EBRI Issue Brief

The Dynamics of Health Insurance Within Families: 2012–2021

Nov 17, 2022 26  pages


Over 70 percent of working adults are covered by a group health plan, making it the predominant source of health insurance coverage. However, there is still substantial variation in health coverage within and across families in the United States. The Patient Protection and Affordable Care Act (ACA) led to changes in the composition of health insurance coverage within families by increasing access to group, non-group, and Medicaid coverage. In this study, we document how health insurance coverage differs within and across families, show evidence regarding the impact of the “family glitch” on enrollment in Marketplace coverage, investigate family coverage trends, and document the profiles of female policyholders over time. These findings indicate that the ACA has increased access to Medicaid and group health insurance, but by reducing the affordability of Marketplace coverage for family members of group policyholders, the “family glitch” is a barrier to enrollment in non-group health plans. Our analyses show:

  • Health plans differ within and across families. Health coverage of partners is highly correlated in two-parent and in two-adult childless families. Children’s coverage is more similar to their parents’ in two-parent families than in single-parent families.
  • There is strong evidence that the ACA “family glitch” reduces the likelihood that partners are covered by non-group coverage, especially among families with children. Women whose partner has group coverage are 2–3 times more likely to be uninsured than have non-group coverage.
  • Coinciding with the ACA’s 2014 Medicaid expansion and the 2016 employer mandate, differences in Medicaid and group coverage within families narrowed.
  • Mothers are increasingly likely to be the provider of group coverage for the whole family and are replacing fathers as the providers of family coverage. On the other hand, group policy-holding rates have been steady for both childless men and women.
  • Increased group policy-holding rates among mothers can be explained by increased labor force participation and an “upscaling” of jobs.
  • Finally, women with group coverage are earning more over time, further reflecting entrance into higher paid occupations.