Health insurance coverage and self-employment

Health Serv Res. 2021 Apr;56(2):247-255. doi: 10.1111/1475-6773.13598. Epub 2020 Nov 4.


Background: Self-employed workers are 10% of the US labor force, with growth projected over the next decade. Whether existing policy mechanisms are sufficient to ensure health insurance coverage for self-employed workers, who do not have access to employer-sponsored coverage, is unclear.

Objective: To determine whether self-employment is associated with lack of health insurance coverage.

Data sources: Secondary analysis of Medical Expenditure Panel Survey (MEPS) data collected 2014-2017.

Study design: Participants were working age (18-64 years), employed, civilian noninstitutionalized US adults with two years of Medical Expenditure Panel Survey (MEPS) participation in 2014-2017. We compared those who were employees vs those who were self-employed. Key outcomes were self-report of health insurance coverage, and of delaying needed medical care.

Data extraction methods: Longitudinal design among individuals who were employees during study year 1, comparing health insurance coverage among those who did vs did not transition to self-employment in year 2.

Principal findings: 16 335 individuals, representing 121 473 345 working-age adults, met inclusion criteria; of these, 147, representing 1 097 582 individuals, transitioned to self-employment. In unadjusted analyses, 25.7% of those who became self-employed were uninsured in year 2, vs 8.1% of those who remained employees (P < .0001). In adjusted models, self-employment was associated with greater risk of being uninsured (26.1% vs 8.0%, risk difference 18.0%, 95% confidence interval [CI] 9.2% to 26.9%, P = .0001). A time-by-employment type product term suggests that 10.0 percentage points (95%CI 0.3 to 19.7 percentage points, P = .04) of the risk difference may be attributable to the change to self-employment. Self-employment was also associated with delaying needed medical care (12.0% vs 3.1%, risk difference: 8.9%, 95% CI 3.1% to 14.6%, P = .003).

Conclusions: One in four self-employed workers lack health insurance coverage. Given the rise in self-employment, it is imperative to identify ways to improve health care insurance access for self-employed working-age US adults.

Keywords: employment; health insurance; medically uninsured; self-employment.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Adolescent
  • Adult
  • Age Factors
  • Employment / statistics & numerical data*
  • Female
  • Financing, Personal
  • Health Benefit Plans, Employee / statistics & numerical data
  • Health Expenditures / statistics & numerical data
  • Humans
  • Insurance Coverage / statistics & numerical data*
  • Insurance, Health / statistics & numerical data*
  • Longitudinal Studies
  • Male
  • Middle Aged
  • Sex Factors
  • Socioeconomic Factors
  • United States
  • Young Adult