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

objectiveTo 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

designWe 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

findingsParticipants 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.

conclusionOur 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.