Thanks to the Affordable Care Act (ACA), 20 million people have gained health insurance coverage, creating a pathway to better health. However, holding on to that coverage is not always easy and barriers remain for many consumers. Even with the ACA, low-income individuals and families remain at risk of losing their coverage or cycling between different types of coverage—known as churn. Changes in income, employment status or family composition may all result in churning between types of coverage and/or becoming uninsured.

New research on churn

Earlier this month, a new study published in Health Affairs demonstrated the effect of churn across three different states: Kentucky, Texas and Arkansas. Each state has taken a different approach to coverage: Kentucky implemented a straight Medicaid expansion, Texas chose not to expand Medicaid and created a coverage gap, and Arkansas implemented a premium support model that uses its Marketplace to deliver coverage to newly eligible consumers under 138 percent of the Federal Poverty Line (FPL). The data yield interesting results that require further inspection.

The good news is that churn is not as bad as originally predicted. Only a quarter of consumers surveyed experienced a change in their coverage over the last 12 months; prior research estimated that 50 percent of consumers would experience a coverage change in a calendar year. When we look a little closer, some interesting themes emerge. For example, churning was roughly twice as common among those with Marketplace coverage or non-group private coverage, compared to those with Medicaid−consumers mostly cited job changes as the reason for these coverage changes. Additionally, some populations appear to cycle off of coverage more than others. For example, women and younger adults experience coverage changes more than men and older adults, on average. Furthermore, churn is less common among Latinos than among whites.

Churn Illustration 2

Figure 1. Illustration of Churn and Some Data Highlights.

Addressing churn should be a priority.

While the ACA moves us toward increased opportunities for coverage, challenges remain for individuals maintaining coverage. Clearly, churn has serious health impacts on low-income people. When cycling in and out of coverage, people are forced to switch plans that result in changes in their doctor, disruptions in medical care, interruptions in patient-provider relationships and complications with access to medications. At least 13 percent of those who churned had to change at least one provider, 22 percent skipped doses or stopped taking prescription medications and 29 percent reported an overall harmful effect on the quality of their health care. Those who churn with gaps in coverage experience the worst health outcomes as they delay seeking routine care, skip needed treatments or stop taking prescription medications altogether. These findings affirm that mitigating gaps in coverage is vital to better health outcomes and that states need to do more to ensure continuity of care for those who transition between coverage types.

Finally, there are the financial implications for states. The administrative costs associated with dis-enrollment and re-enrollment is much higher than the costs associated with enrollment procedures and processing for new enrollees. States also incur increased costs associated with overuse of emergency rooms for minor health conditions by individuals with gaps in coverage as well as costs associated with unmet health needs that become exacerbated when people go without needed treatment.

Some states are making progress.

Churn is driven by a multitude of factors. For that reason, policy solutions must be tailored to a state’s specific challenges. A number of states have taken actions to minimize the frequency and adverse effects of churn on low-income individuals and families. However, many states do not proactively report data to identify and monitor churn and its impacts—particularly on people of color.

As we contemplate next steps to build on the progress of the ACA, there is an opportunity for consumer advocates to work with their state policymakers and stakeholders to develop a model for estimating churn and a plan of action to support consumers in keeping their coverage. As we approach the Fourth Open Enrollment Period, enrollment specialists have an important role to play in helping consumers understand their insurance options, responsibility to enroll and how to keep their coverage. Stay tuned for upcoming resources!

Back in 2013, Massachusetts became the first state to use a full managed care approach under the CMS-sponsored Financial Alignment Demonstration. This demonstration, known as One Care, serves people with disabilities ages 21-64 who have both Medicare and Medicaid and seeks to provide better care at lower cost. Since the launch, advocates from the disability community have regularly voiced the need for the public reporting of outcome data. And, nearly three years later, that day has arrived! Results from One Care’s first year (October 2013-December 2014) are now available! 

While the evaluation did not reveal any big surprises, and findings are only from the first demonstration year, having the data to back up claims of successes and challenges is critical as our health care system shifts more and more toward integrated models of care for people with complex needs, utilizing various innovative payment mechanisms. A few key takeaways of note from the evaluation:

  • One Care enrollees had a lower 30-day readmission rate compared to non-enrollees.
  • There are opportunities to further improve beneficiary education and engagement. For example, focus groups convened to obtain participant feedback suggest that many beneficiaries were not aware of the formal complaint and appeals processes or available resources to assist them with problems.
  • It’s important to ensure stable financing structures and adequate payments. The evaluation reports that One Care plans experienced losses during the first year, noting that Medicare and Medicaid capitation rates were inadequate to cover new costs associated with care coordination, additional benefits offered, and administrative start-up costs of the demonstration.
  • With the large number of beneficiaries being enrolled during passive enrollment phases, One Care plans reported their greatest difficulty was reaching enrollees, including many who are homeless or without a stable address.
  • The Long-Term Services and Supports (LTS) coordinator role, while widely supported and very much needed, was difficult to implement due to ill-defined roles and responsibilities, which led to inconsistencies and confusion in implementation. The plans and community-based organizations found it difficult to strike the right balance between flexibility and structure for the LTS coordinator role.
  • Participants reported unmet needs for oral/dental care and substance use disorder services.

Though many of these early challenges have been largely addressed, there is still additional work to do both in Massachusetts, which extended the demonstration for another two years, and elsewhere. It will be important to take these early findings and use them to continue to improve One Care. Other states with ongoing demonstrations may also find much of interest within this report, as they work to refine their projects to provide maximum benefit to participants.

And, to continue the virtuous cycle of quality improvement, we eagerly await further demonstration evaluations out of CMS!


Today, Community Catalyst’s Center for Consumer Engagement in Health Innovation submitted comments on the proposed regulations updating the Program of All-inclusive Care for the Elderly (PACE) model. The regulations proposed by the Centers for Medicare and Medicaid Services (CMS) represent the first major update to the PACE program in a decade. PACE is a team-based program available to nursing-home eligible people over age 55 with Medicare or Medicaid, or both (in some states, only Medicaid beneficiaries are eligible). The program’s goal is to keep participants in the community in which they live rather than a nursing home or other care facility. PACE does this by coordinating care and connecting members to many specialists and other providers, as well as to a range of services and supports in the community to provide a well-integrated care experience. Despite evidence showing PACE participants have significantly lower rates of hospital, nursing home, and emergency department utilization and lower overall rates of inpatient days, both the numbers of PACE programs and the level of enrollment has remained relatively small.

To address some of these challenges, CMS is proposing a number of improvements including operational flexibilities, particularly around the Interdisciplinary Team (IDT) that is so central to the benefits of the PACE model. For example, the integration of community-based providers as primary care providers (PCPs) and expansion of the professions which would qualify as PCPs to include nurse practitioners and physician assistants are both steps in the right direction. The ACA has enabled CMS to explore and promote new models of care via demonstrations to integrate care for some of the most high-need, high-cost consumers. Our comment letter urges that some of this work, including the PACE program, be integrated into the work of the Medicare-Medicaid Coordination Office within CMS.

In general, the Center is supportive of the proposed regulations and believes it is important to build upon the lessons learned from PACE’s successes over the past four decades and expand these to other integrated models of care. In our comments, we urge CMS to make building awareness of this model more of a priority and in the final regulations, to encourage provisions that will allow for greater expansion of the number of PACE programs across the nation. 


It’s here: the final rule for CMS’ Quality Payment Program (QPP/MACRA) has been released! You dug through 900+ pages, added new acronyms to your vocabulary, submitted comments, and, at the end of a long campaign, have another 2400+ pages to wrap your head around this weekend. We here at the Center for Consumer Engagement in Health Innovation are no different.

Overall, we are excited about the move that CMS is making toward value-based payment. CMS has been working to move the health care system away from one that is based solely on fee-for-service and toward a system that focuses on better coordination and quality of care. We are supportive of these efforts because of their potential to improve care for consumers.

At the same time, we think it’s important that consumers be the North Star for the kind of reform that is envisioned by MACRA. Thus, when we entered this process, we had four burning items we were looking for on behalf of consumers. As we begin digging into the final rule, here is our preliminary judgment on how well the rule addressed these core concerns:

QUESTION:  Is enough being done to prepare consumers for system change?


This rule will have sweeping and lasting changes on this nation’s health care system and will have significant impacts on the care consumers receive. Consumer outreach and engagement will be necessary for ensuring that the implementation of new models remains patient centered, educating consumers about what these changes mean for how their care is delivered and effectively empowering patients to engage in their own health care decisions. Unfortunately, the final rule does not seem to strengthen consumer engagement requirements beyond what was in the previous proposal. For example, all but one of the beneficiary-engagement improvement activities are given only medium weighting, and CMS is now requiring practices to complete even fewer improvement activities. Additionally, CMS bypassed opportunities that would have ensured robust patient engagement in advanced alternative payment models, such as strengthening requirements for medical homes.

QUESTION: Are there protections in place for consumers as providers take on financial risk for the cost of care?


The Quality Payment Program incentivizes providers to take on greater financial risk for their patient populations. The hope is that this will lead to better care at lowers costs, but it also comes with the possibility that provider losses could lead to disruptions in care for patients. That’s why it’s so important that the final rule include provisions meant to protect consumers in these new payment models. As we continue to analyze the final rule we will be keeping an eye out for consumer protections such as the right to know what risk arrangements a provider is taking on, freedom for consumers to choose their provider, access to all covered services, easy-to-navigate appeals and grievances systems, and easy-to-read accessible program materials for beneficiaries including those with disabilities, speech and vision limitations, and limited English proficiency.

QUESTION: Will consumers get to define “quality” in this program?


A major goal of the QPP is to move toward a more integrated, person-centered system of care. To meet that goal, quality measures should reflect the experiences, goals, preferences and needs of consumers, in particular low-income older adults and other vulnerable Medicare enrollees. Unfortunately, of the 271 quality measurements to choose from, on our first look we only spotted about 15 that are patient reported. We are concerned about the lack of patient-reported measures because it sidelines one of the most important - if not the most important - voice in the room. If the quality of care within our health system is to improve, people must have a more important say in how quality is defined.

QUESTION: Will this new program improve or worsen health disparities in the United States?


The final rule represents a major opportunity to transform the health system in a way that better addresses the persistent health disparities that exist for marginalized and underserved populations. It’s not clear that CMS fully capitalized on this opportunity. For example, the list of clinical practice improvement activities was not expanded to promote cultural competency or implicit bias training. CMS does promise to release best practices for collecting data stratified by demographic characteristics and notes that in future rulemaking they will consider additional strategies for addressing health equity, for example finding ways to incentivize providers who reduce disparities and identifying appropriate measures of health equity. As CMS moves forward with implementing the QPP, we will need to advocate that health equity remains a priority and that payment methodologies do not unfairly penalize practices who are caring for socially and economically disadvantaged patients.

We appreciate that CMS has made changes to make it easier for providers to participate. However, the final rule illustrates the ever-present need for state and federal consumer advocates to continue to elevate the importance of consumer engagement in order to drive reform that will be truly transformative for consumers.


I recently attended Community Catalyst’s Consumer Advocate Convening in Atlanta, Georgia.  It was great to reconnect with so many old friends and welcome new friends to the mix. As I looked around the room during the plenaries and workshops, this convening felt even more powerful because of the many new and diverse participants. And I wasn’t the only one with that observation -- this same sentiment was echoed through the hallways. It reinforced for me the difference we can collectively make as the health advocacy movement continues to diversify and include more voices and perspectives.

Women's Healthcare Leader, Byllye Avery
Byllye Avery, founder of Black Women's Health Imperative, giving a talk about intersectionality at the Community Catalyst 2016 Annual Advocate Convening. (Stephen Eisele/FOR COMMUNITY CATALYST)

At Community Catalyst, we know that diversifying the health advocacy movement is critical. Achieving health equity and minimizing health disparities will be realized only with the full participation of communities of color and other marginalized people. The best change occurs when the communities most affected are involved in creating solutions.

“Being at this conference helped me see the connections between the work we do in our communities and making sure the voices of our communities are represented in health advocacy and policymaking, ” said Helen Sun of the Light and Salt Association, a Houston, Texas-based organization primarily focused on outreach and enrollment within Asian communities. 

Community Catalyst has been working to address health equity and reduce racial disparities in all of our programmatic work. For example, our Close the Gap campaign seeks to engage Latino organizations or those serving the Latino community so hard-to-reach communities can gain access to affordable health care. Our Center for Consumer Engagement in Health Innovation prioritizes expanding the collection and reporting of data on health disparities to ensure efforts to improve care specifically address those inequities in our health system. Our Substance Use Disorders team also works to identify and end racial bias in treatment for substance use disorders.

In addition to integrating an equity lens in our programs, we are working to diversify the attendees at our conference and the recipients of our grants. This past year, Community Catalyst spearheaded an initiative to incorporate equity and inclusion into our initiatives by funding and raising the voices of communities of color. We are reaching out to organizations of color and supporting our state and local partners to do the same.

Mirna Castro, Director of Health Enrollment, Literacy and Promotions at Servicios de la Raza, Inc., shared the impact this funding change has had on her organization in their work to engage and make enrollment more accessible for the Latino community. Her organization was able to participate in the Connect for Health Colorado (C4HCO) Outreach & Communications Advisory Group and share concerns about the workings of the Connect for Colorado, Colorado’s Affordable Care Act Marketplace, from the cultural and linguistic lens of the Latino community. These efforts led to the translation of provider directories into Spanish.

“There is no doubt that Community Catalyst needs to do much more to create and sustain a diverse health advocacy community,” said Jacquie Anderson, Community Catalyst’s Chief Operating Officer. “We will continue to encourage the participation of diverse communities in our convenings, and to ensure these communities are meaningfully engaged in our work and supported through our grantmaking initiatives. When we work together we can make a difference in reducing health disparities, eliminating barriers to quality care, addressing structural injustices, promoting meaningful collaboration and fostering leadership.”

Think of your coalition, your constituents and your funded partnerships: Are you doing your part? Join us in building a diverse health advocacy movement.

Nell O’Connell is Community Catalyst’s Grants Manager and a member of the Health Equity Team.