Policy experts have worried that lower-income people would get bumped back and forth between Medicaid and exchange plans under the Affordable Care Act. But a Modern Healthcare survey of exchanges and insurers suggests such disruption has been modest so far.
When this churning has occurred, health plans and providers have found ways to mitigate the impact on patients' continuity of care, experts say. But much remains unclear about what happens to this population as it shifts between different types of coverage.
People may move between private coverage, Medicaid and no insurance because of job loss, reduced work hours, employers deciding to offer coverage, or other changes in life circumstances. A 2011 Health Affairs article estimated that 50% of all adults with incomes below 200% of the federal poverty level would experience a shift from Medicaid to an exchange plan within a year. Churn can be disruptive to care continuity.
“There was this huge fear about churn, but I haven't been hearing much about it,” said Katherine Hempstead, health insurance policy director at the Robert Wood Johnson Foundation.
Since January 2014, about 8% of those who signed up for private plans on California's exchange exited a private plan and enrolled in Medi-Cal, state officials said. In New York, about 7% of people who signed up for an exchange plan had an income change that made them eligible for Medicaid.
In Massachusetts, 13% went from an exchange plan to Medicaid, compared with 7.6% in Connecticut, 6% in Washington state, 5.5% in Rhode Island and less than 2% in Hawaii. Other state-run exchanges did not provide data.
A CMS spokesman said no data on churning between private plans and Medicaid were available for states using the federal marketplace.
Insurers say they lack a basis of comparison for whether the churn rate so far under the ACA is high, low or typical. But Taylor Burke, a health policy expert at George Washington University, said the fact that there are 25% more insurers offering federal exchange plans this year shows they aren't particularly worried about churn.
“They are not running away from the exchanges,” he said.
To mitigate the effect of churn and maintain continuity of coverage and care, some insurers, including Kaiser Permanente and Molina Healthcare, are offering both Medicaid plans and exchange plans, enabling enrollees to transition seamlessly between types of coverage.
