In the 46 years since the late Dolly Parton wrote the working person's anthem "9 to 5," U.S. jobs and access to employer-sponsored health insurance have changed a great deal. Today millions more people work several part-time jobs, are self-employed, or work as contractors or freelancers.

How do the unstable incomes and the fluctuating work hours associated with this kind of work affect low- and middle-income Americans' access to health insurance? Researchers at the University of Michigan and Mount Sinai Hospital in New York decided to find out. “We wanted to highlight the health insurance landscape for these types of workers,” Vineeth Amba, lead author on the study, told TheDoctor.

Medicaid enrollees in 44 states will be required to work at least 80 hours a month or be at risk of losing their healthcare coverage in 2027. Those who work part-time or are self-employed are vulnerable.

Workers with unstable work hours and fluctuating employment who earned low- and middle-incomes were more likely to be young and female than those with higher incomes and more stable employment, they found. They were also more likely to rely on Medicaid or health care plans bought through Affordable Care Act marketplaces.

These workers rely on Medicaid and ACA marketplaces because they cannot rely on employer-sponsored health insurance, Sumit Agarwal, senior author on the study and an assistant professor at the University of Michigan Medical School and School of Public Health, explained. One reason for this is that companies are increasingly outsourcing certain jobs to contractors or hiring employees for jobs that are ineligible for benefits.

Workers with more stable incomes and employment were more likely to have health insurance through their employer, even if they had incomes similar to those of part-timers or independent contractors.

The researchers analyzed data from more than 1,860 U.S. adults who participated in the Medical Expenditure Panel Survey between 2022 and 2023. People surveyed were between the ages of 18 and 64 and had a household income less than or equal to 400 percent of the federal poverty level. The highest income in the study was $58,300 for a single person and $120,000 for a family of four.

More than 940 of the respondents — representing 14.6 million people in the U.S. — had fluctuating incomes, compared with 10.6 million who had stable incomes. More than 730 respondents — representing 11.4 million people — had fluctuating work hours, compared to 13.5 million with stable hours. Over 180 respondents — representing almost three million people — experienced employment disruption, compared to 22.4 million who had stable jobs.

The study is published as 44 states are set to require Medicaid enrollees to document they work at least 80 hours a month, about 20 hours a week, or meet other requirements. Those who do not meet these requirements risk losing their Medicaid coverage in 2027.

Workers with unstable employment are particularly vulnerable to losing their health insurance, despite often working 33 to 35 hours in a week.

Medicaid recipients should make sure they have an updated address on file because that is where information about Medicaid eligibility and work requirements will be sent.

This fluctuation in hours is a problem: They might work more than 20 hours some weeks and less than 20 hours other weeks. “But they may not work 20 hours a week on average, and that may put them at risk when documentation procedures get rolled out in January,” Amba said.

Specific requirements and the systems used to track work hours will vary by state. A work requirement tracker is available from the Kaiser Family Foundation.

Another option for information is Healthcare.gov. Medicaid recipients should make sure they have an updated address on file because that is where information about Medicaid eligibility and work requirements will be sent, explained Amba, a resident physician at Mount Sinai Hospital in New York City. State web sites and healthcare professionals are also good resources as rules become finalized.

The study is published in JAMA Network Open.