Study: Despite ACA’s success, consistent insurance coverage still a problem for many Americans

If you look at the numbers, there’s no doubt that the Affordable Care Act is making a positive difference. In fact, just last month, the U.S. Census Bureau reported that the nation’s uninsured rate had hit a record low. At the same time, the health reform law wasn’t intended as a silver bullet and a number of problems remain. One of those problems is known as “churning.”

“Churning” describes changes in a person’s insurance coverage over time and it’s an issue that can have a significant impact on a patient’s continuity of care and health status. Of course, changes in insurance coverage are hardly a new phenomenon — it can happen when a person switches jobs or becomes ineligible for Medicaid, for instance — but recently a group of researchers set out to see if the ACA had had any effect on churning rates. Their study, published this month in Health Affairs, found that the ACA hadn’t worsened the problem of churning, but it hadn’t improved it either. The finding means that while the ACA has certainly expanded insurance to millions who may have otherwise gone without coverage, maintaining stable insurance coverage is still a challenge for many Americans.

“It’s been well known for many years that coverage in the U.S. is inconsistent over time,” study co-author Benjamin Sommers, assistant professor of health policy and economics at Harvard’s T.H. Chan School of Public Health, told me. “That’s just inherent to the kind of multi-payer, patchwork approach we have…but it wasn’t clear how that had changed since the ACA and in particular, how it had changed for low-income adults, who are potentially at high risk for facing barriers to care.”

In turn, Sommers and colleagues surveyed more than 3,000 low-income adults in 2015 in three states that took different approaches to the ACA-authorized Medicaid expansion: Kentucky, which expanded eligibility for traditional Medicaid; Arkansas, which uses Medicaid expansion funds to enroll eligible residents into a private marketplace plan; and Texas, where legislators decided not to expand Medicaid at all. Survey responses were then compared to survey data from 2013.

Overall, the study found that churning rates remained pretty much status quo. About 25 percent of 2015 survey respondents in each state said they had switched health coverage at some point in the prior 12 months, which is not significantly different from the percentage that reported churning prior to ACA expansions. More than half of 2015 respondents who experienced coverage changes reported a gap in coverage, and more than 25 percent were uninsured for longer than four months.

About 20 percent of those who experienced churning did so because they gained insurance, with the proportion of those who gained coverage in Arkansas and Kentucky double that of Texas. Other top reasons for churning were changing jobs, becoming ineligible for Medicaid or marketplace subsidies, or simply being unable to afford insurance coverage. Researchers also found that in 2015, churning was most common among women and younger adults, less common among Hispanics than among whites, and twice as common among those with marketplace coverage or nongroup private coverage than among those with Medicaid.

“Overall, the message is that even though the ACA has made historic gains in the number of people with insurance, there’s still a lot of mobility and changes in insurance over time,” Sommers said. “These transitions are often problematic for people’s quality of health care.”

The study found that nearly 20 percent of people who experienced churning had to change at least one doctor and 9 percent had to switch primary care and specialist providers. The proportion of churners who had to switch providers was highest in Texas, at more than 32 percent, compared to Kentucky, at about 11 percent. About 16 percent of churners had to switch or change their prescription medications, while nearly 34 percent either skipped medication doses or stopped talking their medications altogether.

Not surprisingly, skipping meds and having to switch doctors was more common among churners who experienced a gap in insurance coverage. Also, significant portions of churners who experienced a coverage gap and even those who didn’t experience a gap said that having to switch coverage negatively impacted their health and the quality of their health care.

So, how can we address a problem like churning, which is somewhat inherent to how our health care system is organized, but also poses very real problems for a person’s continuity of care. Sommers said one way is to guarantee Medicaid coverage for 12-month spans. Typically, he said, Medicaid coverage is subject to monthly changes if a person’s eligibility changes and that easily lends itself to disruptions in medical care. He noted that while many states do cover kids for year-long spans via Medicaid and the Children’s Health Insurance Program, only New York offers such a coverage guarantee for low-income adults.

Another way to lessen the impact of churning, he said, is to create some overlap between Medicaid and marketplace plans. In other words, if the same insurer participates in both Medicaid and the marketplace, people who experience changes in eligibility may be able to keep the same insurance carrier and therefore, the same doctors.

Still, while churning is definitely an issue that deserves attention from policymakers, Sommers said the “ACA has clearly made a difference.”

“Overall, it’s reasonable to think people would rather have coverage and switch every year than not have insurance at all…and to argue that the millions who now have insurance are worse off now is completely at odds with what people are saying about having health insurance,” he told me. “But if we want to make that coverage as useful and meaningful as possible, reducing the effects of churning should be a policy priority.”

To request a full copy of the new study, visit Health Affairs.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for nearly 15 years.

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