
C+ = 8.5–9.49 points
C = 6.5–8.49 points
C- = 5.5–6.49 points
D+ = 4.5–5.49 points
D = 2.5–4.49 points
D- = 1.5–2.49 points
F = 0-1.49 points

Creating a grading system presented many options, such as whether to grade states on a relative scale against each other, or based on their progress over time. Instead, the report measures whether states had ideal policies in place, using the most recent data available to capture their status at this particular moment in time.

The report recognizes that these issues are complex and simply having a law on the books does not necessarily mean that people are being served well. To try to account for this challenge, the report uses data that indicates the likely effectiveness (or ineffectiveness) of those laws. This report, however, should not be considered a comprehensive review of how states are serving their constituents’ care needs on a day to day basis, as it does not reflect an in-depth study of each state to explore how policies in place are being implemented nor interviews that convey the experiences of those impacted. Instead, the data and observations presented in this report reflect an overview of how states are doing regarding pursuing their care policy agendas, relying as much as possible on single sources of data that have information for all fifty states and Washington, D.C.8

In addition, many cities and counties have also enacted care-related policies, and these policies not only are impactful and have a positive impact for people where they live, but also help encourage states to adopt the policies as well. This report, however, does not analyze local policies and their impact, but instead focuses solely on state policies.

The Results

The majority of states (thirty-five) received below a C, demonstrating that they have a long way to go to be considered a good state for care policy. No state received an A, five states (California, Oregon, Connecticut, New York and Massachusetts) received a B, and five (Florida, Alabama, Indiana, West Virginia, and Mississippi) received an F. Four states received a B- (Colorado, New Jersey, Washington, and District of Columbia).

To understand these grades, it’s useful to note that the majority of states have no paid family and medical leave policies or paid sick and safe day policies, so they received a 0 in those categories. States that have such policies in place scored higher. In addition, most states have a pre-K program, so they received at least partial credit for that in the child care and early learning section.

map 1. Care Report Card Grades

The Economic Benefits of Care Policies

Good care policies have many benefits to children, families, and communities that can be hard to measure. However, one of the more straightforward ways to view them is through their economic benefits. As Table 1 and Figures 1 and 2 show, states with higher care economy scores have higher rates of women’s labor force participation and narrower gender pay gaps, on average. This offers yet another piece of evidence of what is discussed throughout the report: investments in the care economy are necessary precursors to an equitable and sustainable economy overall, and a lack of care economy policies hinder progress toward those goals.

Women’s Labor Force Participation and Wage Gap, By State Care Economy Score
Letter Grade Prime-Age Women’s Labor Force Participation Rate Wage Gap (what women make for every dollar men make)
B 77.3 $0.82
C 77.7 $0.84
D 76.8 $0.79
F 73.3 $0.77
Note: Letter grades in this table are inclusive of +/- grades; for example, C includes C+ and C-.
Source: Authors’ calculations; prime-age women’s labor force participation rate from the Bureau of Labor Statistics and wage gap data from the National Women’s Law Center. See Appendix C for the full data table.

Child Care and Early Learning

Comprehensive child care and early learning policies benefit everybody. They help improve economic prosperity and lead to greater gender, racial, and economic equity.9 A state system that includes these priorities would support healthy child development and improved health, economic, and wellness outcomes that can persist into adulthood and even the next generation.10 It would support family economic security and well-being—supporting the ability of parents to work and advance in their jobs and careers, early educators to be compensated well, child care fees that fit easily within family budgets, and an overall reduction in stress across all households. And in doing so, such a system would grow a state’s economic activity in the form of job creation and support, increased tax revenues, and other economic benefits.

Scoring Rubric

Measuring a state’s policy progress on child care and early learning priorities is a challenge. The aim is to grade states based on their proactive policy making, but the policy details are complex and nuanced.

Right now, the major child care policy instrument in the United States is the Child Care Development Block Grant (CCDBG). For this block grant, the federal government sets parameters for the use and matching of state funds to support child care assistance for children from birth through age 12 (19 for children with disabilities). CCDBG only allows states to serve families up to 85 percent of SMI who meet additional criteria, which means that the majority of families in the United States do not even qualify for support from the programs. Even for those that do qualify, underfunding has created the situation where only one in seven eligible children receive assistance, and fewer than one in eight eligible young children (under age 5) receive it. Thus, even the states with the best policies in place are not solving the child care challenges for the majority of families. As a result, the majority of states received a low grade for child care and early learning.

In addition, while many states made temporary policy changes in 2020 and 2021 as a result of the pandemic and pandemic-related funding, this report uses pre-pandemic policies and data wherever possible to avoid measuring the possible distorting effects of temporary pandemic-related challenges and policy responses.

The scoring rubric attempted to measure state child care and early learning efforts according to four specific criteria: affordability of child care and early learning; accessibility of a diverse supply of options; the quality of care; and success in achieving universal pre-K.11

  • Affordability of child care and early learning. It is essential that states work toward guaranteeing affordable child care for every family, prioritizing those most in economic need, where families pay no or low fees to access safe, nurturing care for their children. Child care remains extremely expensive and out of reach for too many families. In more than half of states, child care for an infant in a child care center costs more than in-state college tuition.12 The affordability of child care in each state was scored by looking at two measures related specifically to federal–state child care assistance programs: income eligibility and copayments that are set by the states.
  • Accessibility to a diverse supply of options. States need to support diverse, inclusive, flexible, culturally competent, bilingual care options that serve children with disabilities, including care in a variety of settings. Analysis from the Center for American Progress (CAP) found that more than half of American families with children under age 5 lived in a child care desert, which they defined as “any census tract with more than 50 children under age 5 that contains either no child care providers or so few options that there are more than three times as many children as licensed child care slots.”13 CAP found that every single state has a child care desert, so the report gave partial credit for states that had less of their population living in deserts.
  • The quality of care. States must work with families and providers to ensure that children are safe, nurtured, and learning in high quality settings with well-compensated staff to optimize children’s cognitive, social, and emotional development. The scoring rubric relies on the Early Childhood Workforce Index from the Center for the Study of Child Care Employment (CSCCE) at the University of California, Berkeley14 and includes whether a state has a Child Development Associate (CDA) credential in place and whether states provide support for pursuing and achieving a credential or additional training in the form of scholarships, apprenticeships, stipends, or tax credits and bonuses.
  • Success in achieving universal pre-K. States should make every effort to provide universal pre-K for children ages 3 and 4. Pre-K programs are an important part of education. They are included in this report card on care because parents that are able to rely on public pre-K or other preschool programs have child care during the hours that their children are supervised. The National Institute for Early Education Research’s (NIEER) reports annually on state preschool policies, including on child enrollment, funding, staffing, and quality standards, and ranks states based on these data and this report usese those rankings to grade states on their preschool policies.15

Best and Worst States

No state met the ideal criteria according to the scoring rubric. The financial resources needed for investments to achieve this are significant. A 2018 study by the National Academies of Sciences, Engineering, and Medicine found that a truly accessible, affordable, high quality early care and education system nationwide would require at least $140 billion from combined public and private sources when fully phased in.16

That said, Washington, D.C. came the closest. In 2009, Washington, D.C. began offering two years of universal, full-day preschool using a mixed delivery model across the city’s public schools, public charters, and some private preschool programs administered by community-based organizations.17 In 2018, they added Birth to Three DC, establishing a system to ensure that—when fully funded and implemented, ideally by 2028—all children under age 3 would have access to high-quality early learning and health care opportunities. Birth to Three DC phases in eligibility for subsidized child care by first expanding slots for infants and toddlers in families who are paid lower wages. Once the needs of lower-income families are met, it expands support to families in need of all income levels, ensuring that families pay on a sliding scale based on income and no family pays more than 10 percent of their income for child care.18 The law also requires that the Office of the State Superintendent of Education (OSSE) develop a competitive compensation/salary scale for lead teachers and teacher’s assistants with a “cost modeling analysis” to help establish reimbursement rates that reflect the competitive salary scale.19

Wyoming and Idaho stand out as among the lowest scoring based on this rubric. Neither state has a pre-K program and they both have particularly low income eligibility for families for their child care programs.

Home and Community-Based Services/Long-Term Care

A robust system of home and community-based services and long-term care is essential to supporting quality of life for people with disabilities, the ability to age with dignity, and the family members who love those in need of support, yet much of the country seems unprepared for providing it. According to the National Academy of Social Insurance, America will experience more than 200 percent growth in the population of people age 85 and over from 2015 to 2050.

Furthermore, 61 million adults with disabilities, injury, or illness currently need care provided by a family member or professional caregiver.20 The need for public investments in long-term supports and services grows every day, as the needs outpace families’ financial resources and time available to support their loved ones. Among those age 65 and over today, 70 percent need help with at least one activity of daily living (ADL) and 52 percent have significant need for long-term services and supports (LTSS), indicated by needing help with two or more ADLs and/or a significant cognitive impairment.21 While some families rely on institutional or congregate care, many people in this population prefer to live and age in their homes or communities22 and others cannot afford the high cost of nursing homes or assisted living facilities.23

Investing in home and community-based services has significant benefits for economic growth, equity, families, and communities. With a more robust care system in place, working family caregivers would be more productive in the economy, increasing economic activity by an estimated $17.1 billion to $33.6 billion.24 More investment would also improve the quality of caregiving jobs, which are held primarily by Black, Latinx, and immigrant women. Increased public investment would also help families achieve financial security so they can continue to live and spend money in their communities. And lastly, strong and robust policies can support the inclusion of people with disabilities and older adults’ participation in the workforce and in the nation’s economy.25

Scoring Rubric

For the scoring of this policy area, the rubric relies on data from the “Advancing Action” scorecard from the AARP Public Policy Institute, which ranks states based on the following five dimensions:26

  • affordability and access: nursing home and home care cost, accessibility of services through Medicaid, and other aging and disability services;
  • choice of setting and provider: Medicaid spending and usership, supply of home health aides, assisted living, and other day services, and subsidized housing opportunities;
  • quality of life and care: rate of employment for persons with disabilities, nursing home use of antipsychotic drugs and prevalence of bed sores, and HCBS quality benchmarking;
  • support for family caregivers: policies that support working family caregivers, make home and community based services available to Medicaid recipients, improve nursing capacity and responsibilities, and transportation; and
  • effective transitions: outcomes for nursing home residents, home health and nursing home clients, and successful discharge of patients into communities.

Best and Worst States

Based on the aggregate score for all five categories, the top ten states are: Minnesota, Washington, Wisconsin, Oregon, Vermont, Connecticut, Hawaii, Colorado, California, and Massachusetts, in that order. The lowest scoring states, starting with the lowest, are Florida, West Virginia, Alabama, South Carolina, Kentucky, Oklahoma, Arkansas, Indiana, Tennessee, and Louisiana.

Clearly states with low scores are not serving the needs of their aging and disabled populations or those of family caregivers. But even high scores in some states do not negate their need for improvement and specific policy action in some areas. For example, the highest scoring state, Minnesota, ranks eleventh out of fifty-one in terms of effective transitions; the second highest scoring state, Washington, scores 27 in terms of quality of life; and the third highest scoring state, Wisconsin, scores 17 in terms of support for family caregivers. Even states that rank the highest for a single policy area face significant challenges: for example, in the five states that rank highest for affordability, nursing home costs consume more than 170 percent of a typical older household income.27 And despite the ambition of Washington State in being the only state to implement a state-run long-term care insurance program, various other policies will determine the efficacy of that program over time. Other states have shown improvements over time. Six states—New York, Maryland, Connecticut, New Jersey, Pennsylvania, and Rhode Island—have improved in at least six of the twenty-one indicators tracked by the AARP scorecard since its prior assessment.

Paid Family and Medical Leave

At some point in life, nearly everyone will need time away from work to recover from an illness or childbirth, provide care to an ill family member, or take care of a new child. Paid family and medical leave policies provide wage replacement and job protection so people can take the time they need to recover, or provide care for a family member, without worrying about forgoing income or losing a job. Research shows that paid family and medical leave improves childhood development, public health, and the economic stability for families. If a child is critically ill, either at birth or later, the presence of a parent reduces the length of their hospital stay by 31 percent.28 Mothers who take paid leave after childbirth are less likely to experience symptoms of postpartum depression.29 Access to paid leave helps cancer patients complete their treatment and better manage any side effects.30

Paid family and medical leave supports the livelihoods of hardworking people by helping to cover their everyday expenses during a health crisis or after the birth of a child, increasing the financial stability of families, and helping caregivers join the workforce. Evidence from states with existing paid leave policies, such as California, shows paid leave increases the labor force participation of caregivers.31 Studies from California also show that paid leave programs reduce the risk of poverty among mothers with infants, reduced food insecurity in households after childbirth, and increased household income for mothers by 4.1 percent.32 Paid family and medical leave policies also help employers by attracting and retaining talent and avoiding the cost of turnover, which can be as high as one-fifth of a worker’s salary.33

The lack of access to paid leave exacerbates economic and gender inequality, as care work disproportionately falls to women. This policy shortcoming also has racial implications, as four out of every five Black mothers and two out of three Native American mothers are the key or sole breadwinners for their families.34 Furthermore, Black and Brown workers are more likely to work in low-wage jobs that do not provide paid family and medical leave, requiring them to take unpaid time off in response to a medical or family emergency and contributing to racial economic inequities.35

Right now, through the Family and Medical Leave Act (FMLA) of 1993, the U.S. federal government requires some employers to provide twelve weeks of unpaid job-protected family and medical leave for eligible employees. Furthermore, the eligibility criteria for FMLA excludes nearly 40 percent of workers, and many who do have access cannot afford to take it.36 In the absence of federal policies, ten state governments, including the District of Columbia, have implemented paid leave policies.37 Still, only 19 percent of U.S. workers currently have access to paid family leave, and just 40 percent have access to personal medical leave through employer-provided short-term disability insurance.38

Scoring Rubric

An ideal paid family and medical leave policy prioritizes universal coverage without placing an undue burden on workers, helping to ensure those who need to take time off work to care for themselves or their families can do so. In the scoring rubric, a state can receive up to 3 points for its paid family and medical leave policy. Any state with a paid leave policy automatically receives 1 baseline point. States where workers are covered only by FMLA receive 0 points. States that have expanded eligibility criteria beyond the federal law to cover more workers than are typically covered under FMLA receive some consideration and receive 0.5 points.

To earn points above the baseline, each state’s paid leave policy is evaluated against ten advocacy criteria from model legislation guidelines copublished by A Better Balance and the National Partnership for Women & Families.39 Each of the ten policy criteria are equally weighted for an additional 0.2 points based on whether the state’s policy addresses these priorities:

  • eligibility standards: includes all workers regardless of employer size, including public employees, private employees, and self-employed or independent contractors;
  • family member definition: includes reasons a person can take leave that cover a variety of personal, medical, and caregiving needs and defines eligible family members broadly to include close personal relationships that would require a worker to provide care to someone in their lives;
  • reasons for leave: covers a broad range of medical and family caregiving needs that would require a worker to take time off work, including military reasons for “qualifying exigency” leave to support an active-duty member of the U.S. military;
  • benefits duration: provides more than twelve weeks of leave for any reason, either medical or family;
  • benefit amount: includes a progressive wage replacement benefit that prioritizes replacing the most wages for low wage workers;
  • contribution levels: requires both the employer and employee to share contribution for either the paid or medical leave system (a state does not receive credit if the full costs of both programs fall entirely on the employee);
  • scheduling flexibility: allows for intermittent leave, permitting an employee to spread the leave across different blocks of time for a single reason for leave;
  • job protection: includes job protection beyond FMLA for any reason, for either medical or family leave (a state receives credit for job protection despite business size or minimum employee count requirements);
  • continued health care benefits: requires coverage of health care benefits through the employee’s leave period; and
  • retaliation and non-discrimiation: goes beyond protections defined in FMLA.

Best and Worst States

Of the ten states and District of Columbia that have paid family and medical leave policy, two states get closest to the ideal: Colorado and Massachusetts. Both states provide more than twelve weeks of leave with progressive wage replacement; allow workers to take leave to support active-duty military; provide additional job protection and non-discimination beyond FMLA; and ensure an employee can remain on employer-provided health insurance through the duration of the leave period. Colorado’s policy does not allow for intermittent scheduling of leave. Massachusetts’s paid family and medical leave policy does not define family members by blood or affinity.

Forty-one states—an overwhelming majority of states across the country—do not have a statewide paid family and medical leave policy of any kind, leaving workers to make the difficult choice between work and wages, or taking care of their health or a family member. Only four states receive some consideration for expanding access to FMLA; however, unpaid leave policies do not provide enough support for workers to be able to take the time they need.

The differences in the state policies, and the vast policy deficit nationwide, highlight the need for a federal policy to help extend access to paid family medical leave to workers across the country.

Paid Sick and Safe Days

Access to paid sick and safe leave provides workers with the flexibility essential to meeting their own health needs and those of their families without jeopardizing their financial security. Being able to take a few hours or a few days away from work to attend doctor appointments, receive medical treatment, accommodate a school closing or public health emergency, or navigate a situation related to domestic or sexual abuse—all without losing pay—helps workers maintain their financial stability.40 Because the United States lacks a national paid sick days standard, more than 30 million workers have to choose between their health and their paycheck.41 Paid sick days are particularly important given the pandemic. Workers without paid sick days are 1.5 times more likely to go to work with a contagious illness than those with paid sick days.42 Additionally, workers without paid sick leave are three times more likely to delay accessing medical care (such as delaying a COVID-19 test or vaccination) and twice as likely to delay or forgo medical care for their families.43 As with other benefits, workers that tend to lack access to paid sick and safe leave are primarily Black and Brown: more than one-third of Black workers44 and nearly half of Latinx workers45 are unable to accrue even one paid sick day.

Scoring Rubric

An ideal paid sick and safe leave policy should cover all workers (including independent contractors and seasonal workers), provide a meaningful amount of time off, have an inclusive family definition, and include safe days and additional time for public health emergencies—such as the COVID-19 global pandemic.46 For the rubric, states were graded on a scale of 0 to 3. Jurisdictions with a statewide paid sick and safe days law automatically receive 1 point. To receive additional points, eight factors/provisions of each state’s law were reviewed and weighed against the provisions of a “gold standard” legislation drafted by A Better Balance and the National Partnership for Women & Families.47

When considering the scoring of each law, this report reviewed the following provisions:48

  • Number of employees. Employer thresholds absolve employers with a certain number of employees from having to provide paid sick and safe leave. These high thresholds leave millions of workers without this necessary protection and jeopardize their health, their families’ health, and their financial security. States whose laws cover all workers—regardless of the number of employees—received an additional 0.25 points in our scoring.
  • Accrual rate of paid sick and safe days. The rate at which an employee can accrue paid sick and safe leave directly contributes to how much leave they can acquire and how quickly they can use it. States with the standard rate of accrual (one hour of paid sick time for every thirty hours worked) were given an additional 0.25 points.
  • Number of days that can be accrued. For a policy to be truly effective, it must provide workers with a meaningful amount of leave. While some states have varied the amount of leave that can be accrued based on the number of workers an employer employs, the majority of laws provide workers with five days. For the purposes of grading, an additional 0.25 points were given to states that had laws that provided more than five days.
  • Inclusive family definition. Having an expansive and inclusive family definition allows workers to take care of more than their immediate family (child, spouse) and better recognizes the makeup of most American families. For grading purposes, an additional 0.25 points was given to those states that had laws that include language to allow workers to use their accrued time to care for “any individual related by blood or affinity.”
  • Private right of action for violations. Enforcement of any law is critical to ensuring that workers remain protected and are able to access their accrued time off. States that had laws that included a private right of action for workers whose rights have been violated by the employer were given an additional 0.25 points.
  • Inclusion of paid safe days. An instance of domestic abuse, sexual abuse, or stalking is traumatic for any individuald and their family. Allowing accrued days to be used to address any circumstance and attend any meetings or court appearances arising from an instance of abuse or stalking is critical to protecting workers. States whose laws allowed accrued time to be used for this purpose were given an additional 0.25 points.
  • Use of sick days. Being sick or needing to address circumstances arising from domestic or sexual abuse are not the only reasons a worker might need to take time away from work. Needing to respond to a public health emergency, a school or business closure, or address a child’s needs at school are also important matters that workers often face. States that had laws that allow for accrued time to be used for these additional purposes received an additional 0.25 points.
  • Tenure before being able to access accrued time. The time between when workers begin to accrue paid sick leave and when they are able to use their accrued time is often a barrier for many workers in being able to maximize the benefit. Millions of workers often find themselves unable to use the benefit because they are too new to their roles. Additionally, a longer waiting period often excludes seasonal workers as they are not employed long enough to access the accrued time. Ensuring every worker is able to access paid sick and safe leave quickly—regardless of tenure—is critical to making sure that all workers are able to use this benefit. States whose laws allowed workers to be able to access their accrued time immediately received an additional 0.25 points as their benefits are the most accessible.

Best and Worst States

Fourteen states and Washington, D.C., have passed and/or enacted statewide paid sick days laws. These states are leading the way in providing meaningful and helpful protections for their workers. New Mexico and Colorado have the most expansive paid sick and safe leave laws that provide the most benefits and cover the most workers.

Unfortunately, workers in thirty-six states lack statewide paid sick and safe leave protections. While some cities have enacted their own paid sick and safe days policies, millions of workers remain unprotected without a statewide law. In Texas, the cities of Austin,49 San Antonio, and Dallas50 worked hard to enact paid sick and safe leave ordinances that would have benefited hundreds of thousands of workers. But the Texas state courts and legislature have blocked the ordinances from going into effect, leaving those workers vulnerable to illness and lost pay. Additionally, seventeen states have preempted paid sick and safe leave laws, prohibiting local jurisdictions from passing any ordinance or law that would provide the benefit.51

Fair Working Conditions for Care Workers

The pandemic has shown just how essential care work is to the functioning of the nation’s economy. It is, and has always been, woven into the fabric of daily life—from mothers doing a majority of unpaid care work at home, to the majority women of color and immigrants supporting families in their homes through domestic work, and those taking care of children, older adults, and people with disabilities outside of their homes. While care work has long been undervalued, reflected in these workers’ low wages and poor working conditions, policymakers in some states have taken steps toward equity and justice for care workers, writing vital policies for ensuring dignified work lives for those keeping so many others safe and healthy.

Domestic workers—nannies, house cleaners, personal care aides—in particular have long been left out of labor policy. Domestic workers are some of the lowest paid and least protected workers, yet they are often essential to ensuring others are able to work, and deliver care and peace of mind for children, people with disabilities and older adults. Due to the racial and ethnic makeup of the domestic workforce, protecting domestic workers means protecting women of color and immigrants who deserve the same rights and worker protections as all other workers. A National Domestic Workers Bill of Rights policy has been reintroduced in Congress in 2021,52 but until federal standards are put in place, only states and cities can ensure dignity and legal protection for domestic workers.

Domestic workers and other care workers have also born the brunt of a long history of racial and gender based discrimination, exclusion from labor law, and anti-union laws, from the New Deal, when domestic workers were excluded from the National Labor Relations Act, to Harris v. Quinn, a 2014 U.S. Supreme Court court decision that ruled that home care workers could not be required to pay union dues—a major blow in the decades-long effort to organize the sector.53 Despite these setbacks, many states have found ways to support the collective bargaining rights of care workers.54 If all home health care and child care workers were covered by union contracts, due to the wage-boosting effects of such agreements, these workers would likely see wage increases up to 60 percent, according to one analysis by the Economic Policy Institute.55 They would also be much more likely to have health insurance, paid time off, and equitable pay, since these provisions are often included in bargaining negotiations.

Scoring Rubric

The scoring rubric tracked two core policy areas of state support for care workers and also assigned points for higher wages as compared to fixed measures, such as cost of living in the state:

  • The Domestic Workers Bill of Rights. The push for a Domestic Workers Bill of Rights nationally and in states has helped frame what policy should look like in this area. Ideal state policies for domestic workers would need to cover a range of elements. While care workers are covered under the federal minimum wage, state policies need to explicitly include care workers when setting minimum wages that are higher than the federal rate. Workers should receive overtime pay for working beyond forty hours per week, and states that fund home health care should provide funding for overtime payments to support families that need more care. Employers should be required to provide lunch breaks, at least one day of rest per week, paid time off, and advanced notice of schedule changes or layoffs. And since domestic workers are often left out of labor laws, states should implement legal protections for workers against harassment and discrimination. Each state earns 1 point for passing legislation in this policy area, and an additional 0.10 points for each of the characteristics, benefits, and protections under the policy.
  • Legislative support for care worker unions. While there is no single ideal policy, there are a few good examples of how states can support care worker unions. Most state policies involve codifying the ability of unions that represent care workers, whether subsidized by the state or not, to negotiate directly with the state to set terms for the industry. At least ten states have policies in place, and a few others had once put policies in place but then had them revoked. While care workers in some states may be covered by union contracts, the scoring rubric focuses on explicit state policies that support collective bargaining. States are awarded 1 point for passing home care worker union legislation.
  • Pre-K and child care worker wages. While most indicators scored in this area are policies, the rubric reviews wage data as an indication of how well workers are supported in each state. The rubric relied on data from the Center for the Study of Child Care Employment (CSCCE) at University of California, Berkeley, that compares median pre-K and child care workers wages with state level cost of living, to rank states from best to worst. The rubric awarded 0.25 points to each state in the top ten of that ranking.
  • Home health and personal care aide wages. Home care is one of the fastest growing occupations in the economy, but one of the lowest paid. Nationally, median pay for care aides is $27,000.56 At the state-level, the rubric awarded 0.25 points to the ten states with the highest median care aide wage, compared with the state-wide median wage.

Best and Worst States

Top-ranked states for fair working conditions for care workers according to the rubric were Connecticut, California, Oregon, Massachusetts, and Illinois, all of which scored at least 2.5 points for having a Domestic Workers Bill of Rights in addition to pro-union laws in place.

As of July 2021, ten states have passed bills of rights for domestic workers: New York, Illinois, Oregon, California, Nevada, Connecticut, Massachusetts, Hawaii, New Mexico, and Virginia. Connecticut, Oregon, and California have the most comprehensive bills. In addition, seventeen states provide funding for overtime payments. It is worth noting that accessibility of information about these laws is critical for their efficacy (though this rubric did not assign points for this). One good example is New York State, which provides fact sheets on its Domestic Workers Bill of Rights translated in sixteen languages easily accessible on their website.57

The ten states that have care worker collective bargaining policies in place are California, Connecticut, Illinois, Maryland, Massachusetts, Rhode Island, Oregon, Washington, Minnesota, and New Jersey.58

The worst states, which would receive negative credit if such a thing were part of the rubric, would be the twenty-seven states with so-called right-to-work laws in place, which undermine unions—many of which are the same states that have never raised the minimum wage above the federal rate.59

In terms of cost of living-adjusted wages for preschool teachers, the best states were Minnesota, Nebraska, and Michigan.60 For child care workers, the top three states were Washington, Michigan, and Colorado.61 For care aides, the top three states for wages relative to state-wide median wages were District of Columbia, Virginia, and Louisiana.62

Extra Credit for Pregnant Workers Fairness

While the 1978 Pregnancy Discrimination Act (PDA) ostensibly banned pregnancy discrimination by declaring it an illegal form of sex discrimination, rampant prejudice against pregnant workers persists today.63 Pregnancy discrimination disproportionately hurts immigrant workers and Black, Latinx, and other workers of color, as they are more likely to hold low-wage or physically demanding jobs that pose distinct challenges for pregnant workers.64 Workers who cannot obtain a reasonable accommodation may be forced into taking leave early, resulting in significant lost wages, and may also be forced to return to their jobs before they planned or before what might be medically advisable.65 Working in physically demanding jobs while pregnant has been shown to negatively impact maternal health outcomes, which is particularly problematic for race equity, as Black women and Indigeneous women face disproportionately higher maternal mortality rates than white women.66 Reasonable accommodations for pregnancy is an important part of the care agenda.

Scoring Rubric

Any state that had a policy requiring employers to provide pregnant workers with reasonable accommodations received extra credit of up to 1 point.67 Within those policies, we analyzed five categories:

  • Employee threshold. States earned a higher score for policies that impacted a higher number of employees (the closer their employee threshold was to one employee).
  • Undue hardship exception. States did not earn as much if their policy included an exemption that allowed employers to deny a request for reasonable accommodation if it would pose an “undue hardship,” as these exceptions significantly constrain the effectiveness of these protections.
  • Adverse action protections. States earned a higher score if their policy prohibited employers from denying employment opportunities to current or prospective employees due to pregnancy or from forcing their workers to take leave (paid or unpaid) due to pregnancy.
  • Provider documentation requirements. States did not earn as much if their policy allowed employers to require documentation from a health care provider to approve a pregnancy accommodation request.
  • Notification of rights. Fairness policies that require employers to proactively inform their employees of their right to request an accommodation for pregnancy received a higher score.

Best and Worst States

The two states that lead the nation in enacting protections for pregnant workers are Hawaii and California; however, even their policies fall short of an ideal policy. Hawaii earned the most points out of all fifty states, as its 1990 law requires employers to provide reasonable accommodation to employees with health needs due to pregnancy, childbirth, and other related medical conditions, and includes no undue hardship exception. Hawaii’s law also protects pregnant workers from sanction if they request a reasonable accommodation. However, Hawaii does not require employers to proactively inform workers about their rights pertaining to reasonable accommodation.

California’s 2000 law also requires employers to provide reasonable accommodations without an undue hardship exception and notably requires that employees be provided with advance reasonable notice of their rights. Similar to Hawaii’s law, California prohibits retaliation against employees for seeking reasonable accommodation. However, California sets the employee threshold at five employees and allows employers to require the advice of a health care provider in order to seek reasonable accommodation.

Overall, twenty states have no laws requiring employers to provide any form of reasonable accommodation to pregnant workers, leaving it up to employers to decide whether or not to treat its pregnant workers with dignity and care. These states include Alabama, Arizona, Arkansas, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Michigan, Mississippi, Missouri, Montana, New Hampshire, Ohio, Oklahoma, Pennsylvania, South Dakota, Wisconsin, and Wyoming. In terms of the states with reasonable accommodation laws, Louisiana has the most restrictive policy, as it only applies to employers who have over twenty-five employees, which is the highest employee threshold in the country.

Extra Credit for Fair Scheduling

Some of the most constant conflicts between work and care come when workers have no flexibility or predictability in their work schedules. Families need flexibility and predictability to be able to manage the variety of needs that come with being a caregiver—everything from planning to take an older parent to doctor appointments to picking up children from school since the school day and the work day do not match. Ten states have enacted fair workweek policies to make work more stable and predictable so that people can better plan and prepare and be there for their families and/or policies that acknowledge the need for sometimes changing hours or schedules to address care needs.68

Scoring Rubric

The scoring rubric included fair scheduling policies in assigning extra credit. A Better Balance and the National Women’s Law Center (NWLC) have both pulled together recent data on state fair scheduling policies. The rubric used this data to give states credit for having policies that require advance notice, predictability pay, right to request, right to rest and split-shift pay. States received credit for having a policy in place (the majority did not) and additional credit for each of the specific policies.69

Extra Credit for Supportive Tax Policies

Tax credits have proven to reduce poverty dramatically,70 allow earners to pay down debt,71 and increase spending in their communities.72 And since there are a higher share of Black and Brown workers, families, and children in poverty than their white counterparts,73 providing support to low-income workers, families, and children is a matter of racial justice.

Three main tax credits that support families are the Child and Dependent Care Tax Credit (CDCTC), which helps working parents pay for care and assists millions of families each year;74 the Earned Income Tax Credit (EITC), which is a refundable credit to low-income workers; and the Child Tax Credit (CTC), which provides up to $2,000 per child under age 17 (that maximum was temporarily raised for 2021 under the American Rescue Plan75).

Scoring Rubric

The scoring rubric awarded states extra credit points based on two criteria for tax policies:

  • Refundability. States should offer a supplement to federal credits that are fully refundable to low-income individuals. Refundability is critical for the lowest income individuals who do not owe taxes or filers who have tax credits that are greater than their tax liability.
  • Generosity. States are able to set their funding formula as a percent of the federal benefit, and the higher the percent the better. Most states offer a benefit that is between 20 percent and 50 percent of the federal benefit, but some offer more or less than that, and some have created a funding scale based on income levels of recipients.

Each state is awarded the following extra credit points for this section: 0.3 points for each tax credit offered; 0.1 points for each credit being refundable; 0.1 points for different levels of generosity for each credit (0.1 points if the credit is at least 25 percent of the federal benefit; 0.2 points if the credit is at least 50 percent of the federal benefit).

Best and Worst States

The only states that offer supplements to federal credits for all three credits mentioned above are California, Colorado, New York, and Oklahoma; of these, only New York and Colorado have fully refundable credits for all three policies. New York is the only state to offer a CDCTC that is more than 100 percent of the federal credit for those who make up to $40,000 per year, and California is the only state to have two of the three credits (CDCTC and EITC) supplement more than 50 percent of the federal credit (for those with incomes up to $40,000 for the CDCTC and up to $30,000 for the EITC).

On the low side of the ranking for this policy, fifteen states do not offer any family tax credits on top of what the federal government offers, and thus have 0 points for this policy area: Alabama, Alaska, Arizona, Florida, Missouri, Nevada, New Hampshire, North Dakota, Pennsylvania, South Dakota, Tennessee, Texas, Utah, West Virginia, and Wyoming.

Looking Ahead

This report card shows how far the United States has to go to enact care policies that serve the needs of families, communities and an equitable economy. Despite state advocacy and interest, no state has achieved an A, and the majority are stuck with a D. This starkly demonstrates the importance of Congress passing the care policies in the Build Back Better plan. The national leadership, framework, and funding are key to a future that prioritizes effective care policies in every state.

Acknowledgments: The authors would like to thank Whitney Pesek, Karen Schulman, Sherry Leiwant, Sarah Brafman, Charlotte Dodge, Krista Olson, Vasu Reddy and Jessica Mason for their input

Appendix A: Glossary

Advance Notice: Advance notice are fair scheduling provisions that require employers to provide employees with a certain amount of advance notice of their schedules. Some provisions also require employers to provide estimates of schedules and minimum hours before an employee begins employment.

Care: The range of services and supports needed to meet needs related to age, disability, health, or illness. Care can be provided by loved ones, institutions, or professionals. Other terms for care include family care (commonly used by research or advocacy organizations) and dependent care (commonly used by government entities).76

Child Care and Early Learning: The care of children, including infants, toddlers, and school-aged children. Early education is an important component of child care that involves teaching and fostering healthy brain development. Common child care employment options include center-based child care, family child care, and home-based child care.

Domestic Workers Bill of Rights: National and state legislation that establishes rights for home care workers, nannies, and house cleaners to ensure safety and dignity at work.

Home and Community-Based Services: Home and community based services (HCBS) provide opportunities for people who need assistance with the activities of daily living to receive services in their own home or community rather than institutions or other isolated settings.

Long-Term Services and Supports (LTSS): The range of services and supports used by individuals of all ages who need assistance with activities of daily living because of disabling conditions or chronic illnesses, including adult care and elder care. LTSS is also known as long-term care.

Paid Family and Medical Leave: Paid family and medical leave policies provide wage replacement and job protection so people can take the time they need to recover, or provide care to a family member, without worrying about forgoing income or losing a job.

Paid Sick and Safe Days: These days consist of time that a worker accrues over hours worked that can be taken in hourly or daily increments to recover from a personal illness, take care of a sick family member, respond to a public health emergency, or a matter arising from an incedent of domestic or sexual abuse.

Predictability Pay: Predictability pay provisions are fair scheduling provisions that require employers to pay employees a certain number of hours of compensation, in addition to payment for any time actually worked, when employers make last-minute changes to employees’ shifts, including additions or reductions in hours and cancellations of regular or on-call shifts.

Pregnant Worker Fairness: Pregnant worker fairness policies require employers to provide employees with needs due to pregnancy, childbirth, and related medical conditions with reasonable accommodations in order to allow employees to safely continue working during their pregnancy. Some examples include longer or more frequent breaks, allowing the worker to sit in a chair while performing their duties, temporary transfer to a less strenuous or hazardous job, modified work schedules, assistance with manual labor, and access to a non-bathroom private lactation area.

Reporting Pay: Reporting pay provisions are fair scheduling provisions that require employers to pay employees for some portion of their originally scheduled shifts when employees report for work but are then told that their shifts have been cancelled or reduced. Laws and regulations requiring repeating pay typically predate, and are more limited than, those requiring predictability pay.

Right to Request: Right to request laws protect employees who want to request flexible working arrangements or other changes to their schedules by granting them the express right to do so free from retaliation by their employers.

Right to Rest: Right to rest provisions are fair scheduling provisions that require employers to provide a minimum amount of rest time between shifts and to pay employees who consent to work without the rest time at a higher rate.

Split-shift Pay: Split-shift pay provisions are fair scheduling provisions that require employers to pay employees additional wages as compensation for any day on which they are required to work shifts in which they have a gap or gaps between scheduled hours in the same day.

Appendix B: State Care Economy Grades

California B
Oregon B
Connecticut B
Massachusetts B
New York B
Colorado B-
New Jersey B-
Washington B-
District of Columbia B-
Rhode Island C
Vermont C
New Mexico C
Maryland C
Minnesota C
Illinois C-
Hawaii C-
Virginia D+
Arizona D+
Ohio D
Maine D
Delaware D
Nebraska D
Wisconsin D
Alaska D
Texas D
Iowa D
Nevada D
Utah D
Michigan D
Pennsylvania D
North Dakota D-
Louisiana D-
North Carolina D-
Missouri D-
Georgia D-
Oklahoma D-
New Hampshire D-
Montana D-
Arkansas D-
Kansas D-
Idaho D-
South Dakota D-
South Carolina D-
Tennessee D-
Kentucky D-
Wyoming D-
Mississippi F
West Virginia F
Indiana F
Alabama F
Florida F

Appendix C: State Care Economy Scores, Grades, and Economic Indicators

State Care Economy Score Letter Grade Prime-Age Women’s Labor Force Participation Rate Wage Gap (what women make for every dollar men make)
California 12.3 B 71 $0.88
Oregon 11.9 B 77 $0.80
Connecticut 11.7 B 78.7 $0.84
Massachusetts 10.9 B 80 $0.81
New York 10.9 B 74 $0.86
Colorado 10.3 B- 78.1 $0.80
New Jersey 10.0 B- 76.2 $0.80
Washington 9.6 B- 76.6 $0.79
District of Columbia 9.5 B- 84 $0.83
Rhode Island 8.2 C 76.7 $0.85
Vermont 7.6 C 83 $0.91
New Mexico 7.4 C 69 $0.78
Maryland 6.8 C 79 $0.89
Minnesota 6.5 C 85.1 $0.81
Illinois 6.1 C- 77 $0.78
Hawaii 6.1 C- 74.4 $0.89
Virginia 5.0 D+ 77 $0.80
Arizona 4.8 D+ 74.7 $0.83
Ohio 4.4 D 77.4 $0.79
Maine 4.2 D 79 $0.80
Delaware 4.1 D 80.3 $0.83
Nebraska 3.8 D 83 $0.80
Wisconsin 3.8 D 81.6 $0.81
Alaska 3.1 D 74 $0.85
Texas 3.1 D 72.5 $0.80
Iowa 2.9 D 82.2 $0.78
Nevada 2.8 D 73.1 $0.87
Utah 2.7 D 73.2 $0.70
Michigan 2.7 D 75 $0.78
Pennsylvania 2.6 D 78.5 $0.79
North Dakota 2.4 D- 84 $0.76
Louisiana 2.4 D- 73 $0.72
North Carolina 2.4 D- 73.5 $0.86
Missouri 2.2 D- 79.3 $0.80
Georgia 2.1 D- 74.4 $0.80
Oklahoma 2.1 D- 69.7 $0.73
New Hampshire 2.1 D- 82 $0.82
Montana 2.1 D- 79.1 $0.78
Arkansas 1.9 D- 72 $0.79
Kansas 1.8 D- 81.1 $0.80
Idaho 1.8 D- 72 $0.75
South Dakota 1.8 D- 82 $0.75
South Carolina 1.7 D- 75.8 $0.77
Tennessee 1.7 D- 75 $0.80
Kentucky 1.6 D- 71.3 $0.80
Wyoming 1.5 D- 79 $0.65
Mississippi 1.4 F 71 $0.77
West Virginia 1.1 F 73 $0.76
Indiana 1.1 F 75.9 $0.76
Alabama 1.0 F 72.5 $0.74
Florida 1.0 F 74 $0.83
Source: Authors’ calculations; prime-age women’s labor force participation rate from the Bureau of Labor Statistics and wage gap data from the National Women’s Law Center.

Appendix D: Methodology and Data Limitations

Child Care and Early Learning

No state has fully implemented a comprehensive child care and early education system. The information available about state child care policies can help demonstrate states that have done better and worse, but do not reflect the full picture of how children, families, providers, and early educators are experiencing the child care and early learning systems in their states.

  • Affordability of child care and early learning. For example, measuring affordability by state is complicated. Child Care Aware annually reports data on the price of child care in each state and how it compares to median family incomes, which could be useful. However, this data on its own does not provide enough information. Less-expensive programs may be of poor quality, so the lower price tag does not necessarily make it better; just as more-expensive programs are likely paying early educators better and therefore serving children better. In addition, the price of care does not reflect state policies.For the affordability measure for income eligibility, the scoring relied on data reported by the National Women’s Law Center (NWLC) on state income eligibility levels as a percentage of income levels.77 For every state that has income eligibility above 75 percent of state median income, the scoring rubric gave them 0.2 points;78 any state with an eligibility below 75 percent of SMI received 0.For copayments, the scoring relied on data from the Department of Health and Human Services, Administration on Children and Families Office of Child Care, specifically their data on the average monthly mean family copayment as a percent of family income. The most recent data available was preliminary data for FY2019, which was used for this report. The scoring was based on (1) the percentage of eligible families that had no copayment and (2) the average copayment as a percentage of income for families that do have copayments. Those states where 60 percent or more of families had no copayments, received 0.2 points and those states where the average copayment as a percentage of income (not including $0 copayments) was below 5 percent also received 0.2 points. Even though 7 percent of income is the affordability measure according to the Department of Health and Human Services, since the families included had income that is at most only 85 percent of SMI and the majority were between 100 percent and 150 percent of the federal poverty level, the rubric used the lower percentage as a more accurate sign of affordability.79 To confirm that these measures depict affordability for low-income families, the results were cross-referenced with data reported from NWLC that looked at 2020 parent copayments for a family of three with an income at 150 percent of poverty and one child in care.80 Four states had copayments under 5 percent for these families in 2020 that had higher copayments in the FY2019 data, so the rubric also gave them 0.1.
  • Accessibility to a diverse supply of options. The CAP child care deserts analysis is the most comprehensive source of data on the supply of child care by state. Since it looks specifically at licensed child care slots as compared to demographics, however, it does not tell the story of whether the child care programs that do exist are diverse, inclusive, flexible, or culturally competent, or have bilingual care options, or serve children with disabilities. Nor does it reflect the supply of informal or license-exempt care that many families rely on. However, it is the best single source data currently available. Based on the CAP data, the scoring rubric gave states with under 25 percent of the population living in a desert 0.3 points and under 50 percent 0.1 points; any state with a desert above 50 percent received 0.
  • The quality of care. For the quality measure, ideally, the CDA and support for achieving it would not be the only scores included, but unfortunately, there is not a standard, agreed upon measure of quality in the child care sector. Most states have their own quality rating and improvement system (QRIS),81 but few of these systems take into account teacher and staff wages and working conditions, which can have the biggest impact on the quality of a child’s experience. And some advocates feel that existing quality measures have been developed without a cultural sensitivity or consideration for racial equity.82 As a result, the rubric does not include a separate measure for high quality child care and early learning programs, despite acknowledging that it is an essential part of such a policy.In terms of using the CDA specifically, CSCCE researchers write, “For early care and education, experts . . . recommend that lead teachers and program administrators acquire degrees and specialization equivalent to those working in elementary schools and that others working with young children, like assistant teachers or aides, attain foundational knowledge, such as a Child Development Associate (CDA) Credential. However, unlike K-12, these recommendations by and large have yet to be implemented in state requirements for early care and education.”83Debate remains about whether a CDA is enough, or if early educators should also have an Associates or Bachelors degree.84 Some advocates feel that experience with children and being a consistent, stable presence is enough, while others feel that more education is needed.The scoring rubric gives states credit (0.2 points) for having a CDA requirement but does not give any additional credit for requirements above a CDA. It further gives states credit (0.4 points) for providing support for pursuing and achieving a credential or additional training in the form of scholarships, apprenticeships, stipends, or tax credits and bonuses. Additional credentialing requirements must also come with an increase in compensation. This policy was not measured as part of the data set this report used, but it is important to note. (In addition, additional scoring based on early educator wages is included in a later section.)There are also other priorities for high quality child care that are particularly hard to measure, such as how states are faring in terms of cultural competency and supporting dual language learners, how they are supporting parents and children with disabilities, how they are addressing racial justice and racial and economic integration, and how they are including diverse stakeholder voices in decision making. In addition, this report does not include how states are investing in after school and summer programs since there was no single source data set. The After School Alliance collects data regarding parent perspectives and use of federal funds, but not on state-specific policies.
  • Success in achieving universal pre-K. The scoring rubric for pre-K for this report assigned 0.2 points to the top 10 states in terms of access for children age 4; 0.15 points for states 11–25; 0.1 points for states 26–39; 0.05 for states 40–50; and 0 for those that did not have any program at all. The rubric assigned the same scores again for states according to pre-K access for children age 3, although many fewer states had a program in place that served that age. Since NIEER created a way to measure whether state preschool policies meet ten quality criteria, the scoring rubric used that scale for the report card. States that met NIEER’s maximum of 10 on the quality checklist received 0.1 points; those that met 6–9 received 0.05; and those that met 1–5 received 0.025. Finally, the rubric used the NIEER ranking of state spending per child on preschool to assign scores there. States in NIEER’s top 10 received 0.1; those ranked 11–25 received 0.05; and those ranked 26–50 received 0.025; states without a program received 0.

Paid Family and Medical Leave

The analysis draws from two state-level policy data sources compiled by the National Partnership for Women & Families and A Better Balanced on paid family and medical leave in each state.85 Data on states with expanded FMLA comes from the National Partnership for Women & Families.86

This measure uses model legislation to identify ideal policies. While the model legislation identifies twenty-five areas for advocacy, this analysis uses only the ten criteria that most connect to the principle that every worker who needs to take time away from work for family or medical reasons can do so. Some aspects of an ideal paid family and medical leave policy that would impact access to leave, such as minimal unpaid waiting periods or specifications on the minimal increments of leave, are not included here to maintain focus on the key provisions that impact access. Outside of benefits duration, this report does not evaluate the quantitative specifications such as the amount of wage replacement or specific work-hour or earnings eligibility criteria. Additionally, due to data limitations, the rubric does not evaluate aspects of the policy related to paid leave implementation, such as education requirements for public agencies and employers that help workers learn about the benefits that are available to them.

Paid Sick and Safe Days

This analysis uses eight criteria that most connect to the principle that every worker who needs to take time away from work for family or medical reasons can do so. It draws from model legislation as well as two state-level policy data sources compiled by the National Partnership for Women & Families and A Better Balance on paid sick and safe leave in each state.87

Domestic Workers Bill of Rights

One key data limitation in this policy area is the level of enforcement or adherence to the law. Some states require workers’ rights and home policies to be provided in writing to their employee, but there is no data to determine whether it’s common practice. In states that don’t require written notice, it’s unclear how many workers or employees know about these policies at all. Another unknown, and opportunity for further research, is the difference in adherence and enforcement for home care workers that work for agencies versus those who are hired directly by a household employer.

Care Workers Unions

There is no comprehensive source on the number of care workers covered by union contracts, by state, sector, or occupation. These data would be useful in understanding how comprehensive state laws are in terms of the percentage of care workers actually covered, and the impact on their wages and working conditions.

Pregnant Workers Fairness

This section uses data from A Better Balance and the National Partnership for Women & Families. The two sources had some discrepancies in how the laws were described so this analysis uses a combination of the two. Some additional variance among states exists, but this report limits the review to the top five policy issues.

Tax Policy

This scorecard does not capture the full extent of the progressivity or adequacy of tax credits in place. Some states have progressive taxation, in that lower income recipients receive a higher benefit relative to the federal benefit. However, the bend points and cutoffs vary from state to state. This report did not attempt to identify whether those bend points and cutoffs are adequate based on poverty levels and cost of living in each state, or if the benefits get individuals and families closer to a living wage.


  1. The funding that passed for home-and community-based services was less than what was originally proposed and less than what is needed.
  2. As of June 2021, New Hampshire became the eleventh state, including the District of Columbia, to enact a paid family and medical leave policy. Analysis of the new state law is forthcoming and therefore it is not evaluated in this report. See “Comparative Chart of Paid Family and Medical Leave Laws in the United States,” A Better Balance, July 28, 2021,
  3. “Fact Sheet: Current Paid Sick Days Laws,” National Partnership for Women & Families, March 2021,
  4. “Passed Legislation: States and Cities with a Domestic Workers Bill of Rights,” National Domestic Workers Alliance, accessed September 15, 2021,
  5. Allison H. Friedman-Krauss, W. Steven Barnett, Karin A. Garver, Katherine S. Hodges, G. G. Weisenfeld, and Beth Ann Gardiner, “The State of Preschool 2020: State Preschool Yearbook,” The National Institute for Early Education Research, Rutgers Graduate School of Education, 2021,
  6. Julie Kashen and Katie Hamm, “Child Care for All: A Blueprint for States,” The Century Foundation, August 8, 2019,
  7. Laurie Jenkins, “First in the Nation: Washington State’s Long-Term Care Trust Act,” The Millbank Quarterly, March 2020,
  8. Unfortunately, the sources did not consistently have data for the U.S. territories, so this report does not include American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the Virgin Islands,
  9. Julie Kashen, “The Case for Child Care and Early Learning for All: Economic Prosperity,” The Century Foundation, August 2021,
  10. Julie Kashen and Halley Potter, “The Case for Child Care and Early Learning for All: Healthy Child Development and School Readiness,” The Century Foundation, September 2021,
  11. The report gives Washington, D.C. one additional point acknowledging its unique progress on child care and early learning.
  12. “The U.S. and the High Price of Child Care: 2019,” Child Care Aware, accessed September 2021,
  13. Rasheed Malik and Katie Hamm, “Mapping America’s Child Care Deserts,” Center for American Progress, August 2017,
  14. “Early Childhood Workforce Index 2020,” Center for the Study of Child Care Employment, 2020,
  15. Ibid.
  16. “Financial Structure of Early Childhood Education Requires Overhaul to Make It Accessible and Affordable for All Families and to Strengthen the Workforce in This Field,” National Academies of Sciences, Engineering, Medicine, February 2018,
  17. Rasheed Malik, “The Effects of Universal Preschool in Washington, D.C.,” Center for American Progress, September 2018,
  18. “What’s in the Birth-to-Three Act,” Under 3 DC, accessed September 2021,
  19. Marlana Wallace, “DCFPI Celebrates the Adoption of ‘Birth to Three For All DC’,” DC Fiscal Policy Institute, July 2018,
  20. Centers for Disease Control and Prevention, “Disability Impacts All of Us,” accessed March, 2021,
  21. Benjamin W. Veghte et. al, “The Case for Action: Long-Term Services and Supports,” National Academy of Social Insurance, 2019,
  22. Joanne Binette and Kerri Vasold, “2018 Home and Community Preferences: A National Survey of Adults Ages 18-Plus,” AARP Research, July 2019,
  23. In 2017, the median annual cost of a nursing facility was $97,455 for a private room and $87,600 for a shared room. The base price for assisted living was $45,000. See Ari Houser, Wendy Fox-Grage, and Kathleen Ujvari, “Across The States Profiles Of Long-term Services And Supports,” AARP, 2018,
  24. “Building our Care Infrastructure For Equity, Economic Recovery, and Beyond,” Caring Across, September 2020,
  25. Ibid.
  26. Susan Reinhard et. al, “Long-Term Services and Supports State Scorecard 2020 Edition,” AARP Public Policy Institute, 2020,
  27. Ibid.
  28. “Expecting Better: A State-by-State Analysis of Laws That Help Expecting and New Parents,” National Partnership for Women & Families, August 2016,
  29. Kathleen Bryant and Kathleen Romig, “A National Paid Leave Program Would Help Workers, Families,” Center on Budget and Policy Priorities, April 2021,
  30. “Meeting the Promise of Paid Leave: Best Practices in State Paid Leave Implementation,” National Partnership for Women & Families, 2019,
  31. Ibid.
  32. Kathleen Bryant and Kathleen Romig, “A National Paid Leave Program Would Help Workers, Families,” Center on Budget and Policy Priorities, April 2021,
  33. “Paid Family and Medical Leave: Good for Business,” National Partnership for Women & Families, September 2018,
  34. Kathleen Bryant and Kathleen Romig, “A National Paid Leave Program Would Help Workers, Families,” Center on Budget and Policy Priorities, April 2021,
  35. “Paid Family and Medical Leave: A Racial Justice Issue—and Opportunity,” National Partnership for Women & Families, August 2018,
  36. “Paid Leave,” National Partnership for Women & Families, accessed September 2021,
  37. As of June 2021, New Hampshire became the eleventh state, including the District of Columbia, to enact a paid family and medical leave policy. Analysis of the new state law is forthcoming and therefore it is not evaluated in this report.
  38. Ibid.
  39. “Model State Paid Family and Medical Leave Statute,” A Better Balance and National Partnership for Women & Families, 2015,
  40. Paid sick days can be used for shorter-term medical needs than paid family and medical leave, which covers longer-term needs for serious illnesses.
  41. “National Compensation Survey: Employee Benefits in the United States, March 2020 (Table 6),” U.S. Bureau of Labor Statistics, September 2020,
  42. Tom Smith and Jibum Kim, “Paid Sick Days: Attitudes and Experiences,” National Opinion Research Center at the University of Chicago for the Public Welfare Foundation Publication, June 2010,
  43. LeaAnne DeRigne, Patricia Stoddard-Dare, and Linda Quinn, “Workers Without Paid Sick Leave Less Likely to Take Time Off for Illness or Injury Compared to Those with Paid Sick Leave,” Health Affairs, March 2016,
  44. “African Americans and Their Families Need Paid Sick Days,” National Partnership for Women & Families, January 2017,
  45. Elise Gould, Daniel Perez, and Valerie Wilson, “Latinx workers—particularly women—face devastating job losses in the COVID-19 recession,”Economic Policy Institute, August 20, 2020,
  46. Julie Kashen, “10 Ways to Make Workplace Laws Work for Everyone,” The Century Foundation, April 2, 2019,
  47. “Model Law: Establishing a Permanent Right to Paid Sick and Safe Time that Includes Additional Leave for a Public Health Emergency,” A Better Balance, March 2021,
  48. In addition to the fourteen states mentioned in this report, nineteen cities and three counties have passed local paid sick days laws, and three states have passed paid time off (PTO) laws. Advocates across the country have worked hard to pass these laws and help move their states in the right direction of protecting workers. As the focus of this report is on statewide policies and laws, local laws and ordinances and PTO laws were not included in the grading.
  49. “Access to Paid Sick Time in Austin, Texas,” Institute for Women’s Policy Research, May 2018,
  50. Ibid.
  51. H. Elizabeth Peters, John Marotta, and Emily Bramhall, “State Preemption of Local Paid Sick Days Ordinances,” Urban Institute, October 2020,
  52. “Jayapal, Gillibrand, and Luján Re-Introduce National Domestic Workers Bill of Rights Alongside National Domestic Workers Alliance,” Office of Representative Pramila Jayapal, July 2021,
  53. Ross Eisenbrey, “Harris v. Quinn Is About the Right of Home Care Workers to Improve Their Wages,” Economic Policy Institute, May 2014,
  54. Domestic workers, however, continue to be excluded from collective bargaining rights and often work in one-on-one settings in which there is not a collective to bargain with. Sectoral bargaining and standards boards offer better leverage for domestic workers specifically.
  55. Elise Gould, Marokey Sawo, and Asha Banerjee, “Care workers are deeply undervalued and underpaid (Table 1),” Economic Policy Institute, July 2021,
  56. “Home Health and Personal Care Aides,” Bureau of Labor Statistics, accessed September 2021,
  57. “Domestic Worker Bill of Rights,” Department of Labor, accessed September 2021,
  58. “Getting Organized: Unionizing Home-Based Child Care Providers,” National Women’s Law Center, 2014,
  59. “Changes in Basic Minimum Wages in Non-Farm Employment Under State Law: Selected Years 1968 to 2020,” United States Department of Labor, accessed September 2021,
  60. “States Ranked by Median Hourly Wage of Preschool Teachers, Actual and Adjusted for Cost of Living, 2019,” CSCCE, U.C. Berkeley, accessed September 2021,
  61. “States Ranked by Median Hourly Wage of Child Care Workers, Actual and Adjusted for Cost of Living, 2019,” CSCCE, U.C. Berkeley, accessed September 2021,
  62. Authors’ calculations based on BLS Occupational Employment and Wage Statistics: “Occupational Employment and Wage Statistics,” Bureau of Labor Statistics, accessed September 2021,
  63. “The Pregnant Workers Fairness Act: Fact Sheet,” National Partnership for Women & Families, February 2021,
  64. “Accommodating Pregnancy On The Job: The Stakes for Women of Color and Immigrant Women,” National Latina Institute for Reproductive Health, May 2014,
  65. Dina Bakst et. al, “Long Overdue: The Pregnant Workers Fairness Act is a Critical Mesure to Remove Barriers to Women’s Workplace Participation and Promote Healthy Pregnancies,” A Better Balance, June 2021,
  66. “Dr. Wendy Chavkin Letter to Council Member James Vacca,” A Better Balance, November 2018, See also: K. S. Joseph et. al, “Maternal Mortality in the United States: Recent Trends, Current Status, and Future Considerations,” Obstetrics and Gynecology, 2021,
  67. Some, but not all, of these policies also include provisions pertaining to breastfeeding, including providing a non-bathroom private space for expressing breast milk. While these provisions are essential protections for workers who have returned to the workplace after childbirth, they often lack proper enforcement mechanisms so the report did not isolate these provisions for evaluation.
  68. “State and Local Laws Advancing Fair Work Schedules,” National Women’s Law Center, October 2019,
  69. See Appendix A: Glossary for definitions of each policy.
  70. “Policy Basics: The Earned Income Tax Credit,” Center on Budget and Policy Priorities, December 2019,
  71. Mathieu R. Despard et. al, ”Do EITC Recipients Use Tax Refunds to Get Ahead? New Evidence from Refund to Savings,” Center for Social Development, Washington University in St. Louis, July 2015,
  72. Aditya Aladangady et. al, “High-frequency Spending Responses to the Earned Income Tax Credit,” Federal Reserve, June 2018,
  73. David Cooper, “Workers of color are far more likely to be paid poverty-level wages than white workers,” Economic Policy Institute, June 2018,; “Indicator 4 Snapshot: Children Living in Poverty for Racial/Ethnic Subgroups,” National Center for Education Statistics, Updated February 2019,,and%20Asian%20children%20(11%20percent.
  74. Eligible expenses include tuition at day care centers or family day care, payments to babysitters including neighbors and relatives, and before- and after-school care, or summer day camp. “Five Facts about the Federal Child and Dependent Care Tax Credit (CDCTC),” National Women’s Law Center, October 2017,
  75. The CTC was raised to $3,000 per child for children over age 6, and to $3,600 for children under age 6. “The Child Tax Credit,” The White House, accessed September 2021,
  76. Dyvonne Body, “The True Cost of Caregiving,” Aspen Institute, June 2020, The-True-Cost-of-Cargiving-ES.pdf.
  77. Karen Schulman, “On the Precipice: State Child Care Assistance Policies 2020,” National Women’s Law Center, May 2021,
  78. One challenge of this measure is that it may reflect the balance of families across income levels more than a state’s choices regarding the generosity of their sliding fee scale. For example, two states could have the exact same fee scale, but one could have a lower average simply because it was serving only the lowest income families and no one at the higher income levels, while the other state is serving more families and serving families across the income spectrum (up to the maximum eligibility limit). Additional scoring measures in this section attempt to alleviate some of the potential bias in this measure.
  79. “Characteristics of Families Served by the Child Care and Development Fund (CCDF) Based on Preliminary FY2019 Data,” Office of Child Care, U.S. Department of Health and Human Services, accessed September 2021,
  80. Karen Schulman, “On the Precipice: State Child Care Assistance Policies 2020,” National Women’s Law Center, May 2021,
  81. Simon Workman, “QRIS 101: Fact Sheet,” Center for American Progress, May 2017,
  82. Letter from Child Care Resource & Referral Network, Parent Voices and Child Care Law Center, “Re: Quality Improvement in California,” August 14, 2020,
  83. “State Policies to Improve Early Childhood Educator Jobs,” Center for the Study of Child Care Employment, 2020,
  84. Some advocates feel that experience with children and being a consistent, stable presence is enough, while others feel that more education is needed.
  85. “State Paid Family and Medical Leave Insurance Laws,” National Partnership for Women & Families, January 2021,; “Comparative Chart of Paid Family and Medical Leave Laws in the United States,” A Better Balance, July 2021,
  86. “Raising Expectations: A State-by-State Analysis of Laws That Help Working Family Caregivers,” National Partnership for Women & Families, September 2018,
  87. “State Paid Sick and Safe Leave Laws,” National Partnership for Women & Families, January 2021,; see also: “Overview of Paid Sick Time Laws in the United States,” A Better Balance, August 2021,