The “Churning” Effect in Healthcare Coverage

One of the concerns about the ACA expressed by healthcare policymakers is the “churning” effect, in which consumers are involuntarily moved through different coverage levels and to different providers.6,7 Churning is a frequent problem among lower-income people who have fewer choices and fewer resources to rebound from personal and policy changes affecting their coverage. As an article by Buettgens and colleagues6 reported in 2012, “churning already occurs in Medicaid and [the Children’s Health Insurance Program], but the ACA’s Medicaid expansion and subsidized coverage in health benefit exchanges will expand its scope.” 

Analysis at that time indicated that 29.4 million people in the United States younger than age 65 years would be subjected to forced changes in coverage in coming years under the ACA, including multiple moves between Medicaid, insurance subsidy programs, and being deemed ineligible because of incomes above 138% of the federal poverty level.6 This represented nearly one-third of the estimated 95.9 million estimated to receive either Medicaid or exchange subsidies in a year.6

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Churning was a major factor in the withdrawal of the intended AHCA plan, as the Congressional Budget Office report released on March 13, 2016, estimated it would displace 14 million people from their current healthcare insurance by 2018, a number that rose to 21 million by 2020 and 24 million by 2026.8

Suggestions to reduce the effects of churning were offered in a 2014 article by Rosenbaum and colleagues, published by the Commonwealth Fund, advocating a 3-part strategy of multimarket plans, premium assistance for private coverage (subsidized), and continuous enrollment periods.7


The challenges to providing optimal levels of healthcare for people using Medicaid systems are many-fold, involving various levels of affordability and eligibility for suitable plans, maintaining consistency of coverage, and overcoming limited access to providers who potentially delay appointments to Medicaid participants.

As Medicaid expanded coverage is likely to grow in the wake of the current acceptance of the ACA as “law,” attention needs to focus on improvements in how that coverage is segmented in the general population and improvements in wait times for appointments to provide optimum care.

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  1. Where the states stand on Medicaid expansion. Published March 28, 2017. Accessed March 30, 2017.
  2. Japsen B. More states to expand Medicaid now that Obamacare remains law. Published March 26, 2017. Accessed March 28, 2017.
  3. Sommers BD, Gunja MZ, Finegold K, Musco T. Changes in self-reported insurance coverage, access to care, and health under the affordable care act. JAMA. 2015;314:366-374. doi: 10.1001/jama.2015.8421
  4. Health insurance marketplaces 2015 open enrollment period: March enrollment report. Office of the Assistant Secretary for Planning and Evaluation. Updated March 10, 2015. Accessed March 27, 2017.
  5. Miller S, Wherry LR. Health and Access to care during the first 2 years of the ACA Medicaid expansions. N Engl J Med. 2017;376:947-956. doi: 10.1056/NEJMsa1612890
  6. Buettgens M, Nichols A, Dorn S. Churning under the ACA and state policy options for mitigation: timely analysis of immediate health policy issues. Updated June 2012. Accessed March 28, 2017.
  7. Rosenbaum S, Lopez N, Dorley M, Teitelbaum J, Burke T, Miller J. Mitigating the effects of churning under the Affordable Care Act: lessons from Medicaid. Issue Brief (Commonw Fund). 2014;12:1-8.
  8. American Health Care Act: Cost Estimate. Congressional Budget Office. Updated March 13, 2017. Accessed March 28, 2017.

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This article originally appeared on Infectious Disease Advisor