The last decade has seen a shift away from traditional employment and toward a more alternative labor market in which individuals are contracted out by firms, work as freelancers or temporary employees, or hold one or more part-time jobs.1 New technologies combined with the recession and the sluggish economic recovery of the last decade may have contributed to these changes, and one of the many implications of the new labor market has been the loss of employee benefits, including health insurance.

A major goal of the ACA was to make health insurance more available and affordable, especially to those with low incomes. Under the coverage expansions, Medicaid and subsidized Marketplace insurance are available to low-income individuals, and those who have gained coverage are experiencing improved access to care and increased financial protection against medical expenses.2 In addition, because this new coverage is not linked to employment, it allows individuals in various types of work situations to gain and maintain coverage, including entrepreneurs and small-business owners, those who are in school or transitioning to new careers, individuals who work one or more part-time jobs, and the millions who have shifted to other types of labor arrangements, by choice or necessity.

This brief highlights voices from adult focus group participants with low and moderate incomes with Medicaid or Marketplace coverage following implementation of the ACA. These discussions also served to inform a larger Kaiser study that assessed the affordability of ACA coverage for low-income people.3 The observations below provide the focus group participants’ insights on work, including work status, the new labor market, job benefits, and the role of ACA coverage for those with non-traditional jobs.

Key Observations

Several felt the job market had not fully recovered from the economic recession.

Some had full-time jobs, but received few or no benefits from their employers or were offered health coverage that was unaffordable.

A number of participants believed their age or their prolonged period of time out of the workforce was a barrier to getting or keeping full-time, steady employment.

Other participants had health conditions which made it difficult to work full-time or outside the home.

Several were self-employed or ran their own business.

ACA coverage supported some participants as they transitioned into new careers or were looking for work after being laid off.

For others, access to health care through Medicaid or the Marketplace supported their ability to work.

Even with financial assistance, some found that the cost of coverage was not affordable.

And though Marketplace coverage is not linked to employment, some still found that it was designed for those with traditional jobs and predictable incomes.

When asked what they would do if Medicaid or Marketplace insurance were no longer available, some said they would have to change careers or close down their businesses in order to get more traditional jobs that offered insurance.


The majority of nonelderly individuals in the United States are covered by an employer plan, be it their own or that of a family member. However, not all workers receive an offer of coverage through their job and many who do are not able to afford their share of the cost.4 In addition, the last ten years has seen a rapid shift in the U.S. labor market from traditional jobs with benefits to more alternative arrangements where individuals work as freelancers, contract employees, or make a living from multiple part-time jobs.

The vast majority of focus group participants were working at full or part-time jobs but did not have an affordable offer of coverage from their employer or were outside the traditional labor market and had no offer of coverage. Some were in periods of transition; others chose or preferred these alternative work arrangements. Most wanted to move into traditional jobs with steady income and benefits but found it difficult or impossible to do so, a number citing the sluggish economic recovery as the reason for limited job opportunities. Because of their low incomes, some Marketplace enrollees struggled to afford their monthly premium payments and out-of-pocket costs, even with financial assistance. For some without a steady income, verifying and estimating future earnings for the purpose of receiving Marketplace subsidies could be difficult to do, and those who underestimated may have to pay some or all of their subsidies back when they reconcile their income taxes.

Participants with Medicaid were generally able to access the care they needed with few out-of-pocket costs and overall, most participants were positive about gaining coverage and grateful that it was available to them.5 Because ACA coverage is not tied to employment, the expansions help to fill the gaps in employer-sponsored insurance for people in non-traditional work arrangements, those experiencing short or prolonged bouts of unemployment, and those in school or (re)training for new careers. Further, the availability of uninterrupted care and coverage allows individuals to manage chronic conditions and seek treatment for illnesses as they arise, enabling them to participate more fully in the workforce.


ACA Coverage and the Changing Labor Market: Voices from the Field
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