Under a multi-payer system, churning is inevitable and bad for your health

Insurance Churning Rates For Low-Income Adults Under Health Reform: Lower Than Expected But Still Harmful For Many

By Benjamin D. Sommers, Rebecca Gourevitch, Bethany Maylone, Robert J. Blendon and Arnold M. Epstein
Health Affairs, October 2016


Changes in insurance coverage over time, or “churning,” may have adverse consequences, but there has been little evidence on churning since implementation of the major coverage expansions in the Affordable Care Act (ACA) in 2014. We explored the frequency and implications of churning through surveying 3,011 low-income adults in Kentucky, which used a traditional expansion of Medicaid; Arkansas, which chose a “private option” expansion that enrolled beneficiaries in private Marketplace plans; and Texas, which opted not to expand. We also compared 2015 churning rates in these states to survey data from 2013, before the coverage expansions. Nearly 25 percent of respondents in 2015 changed coverage during the previous twelve months—a rate lower than some previous predictions. We did not find significantly different churning rates in the three states over time. Common causes of churning were job-related changes and loss of eligibility for Medicaid or Marketplace subsidies. Churning was associated with disruptions in physician care and medication adherence, increased emergency department use, and worsening self-reported quality of care and health status. Even churning without gaps in coverage had negative effects. Churning remains a challenge for many Americans, and policies are needed to reduce its frequency and mitigate its negative impacts.



By Don McCanne, M.D.

Churning - moving in and out of health plans, whether or not there are gaps in coverage - is clearly bad for the patient’s health.

In this study, the rate of churning did not differ between states with different approaches to implementing the Affordable Care Act. In a multi-payer system, churning automatically occurs due to factors such as changes in employment, changes in income and program eligibility, changes in residency, changes in plan availability, and changes because of administrative disruptions.

Regardless of the reason, churning resulted in “disruptions in physician care and medication adherence, increased emergency department use, and worsening self-reported quality of care and health status.” Negative effects occurred even without gaps in coverage.

Need it be said? A single payer national health program would totally eliminate churning and thus would improve the health of Americans caught up in the churning trap. If this were the only reason for enacting a single payer system, it would certainly be worth doing.