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The perils of a patchwork system

As long as the United States maintains its multi-payer patchwork approach to health insurance, some volatility in coverage over time will be unavoidable

Got insurance?” asked the Obama administration, back when the Affordable Care Act was being launched in late 2013. The marketing campaign was designed to get U.S. residents who lacked health insurance to sign up for coverage. But for many Americans, “Still got insurance?” is the more relevant question.

Every year, millions of people lose their health insurance. It’s one of the neglected perils of the United States’s patchwork health care system, with its dizzying array of insurance options including employer plans, Medicare, Medicaid, the Obamacare Marketplace, and others.

How significant is this issue? Health policy researchers have long studied transitions in health insurance — known as “churning.” More than one in five adults loses coverage annually, numbers that vary depending on the type of insurance. Among those with employer coverage, 1 in 8 lose insurance annually. Meanwhile, drop-out rates are much higher in programs such as Medicaid or the ACA’s Marketplaces. Why?

People in Medicaid or subsidized Marketplace plans qualify based on income. When their income changes, they may no longer be eligible for coverage or may face higher premiums. For Medicaid enrollees, even if they haven’t had a change in income, they must re-verify their eligibility annually or lose their insurance. All told, one pre-ACA study found that more than 40 percent of adults in Medicaid lose coverage within 12 months of signing up, while in the ACA Marketplaces, nearly one in four adults leave their plans mid-year.


The numbers are even worse for pregnant women.

Even though coverage for expectant mothers enjoys bipartisan support and may produce long-term benefits for a short-term investment, current policies essentially guarantee that more than half of this group will lose insurance. Medicaid covers roughly half of all births in the nation, but this coverage comes with an expiration date, with eligibility ending 60 days after delivery. The result, which is troubling but not surprising, is that 55 percent of women covered by Medicaid during pregnancy become uninsured within 6 months of giving birth.


A skeptic might ask whether there is really a major downside to going a few months without insurance. But studies show that even short gaps in insurance lead to negative consequences — such as having to change doctors, skipping doses of medications, and trouble paying medical bills. Most concerning is that half of low-income adults who have a gap in coverage say the quality of their care has worsened, and 47 percent report that their health has been harmed.

What can be done? A variety of policy tools can improve continuity of coverage, and some were already introduced by the ACA. The Obamacare Marketplaces, by offering subsidized coverage for middle-income families that does not depend on one’s employer, benefit people who are between jobs, switching jobs, or work in companies that don’t offer employer coverage — particularly those in blue collar jobs like agriculture and construction. Studies show that the risk of becoming uninsured and the average length of time a person went without insurance afterward declined significantly after the ACA was implemented in 2014.

State Medicaid expansions can help too. One study found that expansion led Medicaid enrollees to gain two months of additional coverage over a two-year period and another study found that the risk of dropping out of Medicaid was roughly half in states that had expanded Medicaid compared to non-expansion states.


Other promising policies include guaranteeing 12 months of stable eligibility for adults in Medicaid (a policy many states use for children, but only two states offer for adults), and extendingpostpartum Medicaid eligibility for a full year after giving birth.

However, some states have moved in the other direction, enacting policies that make it harder to remain in Medicaid. A dozen states have proposed a work-hour reporting requirement in order to maintain Medicaid coverage. In Arkansas, this policy led to the loss of coverage among 18,000 low-income adults — many of whom were confused about the requirement or caught up in red tape. Meanwhile, other states have mandated more frequent income checks beyond the federal annual requirement, which likely contributed to 2.4 million fewer people having Medicaid coverage in 2019 than in 2017.

As long as the United States maintains its multi-payer patchwork approach to health insurance, some volatility in coverage over time will be unavoidable. The simplicity of a universal, automatic, and lifelong coverage option is one of the chief attractions of a single-payer plan or Medicare for All. However, the ongoing debate in the Democratic primary has focused largely on how to structure and pay for such a plan, and the issue of discontinuous coverage has gotten much less attention.

Regardless of whether changes come in the form of incremental policies or a system-wide overhaul, the goal of not just getting people covered but keeping them enrolled in health insurance should be a key priority in the push toward a more effective and just health care system.


Dr. Benjamin Sommers is a professor of health policy and economics at the Harvard T.H. Chan School of Public Health and a primary care physician at Brigham and Women’s Hospital in Boston.