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Research Questions

  1. How important were temporary policies in stabilizing health insurance coverage during the COVID-19 pandemic?
  2. Did the provisions of the ACA contribute to the stability of health insurance coverage during the pandemic?

The coronavirus disease 2019 (COVID-19) pandemic–related recession and resulting job loss raised significant concerns that the U.S. uninsured population could increase, perhaps by millions. However, predictions about coverage loss have not materialized. Because this recession is the first economic downturn since the Affordable Care Act's (ACA's) major coverage provisions took effect in 2014, a possible explanation for the lack of coverage loss is that the ACA's safety-net provisions — such as Medicaid expansion and Advance Premium Tax Credits (APTCs) for marketplace coverage — did their job.

However, it is also possible that other responses to the pandemic contributed to the maintenance of insurance levels. For example, more than half of covered workers who lost their jobs as a result of the pandemic retained their employer-sponsored insurance, perhaps because the layoffs were not expected to be permanent. Temporary policies to retain Medicaid enrollees appear to have increased insurance enrollment. Furthermore, some states opened their health care marketplaces for a special enrollment period in 2020, enabling people to newly enroll in insurance in the middle of the year. In 2021, the American Rescue Plan, which temporarily enhanced marketplace tax credits, also led to an enrollment bump.

To explore this issue, RAND researchers (1) assess the importance of temporary provisions relative to long-standing policies in stabilizing health insurance enrollment despite heavy job loss and (2) run simulations using New York state as a case study.

Key Findings

Temporary provisions played an outsized role in stabilizing coverage in 2020 and will continue to play a large role in 2021

  • This analysis and emerging evidence from other sources suggest that temporary policies — notably, continuous Medicaid enrollment and furlough coverage — are major contributing factors to the success of the health insurance safety net.
  • The temporary extension and enhancement of APTCs likely contributed to enrollment stability in 2021.
  • Workers' ability to retain job-based coverage after being laid off may have been a substantial factor in holding national insurance rates steady.
  • On their own, the ACA's coverage provisions might not have fully prevented insurance loss during the COVID-19 pandemic.
  • For New York state, extending and enhancing APTCs — two temporary policies that legislators have proposed making permanent through the Build Back Better Act — could offset most of the decline in insurance that would be expected because of elevated unemployment in 2021, even without continuous Medicaid enrollment.


  • Expand outreach and enrollment assistance to ensure that U.S. residents remain covered when continuous Medicaid enrollment and other temporary provisions expire.
  • Consider modifying the ACA to ensure that the U.S. health insurance system is prepared for future recessions.

Research conducted by

This research was funded by the New York State Health Foundation and carried out within the Payment, Cost, and Coverage Program in RAND Health Care.

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