In 2023, 19.1% of individuals 12 years old or older in the United States needed treatment for substance use disorder (SUD), but less than a quarter of those individuals received treatment, according to the Substance Abuse and Mental Health Services Administration (SAMHSA). While the War on Drugs has created a barrier to substance use disorder  treatment through criminalization, other common barriers to treatment include the cost, lack of time, and fear that one would lose their job. Medicaid helps address the cost barrier covering nearly 60% of spending on SUD treatment, leaving income loss and fear of losing a job as top unaddressed barriers.  

While overdose rates declined in 2024, nearly six million Americans died of substance use-related causes between 1999 to 2019. Job protected paid medical leave has the potential to alleviate these barriers and permit more individuals in need of SUD treatment to receive it. 

Laws governing medical leave, specifically paid medical leave, vary from jurisdiction to jurisdiction. As of July 2025, although federal medical leave under the Family and Medical Leave Act (FMLA) offers job protection for qualifying employees to undergo substance use treatment when it qualifies as a serious health condition, leave granted under this law can be unpaid. Thirteen states, plus the District of Columbia, have state paid medical leave laws, but these laws vary on which employees are protected, and only Washington state and Minnesota explicitly include substance use disorder under the serious health condition qualification in the law. 

FMLA offers unpaid medical leave for eligible employees (those who have been employed by an employer for 12 months and have worked at least 1,250 hours during the last 12 months) with a serious health condition. However, FMLA does not apply to private-sector businesses with fewer than 50 employees. FMLA allows an employee to take leave for SUD treatment, which may include inpatient rehabilitation, outpatient counseling, behavioral health care, or medication for opioid use disorder (MOUD), only when SUD qualifies as an illness, injury, impairment or physical or mental condition that involves inpatient care or continuing treatment by a healthcare provider. FMLA addresses the fear that one may lose their job by offering job protection for employees covered under this act, however, it does not address an employee’s loss of income. 

Minnesota has enacted a comprehensive paid medical leave law that offers job protection to individuals who work at least 50% of the time from a location in Minnesota and earn 5.3% of the state’s average annual wage in the past year. Although the law does not cover federal employees, self-employed individuals, seasonal employees, or independent contractors, it applies to employers of all sizes in contrast to FMLA’s 50 employee minimum. Minnesota includes substance use disorder in the state’s definition of “serious health condition,” allowing a covered employee to take medical leave for SUDs for inpatient care and/or continued treatment. This explicit inclusion ensures that employees and employers are aware of covered employees’ rights to take paid medical leave for a SUD when it involves inpatient care or continuing treatment, unlike the more vague language included in the Federal FMLA.  

Washington also explicitly includes substance use treatment as a serious health condition qualifying for paid medical leave in the state’s Family and Medical Leave law. Washington provides paid medical leave for full-time, part-time, temporary, and seasonal workers from businesses of all sizes who have worked at least 820 hours in the qualifying period. However, the law does not automatically include federal employees, employees of a tribally owned business on tribal land, self-employed individuals, or workers who are part of a voluntary plan from their employer. While Washington’s medical leave law provides paid leave to employees of all businesses sizes, it only offers job protection to employees who work for an employer with 50+ employees.  

Washington’s Family and Medical Leave Act began to offer benefits to employees on January 1, 2020.  SAMHSA data from 2018-2019 show that there were an estimated 500,000 individuals older than 18 in Washington with a substance use disorder, 463,000 of whom — more than 92% — did not receive treatment for substance use. Following implementation of Washington’s FMLA that number decreased by 10%: SAMHSA data from 2022-2023 show about 82%, or 969,000 of 1,176,000 people with SUD, did not receive treatment. Washington’s paid Family and Medical Leave law may have contributed to this increase in individuals accessing care. 

The implementation of FMLA in Washington and Minnesota, as well as a trend of states passing paid medical leave laws in recent years has the potential to increase access to SUD treatment. However, the recent passage of the Big Beautiful Bill may diminish this access. Medicaid covers nearly 60% of spending on SUD treatment, and the bill will likely cause more than 1.6 million individuals receiving SUD treatment to lose their insurance and their access to care. Insurance coverage diminishes the cost barrier of accessing SUD treatment, but with a loss of coverage and no universal paid leave, these barriers may grow and further prevent individuals from seeking and receiving treatment.