Employment, Income, the ACA, and Health Insurance Coverage of Working-Age Adults During the First Year of the COVID-19 Pandemic: A Reassessment

Objective

To examine the effects of income, income transitions, and the Affordable Care Act (ACA) Medicaid expansion on health insurance coverage for working-age adults who became unemployed during the first year of the COVID-19 pandemic and for those who remained employed.

Study Setting and Design

We estimated panel-data regression models to assess the effects of employment, income and income transitions, and the Medicaid expansion on the type of insurance coverage and uninsurance among working-age adults in the United States during 2019 and 2020.

Data Sources and Analytic Sample

Longitudinal data from the 2019–2020 Medical Expenditure Panel Survey and data on states' Medicaid expansion status. The study participants were 6435 adults aged 26–64.

Principal Findings

Participants in all income groups who suffered spells of unemployment during the pandemic lost employer-sponsored insurance. In expansion states, the Medicaid expansion played a key role in preventing declines in insurance coverage for disadvantaged participants. The expansion was especially beneficial for participants with low pre-pandemic incomes who had unemployment spells during the pandemic (7.5% point increase in Medicaid coverage [95% CI, 1.2 to 13.8]) and for participants who transitioned from high pre-pandemic incomes to low pandemic incomes whether or not they lost their jobs (23.9% point increase in Medicaid coverage [95% CI, 7.8 to 40.0] during unemployment spells; 12.0% point increase [95% CI, 7.2 to 16.9] for those who remained employed). We found weaker evidence that private exchange coverage blunted increases in uninsurance in non-expansion states.

Conclusion

Our findings clarify findings from earlier research by demonstrating that not only employment status and pre-pandemic income, but also income transitions, played a key role in determining who received Medicaid coverage during the pandemic in Medicaid expansion states. All in all, the ACA acquitted itself relatively well during a very stressful period for the United States' system of health insurance.