‘Churning’ following the Affordable Care Act hasn’t worsened, but remains a problem

About one in four low-income adults in three U.S. states have experienced changes in their health insurance coverage—known as “churning”—since the Affordable Care Act (ACA) was passed in 2014, according to a new study from Harvard T.H. Chan School of Public Health. The study suggests that, while the ACA has expanded health coverage to millions, maintaining stable coverage over time remains a challenge.

The study also found that churning has resulted in significant negative effects on health care.

The study, one of the first to look at the impacts of churning since the ACA’s health coverage expansions took effect, will appear in the October 2016 issue of Health Affairs.

“We found that the ACA has not worsened the problem of churning, as some had predicted, but it hasn’t fixed it either,” said Benjamin Sommers, assistant professor of health policy and economics and lead author of the study. “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.”

Previous research suggested that churning was common, particularly among lower-income individuals, even before the ACA’s expanded health coverage for Americans in 2014. To find out what happened after the expansion, the Harvard Chan researchers surveyed more than 3,000 low-income adults in late 2015 in Arkansas, Kentucky, and Texas—three states that have responded in three different ways to the ACA’s option of expanding eligibility for Medicaid—and they compared that information with 2013 survey data from low-income adults in those states. Kentucky chose a traditional expansion of Medicaid; Arkansas chose an expansion that enrolled Medicaid beneficiaries in private plans through the federal health care marketplace; and Texas chose not to expand. The researchers’ goal was to assess the frequency of churning, what was causing it, and how it was affecting health care in each of the states.

They found that nearly 25% of respondents in each state reported that they’d switched their health coverage during the previous 12 months—similar to the percentage who had reported doing so before the ACA’s coverage expansions. About 20% of the respondents who changed coverage were uninsured people who gained insurance. Other common reasons for churning included a change in a job or job-related coverage; losing eligibility for Medicaid or other federally subsidized health insurance; or inability to afford previous coverage. People in Texas were more likely to experience negative effects of coverage changes than those in Kentucky and Arkansas.

Among those who switched health coverage, nearly 20% had to change at least one doctor; 9% had to change both a primary care doctor and a specialist; 16.2% had to switch or change their prescription medications; and 33.9% either skipped doses or stopped taking medications. About half of the “churners” who experienced a gap in insurance coverage—and more than 20% of those who switched without a gap—said that their coverage change had negative effects on the overall quality of their medical care and on their health.

Other Harvard Chan School authors of the study included Rebecca Gourevitch, Bethany Maylone, Robert Blendon, and senior author Arnold Epstein.

The study was support by a grant from the Commonwealth Fund, and in part by the Agency for Healthcare Research and Quality (AHRQ; Grant No. K02HS021291).

“Insurance Churning Rates For Low-Income Adults Under Health Reform: Lower Than Expected But Still Harmful For Many,” Benjamin D. Sommers, Rebecca Gourevitch, Bethany Maylone, Robert J. Blendon, and Arnold M. Epstein, Health Affairs, October 2016, doi: 10.1377/hlthaff.2016.0455

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