Health Insurance "Churning" No Worse After ACA Passage, but Still a Problem

Almost one-fourth of low-income adults in 3 states (Arkansas, Kentucky, and Texas) have experienced changes in health insurance coverage, known as “churning,” since the passage of the Affordable Care Act (ACA), according to a new study by Benjamin D. Sommers, MD, PhD, and colleagues at the Harvard T.H. Chan School of Public Health.

The study suggested that even though the ACA has expanded health coverage to millions of people, maintaining steady healthcare coverage over time remains a challenge even after passage of the ACA. In addition, the study shows that churning has caused significant negative effects on healthcare. The study, published in Health Affairs, noted that previous research suggested that churning was common (especially among lower-income people) even before the ACA’s passage in 2014.

The study’s data came from a survey of over 3000 low-income adults in Arkansas, Kentucky, and Texas in 2015. These states were chosen to study the effect of churning because they responded in 3 different ways to the ACA’s option of expanding Medicaid eligibility: Kentucky chose a traditional expansion of Medicaid; Arkansas chose an expansion that enrolled Medicaid beneficiaries in private plans through the federal healthcare marketplace; and Texas did not expand. The data from 2015 was compared with data from low-income residents of those states from 2013.

The study found that nearly 25% of respondents in each of the states reported that they’d switched health insurance plans during the previous year, which was similar to the numbers who had switched before the ACA was passed. Approximately 20% of the respondents who changed coverage were uninsured prior to the ACA, and had gained insurance because of the law’s implementation. Those who had changed insurers reported that they’d changed because of a change of jobs, a change in employment-related coverage, because they’d lost Medicaid eligibility, or because they could not afford their previous health insurance. Texas respondents were more likely to experience negative effects of churning than were those in Kentucky or Arkansas.

Switching coverage meant that nearly 20% had to change at least 1 physician; 9% had to change both a primary care physician and a specialist; 16.2% had to switch or change prescription medications; and 33.9% skipped doses or stopped taking their medications. Approximately half of those who switched insurers and who experienced a gap in coverage reported that the change had negative effects on the overall quality of their medical care and health.

“We found that the ACA has not worsened the problem of churning, as some had predicted, but it hasn’t fixed it either,” Sommers said in a statement. “People who switched coverage reported frequent periods when they didn’t have any insurance, as well as high rates of skipping medications, having to switch doctors, and receiving low-quality care.”

Churning remains a challenge for many Americans, the study authors conclude. Policy makers and researchers need to ensure that the ACA’s insurance gains are not compromised for many Americans by gaps in coverage and disruptions in care over time.