When the national healthcare law takes full effect next year, millions of Americans risk disrupted health coverage because of common life events: getting married or divorced, having children or taking on a second job.
As their family incomes change, so too will their eligibility for public insurance programs. And if nothing is done, policymakers warn, many low-income patients will lose access to their doctors and medications during this massive game of health coverage pingpong.
Policymakers and healthcare industry leaders across the nation are paying close attention to the issue and working to close the coverage gaps before Jan. 1, said Alan Weil, executive director of the National Academy for State Health Policy.
Life changes are unavoidable, Weil said, but the key will be ensuring that people can move between programs without mountains of paperwork or interruptions in healthcare. "If we fail to effectively move people across programs as their circumstances change, that will be a big problem," he said.
Nationwide, income fluctuations are estimated to interrupt coverage for as many as 28 million people expected to bounce between Medicaid and the federally subsidized health insurance exchanges that states are working to create, according to an article in the journal Health Affairs. Among those most at risk are seasonal and hourly workers and young adults who lack coverage through their parents or jobs, experts said.
Patients who can't see their doctors or get their medication will either avoid care or end up in publicly subsidized emergency rooms, pushing healthcare costs even higher, experts said. And insurance premiums will rise if young, healthy people get fed up with the transitions and opt out of health coverage altogether.
Trivia Hill, 26, knows the game well. She and her fiance had Medi-Cal, California's version of Medicaid, while she was pregnant. But she lost it two weeks after their son was born. Medi-Cal workers told her that her fiance's job — holding signs for a haircutting business — made the family ineligible for the coverage, which paid for his diabetes medication.
"I was devastated," said Hill, who lives in Alhambra. "I thought, 'Oh my God. What are we gonna do?'"
The family couldn't afford to buy private insurance, so they went without. But just a few months later, her fiance got laid off and the family reapplied for Medi-Cal. "I had to do the process all over again," she said.
Jasmine Barajas, 20, also got dropped from Medi-Cal because her job selling cellphones and her husband's job making jeans put them above the income limit. Their young daughter remained on a public plan, but Barajas and her husband couldn't pay for their own coverage.
"We need something permanent," she said. "Everything is a hassle."
The Affordable Care Act will improve access for many low-income workers who currently become uninsured if they are no longer eligible for Medicaid, said Benjamin Sommers, assistant professor of health policy and economics at the Harvard School of Public Health. Beginning in January, those workers will be able to buy private insurance with federal subsidies.
But policymakers must figure out a way to make that coverage affordable and to ease the transition between Medicaid and the state exchanges to prevent more emergency room visits and hospitalizations, he said. "These significant disruptions … can make it hard for people to get high-quality, stable healthcare."
To address the issue, an Urban Institute analysis recommends that states provide intensive consumer assistance to help people navigate the changes, reduce the amount of paperwork and implement policies to maintain continuity of care during transitions.
In Washington, two representatives introduced legislation last month that would make beneficiaries' enrollment in Medicaid last for at least one year. Some states are considering other ways to make it easier for patients to keep their doctors and health plans even when their incomes change.
In California, residents earning up to 138% of the federal poverty level, or about $15,000 a year, will be eligible for Medi-Cal next year. Individuals earning up to 400% of the federal poverty level, or about $46,000, will be eligible for subsidies through the exchange, known as Covered California.
The Covered California board approved a plan in March to help patients expected to jump between the two. The "bridge plan" would enable patients now on Medi-Cal managed care whose incomes rise to continue to stay with their health plan once they move to the exchange.
The program, which still needs federal approval and state legislation to take effect, could serve as many as 840,000 people next year. The plan should streamline the process, keep out-of-pocket premiums low and make it easier for people to keep their providers, said David Panush, external affairs director with Covered California. "It is better for their quality of care, it is better for continuity of care," he said.
When patients bounce back and forth between plans, it leads to worse outcomes for those who are "living on the edge between working poor and just plain poor," said Howard Kahn, chief executive of the L.A. Care public health insurance plan. California's bridge program, he said, should make the transition much smoother.
Anthony Wright, executive director for the consumer group Health Access California, said the bridge plan may be especially important for people who have chronic diseases like diabetes and asthma and whose health will be affected if they have to switch doctors every time they get more shifts at work or their seasonal work ends.
"People don't live their lives neatly in categories above or below 138% of the federal poverty level," he said. "We are trying to create something that is more seamless."