When Unemployed Means Uninsured: The Toll of Job Loss on Health Coverage, and How the Affordable Care Act Will Help

By Michelle M. Doty, Sara R. Collins, Ruth Robertson, and Tracy Garber
The Commonwealth Fund, August 2011

Chronically high unemployment has left millions of Americans without health insurance, which disappeared along with their wages and other job benefits. Although continuing health coverage through COBRA is an option for some workers, the often prohibitively high cost means that relatively few elect to purchase it. When fully implemented in 2014, the Affordable Care Act will dramatically increase health insurance options for people who lose their jobs. Even so, gaps in coverage will remain a risk for many workers who become unemployed or are transitioning to a new job. To help bridge coverage gaps until 2014, policymakers should consider reestablishing the COBRA premium subsidies that helped millions of people who lost their jobs in 2008–2010.



Maintaining Coverage, Affordability, and Shared Responsibility When Income and Employment Change

By Pamela Farley Short, Katherine Swartz, Namrata Uberoi, and Deborah Graefe
The Commonwealth Fund, May 2011

The Affordable Care Act builds on existing sources of public and private health insurance, while creating new health insurance exchanges and subsidies. A potential disadvantage of preserving many sources of health insurance is the likelihood of abrupt changes in coverage or financial responsibility when individual circumstances change. This brief describes four policy challenges related to such changes: adjusting premium and cost-sharing subsidies when incomes change; coordinating eligibility for premium credits, Medicaid, and the Children’s Health Insurance Program; encouraging and facilitating continuous coverage; and minimizing transitions between individual and small-business exchanges. Policy recommendations to reduce uncertainty, simplify coverage decisions, and minimize insurance transitions include extending coverage to the open enrollment period at the end of the year, generous treatment of income gains in correcting premium tax credits, and unifying the small-business and individual exchanges.


How many individuals continue in the same employment for their entire careers, with the same employer-sponsored health plan, with the same network of health care providers, with the same…? Well, we can stop there. Nobody does.

Generally, individuals in well-paid occupations in high demand who change their employment may face some transitional issues with health plans and provider networks, but usually they fare quite well, even if annoyed at the prospect of perhaps having to change their primary health care professionals, or whatever.

But what about low and moderate income individuals? Job instability is the norm. Income levels can fluctuate considerably. Periods of prolonged unemployment are now more common, and, based on economic projections, will likely persist into the foreseeable future.

The Affordable Care Act has so many slippery variables that it is almost impossible to predict what one’s coverage will be beyond a couple of years, if that. Eligibility can change sometimes on a monthly basis (exchange plans) or yearly basis (Medicaid) for various programs including employer-sponsored plans, Medicaid, CHIP, state exchange plans, or state Basic Health Plans. Eligibility for tax credits for premiums in the exchange plans and for cost sharing reductions can be very unstable because of fluctuations in income. Even waiver of the penalty for failure to purchase private insurance can trigger in or out quite abruptly.

The newest Commonwealth Fund report addresses specifically the problem of coverage during intervals of unemployment. COBRA plans allow newly unemployed workers to continue with coverage under their former employer-sponsored plans but with the out-of-work former employees having to pay the full premiums. COBRA plans have had an unacceptably low participation simply because a person out of work cannot pay the premiums.

To address the problem of unaffordable COBRA premiums that became even more prevalent during the Great Recession, the American Recovery and Reinvestment Act (ARRA) authorized premium subsidies for the purchase of COBRA plans, but that program has expired.

To provide coverage during transitions of unemployment in the future, the authors of this report suggest that the subsidies be permanently resuscitated. The problem with this approach is, even with these temporary subsidies, the COBRA take-up rate was still well less than half of eligible former employees. Policies that don’t work shouldn’t take precedence over policies that do.

You can apply all of the patches that you can devise to the leaking ship of the Affordable Care Act, but it is still going to leak. As more patches are applied, it is further weighted down with greater expenses and with even more administrative burdens – enough to sink any ship.

You want something that floats? Try enrolling everyone at birth, permanently. The solid ship of Medicare for All would have no leaks to patch.