How Health Insurance Coverage Varies Across, Within Families

The Affordable Care Act (ACA) increased access to Medicaid and group health insurance, but the family glitch created a barrier to non-group coverage, leading to variations in health insurance coverage across families, a brief from the Employee Benefit Researcher Institute (EBRI) found.

Researchers used data from the Annual Socioeconomic Supplement of the Current Population Survey (CPS ASEC) from 2013 to 2022 to assess how health insurance coverage differed within and across families.

The ACA included several provisions that impacted health insurance coverage, such as Medicaid expansion, the employer shared responsibility mandate, the guaranteed issue provision, the individual mandate, and the creation of state-level insurance exchanges.

The brief looked at how the ACA impacted health plans for four different family types: two-parent families with children, single-mother families with children, single-father families with children, and two-adult families without children.

In two-parent families with children, the father’s coverage strongly influenced the coverage type for the family. For example, if fathers had group coverage, the mother also had group coverage in 96 percent of cases and the children had group coverage in 89 percent of cases. If fathers had non-group coverage, the mother did as well in 80 percent of cases, but children had non-group coverage in only 48 percent of cases.

Almost all children and mothers had Medicaid in the cases where the father had Medicaid. However, children were less likely to be uninsured than their fathers. Uninsurance for fathers was tied to uninsurance for mothers in 77 percent of cases.

Mothers were more likely to be the provider of group coverage for the whole family than fathers. This is likely due to increased labor force participation among mothers and more entrances into higher-paid jobs.

Additionally, when fathers had group coverage and mothers did not, mothers were more likely to have Medicaid or be uninsured than have non-group coverage. This may be attributed to the family glitch, which bases marketplace subsidy eligibility on the affordability of group coverage for the employee only, not the whole family.

In October 2022, the Biden Administration finalized a rule aiming to fix the family glitch. The regulation makes family members of an employee with access to group coverage eligible for marketplace subsidies if the family group premium exceeds 9.5 percent of the family’s income. This change applies to individuals seeking marketplace coverage for 2023.

Almost three-quarters of all families had all members covered by group health insurance, non-group plans, or Medicaid or had all members uninsured. The next most common scenarios were both parents being uninsured and the children having Medicaid, and both parents having group coverage and the children having Medicaid.

In single-parent families, 15 percent of single mothers were uninsured and 40 percent were covered by Medicaid. In comparison, 15 percent of single fathers were uninsured and 18 percent had Medicaid.

When single parents had Medicaid coverage, more than 90 percent of children were also covered by Medicaid. However, less than 70 percent of children had group coverage if their parent had group coverage.

Health insurance coverage was similar among members of two-adult families without children, the brief found. The strongest correlation was in group coverage, with 96 percent of female partners having group coverage if their male partner also had this coverage type. If the male partner had Medicaid, 87 percent of female partners did, too.

Around 80 percent of female partners were covered by non-group plans or were uninsured if their male partners were. Medicare had the lowest correlation, with 69 percent of female partners having Medicare coverage if their male partner did.

Nearly 90 percent of families had all members covered by the same insurance or had all members uninsured. The next most common scenarios were both partners having military health plans and one partner being uninsured while the other had group coverage.

Overall, the ACA helped boost access to health insurance, despite the variations across families. Access to stable coverage is key as it can lead to higher healthcare utilization and better health outcomes.