Publication date: Jun 03, 2025

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. 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. 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. 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. 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.

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