The Relationship between Unemployment and Health Insurance Coverage: Before and after the Affordable Care Act's Coverage Expansions

Joseph Benitez, Timothy Williams, Evan Goldstein, Eric E. Seiber

Research output: Contribution to journalArticlepeer-review

5 Scopus citations


Objective: The objective of this study was to determine whether the Affordable Care Act's (ACA) major coverage expansions mitigated the impact of unemployment on health insurance coverage status. Data Source: A 2011-2019 versions of the American Community Survey developed by the University of Minnesota Integrated Public Use Microdata Series program. Research Design: We use difference-in-difference-in-differences (ie, triple difference) regressions to compare changes in the short-run impacts of local unemployment rates before and after the ACA. Principal Findings: Before the ACA, rises in local unemployment were associated with uninsurance due to losses in private coverage (ie, both nongroup and employer sponsored). Following the ACA's full implementation, the link between employment and coverage was attenuated by access to publicly subsidized qualified health plans on the ACA's nongroup market, and enhanced access to Medicaid in states that expanded. Our findings suggest protections from unemployment-linked uninsured spells are largest in states that expanded Medicaid. Conclusions: Expanded access to coverage under the ACA could mitigate the adverse effects on insurance status and access to care historically linked to job loss. However, should the ACA be repealed, many households stand to lose their ability to turn to Medicaid or subsidized nongroup coverage as safety-net resources to offset the burdens of job loss.

Original languageEnglish
Pages (from-to)768-777
Number of pages10
JournalMedical Care
Issue number9
StatePublished - Sep 2021

Bibliographical note

Funding Information:
J.B. received support provided by the Robert Wood Johnson Foundation Policies for Action Program (grant #77341) as well as the DREAM Scholar Program in University of Kentucky’s Center for Clinical and Translational Sciences. The remaining authors declare no conflict of interest.

Publisher Copyright:
© 2021 Lippincott Williams and Wilkins. All rights reserved.


  • Affordable Care Act
  • Medicaid expansion
  • safety net
  • unemployment

ASJC Scopus subject areas

  • Public Health, Environmental and Occupational Health


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