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Unstable Work Hours Could Leave Millions Struggling to Keep Health Insurance
Workers with unpredictable paychecks or schedules are far less likely to have health insurance through their jobs—even when they work 30 or more hours a week.
A new study published in JAMA Network Open found that workers experiencing unstable income, fluctuating hours, or periods of unemployment were roughly 20 percentage points less likely to have employer-sponsored health coverage than workers with more stable employment. Among those who experienced unemployment, the coverage gap reached about 24 percentage points.
The problem isn't necessarily working less. It's working unpredictably.
Researchers analyzed federal Medical Expenditure Panel Survey data covering adults ages 18 to 64 who worked during 2022–2023 and had household incomes at or below 400% of the federal poverty level.
They tracked three forms of instability:
Income swings
Large changes in weekly work hours
Transitions from employment to unemployment
Across all three groups, workers averaged at least 30 hours per week when employed. But their schedules could swing sharply—sometimes moving above and below roughly 20 hours a week.
That matters because employer health insurance is often tied to employment and eligibility rules based on hours worked.
Employer coverage drops. Medicaid fills part of the gap.
Compared with workers in stable employment, those with unstable income or hours were about 15 percentage points less likely to be offered health insurance through their jobs.
The gap in actually having employer coverage was larger—roughly 20 to 24 percentage points depending on the type of instability.
At the same time, unstable workers were substantially more likely to rely on Medicaid, with coverage rates roughly 12 to 19 percentage points higher than among workers with stable employment. Marketplace coverage was also somewhat more common.
The result is a precarious insurance chain: when work changes, the source of coverage can change with it.
New rules could make the situation harder to navigate.
The findings arrive as major changes to U.S. health coverage take effect.
A federal law enacted in 2025 requires certain Medicaid recipients to document at least 80 hours per month of work, education, training, or community engagement, beginning no later than January 2027, subject to exemptions.
That threshold is particularly relevant for workers with volatile schedules. In the study, many unstable workers repeatedly moved above and below the equivalent of roughly 20 hours per week—even though their average hours were substantially higher.
That could create coverage risks when workers struggle to document fluctuating hours or meet eligibility requirements during periods of instability.
Meanwhile, enhanced Affordable Care Act marketplace subsidies expired after 2025, potentially making an alternative source of coverage more expensive.
The study points to a structural mismatch: health insurance can depend on employment stability even when workers themselves remain employed and work substantial hours.
For people whose schedules change from week to week, losing employer coverage doesn't necessarily mean they have stopped working. It can mean their work has become too unpredictable to fit neatly into a system built around stable employment.
The study is observational, so it identifies associations rather than proving that unstable work directly causes loss of coverage.