Health Insurance Trajectories Following Unemployment: Implications for Implementation and Evaluation of the Affordable Care Act

Open Access
Uberoi, Namrata Kaur
Graduate Program:
Health Policy and Administration
Doctor of Philosophy
Document Type:
Date of Defense:
June 18, 2014
Committee Members:
  • Pamela Farley Short, Dissertation Advisor
  • Dennis G Shea, Committee Chair
  • John Raymond Moran Jr., Committee Member
  • Deborah Jean Roempke Graefe, Special Member
  • Affordable Care Act
  • employer-sponsored insurance
  • ESI
  • health reform
  • health insurance
  • transitions
  • marketplaces
  • exchanges
The Affordable Care Act (ACA) expands current public and private sources of health insurance coverage, while also creating new insurance marketplaces. Employer-sponsored insurance (ESI) will continue to cover 60 percent of Americans under the ACA. Accordingly, changes in employment and employment loss will continue to be primary causes of gaps and transitions in health insurance, and many people may look to the new marketplaces to fill gaps in insurance triggered by unemployment. This dissertation examines the risk of unemployment among workers with ESI, prior to health reform, and studies the nature and timing of health insurance transitions triggered by unemployment. Using the 2004 and 2008 panels of the Survey of Income and Program Participation, I undertake three related analyses to assess the potential demand for coverage into the marketplaces due to unemployment-related transitions. All analyses are grounded in income categories, corresponding to eligibility for Medicaid and subsidies under the ACA: Furthermore, estimates are placed in the context of different macroeconomic conditions corresponding to timeframes before, during, and after the Great Recession of 2007-2009. The sample is limited to working adults, ages 18-64. Over 2.3 million ESI policyholders and their dependents are at risk of utilizing the health insurance marketplaces or Medicaid for unemployment-related insurance transitions; more than half of these workers will be eligible for subsidies under health reform. Almost 1.1 million ESI policyholders will not be re-employed in time to avoid a three month gap, and are potentially subject to the individual mandate penalty. Older workers are more likely to remain on their former employers’ plans post unemployment. While three-fourths, 1.2 million, younger policyholders, ages 26-54, are more likely to be uninsured after losing employment. The majority of individuals who lose employment and ESI are middle income workers. Increased unemployment risk and prevalence of ESI interact to create the highest risk of unemployment-related ESI losses in the middle income group, and will also interact with that group’s eligibility for assistance under the ACA. Accordingly, ACA subsidies are well targeted to protect the majority of newly unemployed individuals who lose ESI.