The union advantage: union membership, access to care, and the Affordable Care Act

We describe a "union advantage" in health insurance coverage and access to care. Using multiple statistical models and data from the Medical Expenditure Panel Survey for 1996-2019, we show that-compared to non-union workers-union workers are more likely to have health insurance coverage (98% vs. 86%), more likely to have a regular care provider (83% vs. 74%), visited office-based providers 31% more often (5.64 vs. 4.27 visits), spend $832 more on healthcare annually, and pay a lower share of their expenditures out-of-pocket (26% vs. 37%). When we control for demographic characteristics across variety of specifications, these differences almost always remain at a statistically significant level. Further, we show that the union advantage is greater for low-income workers. Next, we demonstrate that-although the Affordable Care Act (ACA) appears to have reduced the union advantage in health insurance coverage by increasing coverage rates among non-union workers-a substantial union advantage in access to care remains after the ACA's main provisions become effective. Finally, we explore how the ACA interacted with the trade union  goal of maintaining employer-based health insurance. We show that unionized workers are less likely to contribute to "enrollment shifting," which occurs when individuals shift from existing employer-based insurance to a new government funded program. This suggests that union bargaining over fringe benefits may have positive externalities in the form of cost reductions to the public sector.