Absence of conflict of interest.
Citation
Highlights
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The study’s objective was to examine the impact of the Patient Protection and Affordable Care Act’s (ACA) employer mandate on employer-sponsored insurance (ESI) coverage for low-income and less-educated workers. The authors also investigated the ACA and employment, the profiles of which can be found here.
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The study uses a difference-in-differences design to compare ESI coverage before and after the implementation of the ACA’s employer mandate, comparing coverage for employees of mid-sized or large firms subject to the mandate versus employees of small firms that were not subject to the mandate. The author uses data from 2006 through 2017 from the Current Population Survey’s Annual Social and Economic Supplement.
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The study found that the ACA’s employer mandate significantly increased the share of low-income workers in mid-sized firms (which were subject to the mandate) who reported ESI coverage compared to low-income workers in small firms (which were not subject to the mandate).
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The quality of causal evidence presented in this study is moderate because it was based on a well-implemented non-experimental design. This means we are somewhat confident that the estimated findings are attributable to the ACA’s employer mandate, but other factors might also have contributed.
Intervention Examined
Patient Protection and Affordable Care Act’s (ACA) Medicaid expansion
Features of the Intervention
The employer mandate of the Patient Protection and Affordable Care Act (ACA) required that employers with 100 or more full-time employees (as of 2015) and 50 or more full-time employees (as of 2016) offer employer-sponsored health insurance to all full-time employees or pay a penalty. This study compares ESI coverage for workers at small firms, defined as those with fewer than 100 workers; mid-sized firms, defined as those with 100 to 500 workers; and large firms, defined as firms with 500 or more workers.
Features of the Study
The study uses a difference-in-differences design to compare rates of ESI coverage before and after the implementation of the ACA’s employer mandate, comparing coverage rates for employees of small versus mid-sized or large firms. Data come from the Current Population Survey’s Annual Social and Economic Supplement (CPS-ASEC) for years 2006 to 2017. The CPS-ASEC survey uses a cross-sectional design, meaning that the sample of survey respondents changes each year.
The sample is restricted to adults ages 19-64 years old who participated in the labor market in a given year. The study focuses on low-income and less-educated workers because they are less likely to have ESI coverage. Low-income workers are defined as those with reported incomes in the bottom quartile of their state’s income distribution. Less-educated workers are defined as those with a high school education or less. The study’s statistical model controls for age, gender, race, industry, occupation, year, state, and other characteristics. The sample size is 100,147 workers in the less educated group and 66,341 in the low-income group, but the study does not report the share of the analytic sample who work for small versus mid-sized or large firms.
Findings
Employer Benefits Receipt
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The study found that the ACA’s employer mandate increased by six percentage points the share of low-income workers at mid-sized firms who had ESI coverage relative to similar workers at small firms.
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The study found that the ACA’s employment mandate was not associated with a significant difference in ESI coverage rates for low-income workers at large firms (relative to similar workers at small firms) or for less-educated workers employed at mid-size or large firms relative to similar workers employed at small firms.
Considerations for Interpreting the Findings
Although the study was a well-implemented nonexperimental design, anticipation of the ACA’s employer mandate might have affected the results. The ACA was passed into law in 2010, but implementation of the employer mandate did not begin until 2015. Thus, firms subject to the mandate might have adjusted their employment practices prior to implementation in ways that affected the study’s pre- and post-intervention comparisons. The study attempts to address this possibility by including multiple years of pre-intervention data and showing parallel trends prior to the intervention but it is possible that the study results could partially reflect employer anticipation of the intervention rather than or in addition to the true impact of the policy.
Causal Evidence Rating
The quality of causal evidence presented in this study is moderate because it was based on a well-implemented non-experimental design. This means we are somewhat confident that the estimated effects are attributable to the ACA’s employer mandate, but other factors might also have contributed.