Despite concerns that the changes introduced under the Affordable Care Act (ACA) would lead to a decline in employer-sponsored insurance (ESI) coverage, the available evidence continues to show no changes in ESI offer rates, take-up rates, or overall ESI coverage for workers under the ACA.

In earlier work, we reported that ESI offer rates, take-up rates, and ESI coverage held steady across income levels and firm sizes between June 2013 and September 2014, a period spanning the implementation of the ACA’s health insurance Marketplaces and Medicaid expansions that followed a long trend of declining ESI rates. An updated analysis shows those trends held through early 2015, after a full year of experience for employers and workers (Figure 1). Coverage, offer, and take-up rates were stable between June 2013 and March 2015 for workers in both small and large firms as well as for workers with higher and lower incomes. Employer-sponsored insurance coverage also remained unchanged among all nonelderly adults from June 2013 through March 2015.

While federal survey data providing estimates of employer-sponsored coverage post-2014 are yet to be released, private survey data support the finding that ESI has remained stable if not increased under the ACA. Studies of employers have similarly found no significant changes in offer rates or employee enrollment after the implementation of the ACA’s major coverage provisions.


Source: Health Reform Monitoring Survey, quarter 2 2013 and quarter 1 2015.
Notes: ESI is employer-sponsored insurance. Estimates are regression adjusted. Respondents are coded as having an ESI offer if their own or a family member’s employer offers health insurance or they report having ESI coverage.
^ Among workers offered ESI through their own or a spouse’s employer.
No estimate differs significantly from zero at the 0.1/.05/.01 levels, using two-tailed tests. 

Even as ESI rates have held steady for workers, the rate of uninsurance among nonelderly workers declined 5.9 percentage points between June 2013 and March 2015 (Figure 2) as new coverage options through the Marketplaces and Medicaid expansions became available under the ACA, dropping from 13.8 to 7.8 percent (data not shown). These parallel findings of steady ESI rates with decreasing uninsurance among workers suggest that the ACA coverage provisions are not displacing ESI but instead providing new coverage to previously uninsured workers.

As an example, the declines were particularly pronounced among lower-income workers at small firms, where there was a 15.6 percentage-point decline in uninsurance, dropping from 40.0 percent to 24.4 percent (data not shown). Before the ACA, small firms with predominately low-wage employees were much less likely to offer coverage than larger, higher-wage firms. Lower-income workers at large firms also experienced a significant decline in uninsurance (9.1 percentage points), though with 12.0 percent uninsurance in March 2015 these workers remain significantly more likely to have insurance coverage than lower-income workers at small firms (data not shown).


Source: Health Reform Monitoring Survey,  quarter 2 2013 and quarter 1 2015.
Notes: FPL is federal poverty level.  Small firms includes firms with fewer than 50 workers across all sites and self-employed adults; large firms includes firms with 50 or more workers across all sites.
*/**/*** Estimate is significantly different from zero at the 0.1/0.05/0.01 level, using two-tailed tests.

Gaining coverage is the first step in increasing access to care and improving the health and well-being of workers. In addition to the declines in uninsurance, we are beginning to see improvements in access to care among workers (Figure 3). For example, the share of nonelderly workers with a usual source of care increased 3.4 percentage points, and the share with a routine checkup in the past 12 months increased 2.5 percentage points. In addition, a smaller share of nonelderly workers reported unmet need for care because of cost in March 2015 compared with June 2013.

Factors other than the ACA such as an improving economy could explain increased access to care in this timeframe. Contrary to the predictions of some, however, we do not find evidence thus far that the ACA has impeded access to care for workers.


Source: Health Reform Monitoring Survey, quarter 2 2013 and quarter 1 2015.
Notes: Estimates are regression-adjusted.  Workers includes nonelderly adults working for pay and self-employed adults.
*/**/*** Estimate is significantly different from zero at the 0.1/0.05/0.01 level, using two-tailed tests.

It is too soon to know the full impact of the ACA on ESI. Employers may be slow to understand and react to the ACA’s coverage provisions, and any impacts will likely occur over several years. Further, the rollout of other components of the ACA such as the “Cadillac tax” (an excise tax effective in 2018 on high-cost health plans) and employer mandates will affect the trajectory of ESI. Of course, the strength of the economy and growth in health care costs ultimately shape employer decisions regarding insurance coverage for their workers. Similarly, it may take time to make substantial headway in improving access to care and the health status of workers, as there are very real challenges of limited health insurance literacy and navigating the health care system for workers.

In the meantime, despite concerns to the contrary, the evidence suggests that employers have remained the backbone of health insurance coverage in the United States as uninsurance among workers has dropped and access to care is improving. Continued outreach efforts to reach workers who remain uninsured, as well as education efforts by employers and health plans to improve understanding of insurance coverage terms and benefits, could expand upon the early gains we find to improve the health of the workforce.