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UNITED STATES DEPARTMENT OF LABOR

Medicaid expansion and the unemployed (Buchmueller et al., 2021)

Review Guidelines

Causal Evidence Guidelines

There is no conflict of interest.

Citation

Buchmueller, T. C., Levy, H., & Valletta, R. G. (2021). Medicaid expansion and the unemployed. Journal of Labor Economics, 39(S2), S575-S617. https://doi.org/10.1086/712478

Highlights

  • The study's objective was to examine the impact of the Affordable Care Act (ACA) Medicaid expansion on health insurance coverage and employment among unemployed adults.
  • The study used a difference-in-differences design to compare outcomes between unemployed adults in ACA Medicaid expansion states and non-expansion states. The primary data sources were the American Community Survey (ACS) and the Current Population Survey (CPS). The authors used statistical models to compare the differences in insurance coverage and transitions to employment between the groups.
  • The study found a significant decrease in the percentage of unemployed adults who did not have any insurance and a significant increase in Medicaid coverage in ACA expansion states compared to those in ACA non-expansion states.
  • The study received a moderate evidence rating. This means we are somewhat confident that the estimated effects are attributable to the Affordable Care Act (ACA) Medicaid expansion, but other factors might also have contributed.

Intervention Examined

Medicaid expansion

Features of the Intervention

Medicaid expansion, part of the Affordable Care Act (ACA) that was originally enacted in 2010, required states to expand their Medicaid programs to cover individuals between the ages of 19 to 64 in families that have incomes below 138% of the federal poverty level. The primary objective of Medicaid expansion was to increase access to healthcare for vulnerable populations, lower the number of uninsured individuals, and improve health outcomes. Following a 2012 Supreme Court ruling, states could opt out of the Medicaid expansion. By January 2014, 25 states had adopted state Medicaid expansion. By January 2017, an additional seven states adopted the policy, bringing the total to 32 states. However, as of January 2019, 19 states had chosen not to expand Medicaid under the ACA.

Features of the Study

The study used a difference-in-differences design to compare outcomes between unemployed adults in ACA Medicaid expansion states and non-expansion states. The treatment group lived in Medicaid expansion states, and the comparison group lived in states that did not provide Medicaid expansion. The primary data sources for the study were the American Community Survey (ACS) and the Current Population Survey (CPS). The ACS included data from 2008 to 2017, while the CPS included data from 2007 to 2017.

The sample was restricted to unemployed workers, ages 26 to 64, residing in the United States. The participants classified as unemployed consisted of individuals who were unemployed due to layoffs, voluntary resignations, and those reentering the labor force (excluding new labor force entrants). A total of 162,950 participants from expansion states and 90,231 participants from non-expansion states were included in the analysis. Most participants were aged 26 to 39, had a high school education or less, identified as Hispanic, and were men. The authors used statistical models with controls to compare changes in insurance coverage and transitions to employment between individuals in Medicaid expansion states and non-expansion states.

Findings

Public benefits receipt

  • The study found a significant decline in the percentage of unemployed adults who did not have any insurance in expansion states compared to those in non-expansion states (8 percentage point difference).
  • The study found a significant increase in the percentage of unemployed adults who received Medicaid or other public coverage in expansion states compared to those in non-expansion states (13.3 percentage point difference).

Employer benefits receipt

  • The study found a significant decrease in the percentage of unemployed adults who received employer sponsored insurance in expansion states compared to those in non-expansion states (2.5 percentage point difference).

Employment

  • The study did not find a significant difference in the transition out of unemployment between unemployed adults in expansion states and non-expansion states.

Consideration for Interpreting the Findings

While the study was a well-implemented nonexperimental design, there is a challenge in counting unemployment spells. Specifically, individuals who exit unemployment for a brief time were classified as ‘no transition.’ The underlying reasons for these exits were not observable, and these cases could result from either securing a temporary job or failing to complete necessary paperwork. This classification could impact the observed findings for the employment outcomes.

Causal Evidence Rating

The quality of causal evidence presented in this report is moderate because it was based on a well-implemented nonexperimental design. This means we are somewhat confident that the estimated effects are attributable to the Affordable Care Act (ACA) Medicaid expansion, but other factors might also have contributed.

Reviewed by CLEAR

June 2026