YOU MAY LOSE HEALTH INSURANCE!!!

The Affordable Care Act extends health insurance coverage by both expanding Medicaid eligibility and offering premium subsidies for the purchase of private health insurance through state health insurance exchanges. But by definition, eligibility for these programs is sensitive to income and can change over time with fluctuating income and changes in family composition. The law specifies no minimum enrollment period, and subsidy levels will also change as income rises and falls.


The Affordable Care Act offers near universal guarantee of access to affordable health insurance.  Medicaid eligibility is expanded to all non-elderly citizens and eligible legal residents whose family income does not exceed 133% of the federal poverty line.  Also, Medicaid-ineligible people with incomes up to 400% of poverty line can receive premium subsidies through tax credits for health plans offered through state health insurance exchanges.  The income-sensitive approach to subsidize the cost of health insurance divides these populations into two.  The eligibility requirements are affected by income fluctuations and family size changes.  Research supports that insurance coverage disruptions have adverse effects on access and administrative costs.



A study examined nearly 20,000 low-income adults in the US and explored the frequency of income fluctuations over time that would lead to switching between Medicaid and exchange eligibility under the new reform.  It found that nearly 40% experienced a disruption in Medicaid eligibility within the first 6 months, after a year 38% were no longer eligible and 16% had lost eligibility but later regained it.  After 3 years, 47% were above the 133% poverty line and 30% were below the cutoff but had at least one experience of changes in eligibility.  By the end of the study after 4 years, only 19% were continuously eligible for Medicaid.  This study supports that income changes may lead to the movement of millions of families between Medicaid and state exchanges. 
To help mitigate the potential harm of insurance transition, several ideas come to mind. 
 Establish a minimum guarantee eligibility period
Provide support services for the shift
Align coverage and benefits - currently the move between Medicaid and insurance exchanges lead to variable levels of coverage in terms of benefits, premiums, and cost sharing

The Affordable Care Act offers the opportunity to expand health insurance coverage to millions of low-income.  However, be aware that income fluctuations may lead to changes in eligibility to Medicaid, and possibly periods of uninsured.  State and federal levels should include plans aim to minimize the frequency of coverage transitions and promote quality and continuity of care.