Rapid job losses in the early months of the COVID-19 pandemic raised fears that millions of people would lose their employer-based health insurance and become uninsured. But laid-off workers and their families, regardless of whether they previously had employer-sponsored insurance (ESI), had more options for health insurance than in previous recessions because of the safety net established by the Affordable Care Act (ACA). And Congress further supported access to coverage by not allowing disenrollment from Medicaid through the March 2020 Families First Coronavirus Response Act.
In this brief, we examine national changes in health insurance coverage among nonelderly adults ages 18 to 64 during the pandemic using data from the Urban Institute’s Health Reform Monitoring Survey. Our analysis focuses on changes in coverage across three rounds of the survey: March 2019; March/April 2020, just after the pandemic caused a steep decline in employment; and April 2021, more than one year after the secretary of health and human services declared a national public health emergency. We find the following:
- Between March 2019 and April 2021, the share of nonelderly adults reporting ESI declined from 65.0 to 62.3 percent, a decrease of approximately 5.5 million adults. The share reporting public coverage increased from 13.6 to 17.5 percent, an increase of approximately 7.9 million adults. The national uninsurance rate held steady at approximately 11 percent.
- The share of adults reporting public coverage increased between 2019 and 2021 in both states that had and had not expanded Medicaid under the ACA. Such coverage increased from 14.9 to 19.2 percent in expansion states and from 10.7 to 14.3 percent in nonexpansion states.
- In Medicaid expansion states, the uninsurance rate was near 8 percent across all three study years. In nonexpansion states, the uninsurance rate was higher in 2021 (18.2 percent) than in 2020 (16.5 percent) and 2019 (17.2 percent), though the difference between 2019 and 2021 was not statistically significant.
- Declines in ESI and increases in public coverage between 2019 and 2021 were concentrated among adults with low and moderate incomes. Uninsurance rates among the national nonelderly adult population did not change significantly for any income group examined.
- The share of adults with low incomes reporting public coverage increased in both expansion states (from 54.6 to 62.9 percent) and nonexpansion states (from 30.4 to 37.3 percent) between 2019 and 2021. More than one in three adults with low incomes in nonexpansion states (37.7 percent) were uninsured in 2021, compared with about one in seven of such adults in expansion states (14.5 percent).
Despite losses of jobs, income, and ESI during the pandemic, the uninsurance rate did not change between March 2019 and April 2021. Increased public coverage helped counter ESI losses, protecting many adults from becoming uninsured both in Medicaid expansion and nonexpansion states. Maintaining the current uninsurance rate will require protecting coverage for current and prospective Medicaid enrollees as the economy improves and the Medicaid disenrollment freeze is lifted. Policymakers can further reduce uninsurance by permanently extending the enhanced Marketplace premium tax credits authorized by the American Rescue Plan Act and by addressing the persistently high uninsurance rates among adults with low incomes, particularly in the 12 states that have not expanded Medicaid.