Churn Notice


One of the difficulties people often have with the American health care system is that it's been sliced up into a variety of mostly distinct subsystems: Medicare, Medicaid, employer sponsored insurance, the individual market. Rather than a single, continuous landmass that allows for easy movement from one point to another, it's more like a series of awkwardly linked islands. As a result, it can be frustrating for individuals whose circumstances (income shifts, job loss, etc.) require them to hop between those islands.

Did the authors of last year's health care overhaul make a substantial effort to address the system's lack of continuity? Not really. Instead, they came up with a way to retrofit the old employer-sponsored system—and built in additional transition points that could prove tough to navigate. As California Healthline notes, new research suggests that ObamaCare will actually exacerbate the problem of "churn" within the system, especially at low income levels:

Health care officials who work with large Medi-Cal populations say fluctuations in eligibility cause quality of care to decline and the cost of care to increase because of added administrative expenses. Medi-Cal beneficiaries moving in and out of coverage—known as "churning"—is not a new phenomenon, but it may become more prevalent under health care reform.

The Affordable Care Act's two primary weapons aimed at reducing the number of uninsured—expanded Medicaid eligibility and subsidies for buying private coverage through state health insurance exchanges—could produce considerable churning if they're not carefully implemented.

According to a study published last month in Health Affairs, income fluctuations in the first year of expanded coverage under the new law could produce eligibility shifts for as many as 28 million people who will become newly eligible for subsidized health insurance. According to researchers' predictions, after four years of expanded coverage under ACA, 19% of adults initially eligible for Medicaid will have been continuously eligible. About 31% of adults eligible for insurance subsidies will have remained continuously eligible, researchers predict.

The basic takeaway from all this is that states are going to have to come up with patches to try to reduce the amount of system churn and smooth out the health care experience for those whose income bounces them between systems. In other words, it's more of what we've come to expect from ObamaCare: More bureaucratic busywork for states, and more hassles for those trying to get care.

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  1. and built in additional transition points that could prove tough to navigate.

    More support for the “screw it up so they have to go to single payer” camp.

    1. The nice thing is that once the government fails for any extended period of time, the universal single payer camp will also be wrecked by complete lack of faith in the system.

      With a hard reset, things will likely go back to traditional insurance + personal pay + charity for the minority failed by the previous system + suck it up, buttercup for everyone else. Which, while not perfect, is probably the best of the realistic options, and best for the advancement of medicine as a field.

      1. I’m going to out-cynical you…

        Once single-payer is in place, nothing less than a complete collapse of government will get rid of it. The people pointing out its flaws will be relegated to the fringes of the debate, just like SS, Medicare/aid, and the Military budget. Reform not dismantle will be the game they play. Like schools, universal healthcare could be fixed if we just pumped more money into it.

        Once we get it, we have it forever. That’s why we should fight against as hard as possible right now.

        1. That’s why we should fight against as hard as possible right now.


        2. “Once single-payer is in place, nothing less than a complete collapse of government will get rid of it. ”

          Yes. I expect the U.S. government will collapse, within my lifetime, barring substantial libertarian reforms.

          I suppose a move to fascism could preserve the institutions at grave cost to the populace the institutions of civil society, but even that would require a great deal of cunning and a capacity to identify and cut dead weight; I don’t think ambition and management skills overlap enough for this to do more than delay the inevitable for a few years, at the cost of making the recovery that much harder.

          1. To be clear, when I said “fail”, I meant in terms of existing in any meaningful sense, not in terms of quality of service.

          2. Agree on both points, cynical.

            I see no reason to doubt that the current political class, aided and abetted by their numerous dependents, is incapable of the kind of fiscal and economic/regulatory reform that can stave off a fiscal and thus a monetary collapse, which will put an end to entitlement programs as we now know them.

  2. Nationwide, i think it’s adding about 16 million people to Medicaid. getting them covered is one thing, but having enough docs to treat them largely is left unaddressed. I think these patients are still going to end up at the ER.

    1. MNG|8.12.09 @ 12:48PM|#|show direct|ignore
      To say that someone has a moral duty to provide immediate help to one imminently in need of what you can provide, and that that duty is so strong that it justifies coercion to mke you obey it is not necessarily to say that the duty exists or at the same strength to justify coercion for every situation which exists in the world of someone in need who could use something you my have.

      In On Liberty Mill talks of how it would be OK to use coercion on a person who knows the bridge is out and could reasonably flag down car approaching the bridge-less chasm. That seems right to me. Like imposing a duty on that guy to share his information with the driver I can see imposing duty on a doctor to share his skills on the dying guy at his feet…

      1. that doctor is going to be busy.

      2. I always hated MNG for that post and the subsequent arguments following.

        Sigh. I truly know how Cassandra felt.

        1. What? You meant dying people don’t throw themselves at your feet every day?

          Leave lifeboat ethics in the lifeboat, people.

        2. So Groovus, the reports of you being dragged off to the gulag by the Medicare Police weren’t true?

          1. They touched his butthole. Repeatedly. But he never cried. He was my brave little boy.

        3. Has MNG been to medical school yet?

          I mean people’s lives are at stake here, and he could be a surgeon if he would just make it his life’s mission. And we’d be morally justified in forcing him to do so, according to him, right?

      3. Here’s what I don’t get… A lawsuit may not be able to fuck you over as bad as a disease, but if you’re poor and some corporation or the government sues you you’re still fucked. Now yes, in a criminal context there’s a public defender but not for civil actions. So how do we deal with it? Lawyers offer pro bono help (indeed, in many states a member of the bar consents to being appointed pro bono to represent indigent clients). I know my old dentist used to do offer help to homeless people after-hours. Why can’t the AMA or somebody step up and voluntarily fill that void instead of the government?

        1. Public Defender = Public Pretender. The quality of justice is how much of it you can buy in your advocate within that system and the rolodex he brings.

      4. I don’t know anyone I would trust with that kind of power.

        Do you?

    2. Nationwide, i think it’s adding about 16 million people to Medicaid. getting them covered is one thing, but having enough docs to treat them largely is left unaddressed

      You’ve stumbled across the disparity between “access” and “actually getting healthcare”.

    3. We don’t have to wonder whether or not these patients will end up at the ER, we can look to Massachusetts to tell us. Thanks Mitt!

      ER visits, costs in Mass. climb
      Questions raised about healthcare law’s impact on overuse

      By Liz Kowalczyk
      Boston Globe Staff / April 24, 2009

      More people are seeking care in hospital emergency rooms, and the cost of caring for ER patients has soared 17 percent over two years, despite efforts to direct patients with nonurgent problems to primary care doctors instead, according to new state data.

      1. Interesting. The last post on the I love Obama blog was in 2009, about the time the love stopped. Coincidence? I think not.

        1. Paul,

          That link was hilarious, thanks.

          The last post was ghost-written by that bovine Moore, I would bet even money-

          Obama tells off Wall Street

          I work for a large company that seems to “cost cut” on a monthly basis, and yet our executives are paid more and more ridiculous salaries while getting crazier and crazier benefits (does your job include a plane to fly your son to prep school?). So today’s talk of Obama calling the bonuses paid out on Wall Street “shameful” made me love him a little more. I really don’t see any way for these absurd salaries to be curbed in corporate america (because this sort of absurdity exists across all industries) but it does make me feel a little better that maybe one of these executives sitting in their golden bathtub lamenting the decline of their nest eggs from $100M to $50M is at least embarrassed.

          I hope there will be a way to help the middle class fight this sort of greed – it’s just not right that someone who works their whole life getting paid a decent wage can’t afford to send their kids to school or even pay their mortgage, let alone retire safely or have enough health coverage to not be afraid to go see their doctor.

          I don’t know that way though, and don’t think HOPE is going to do it. How do you un-teach a culture of greed?


          My mom says I’m gloating too much over the failures and hypocrisies from the left these days and I should show some restraint.

          Fuck that.


  3. Suder-man–You can’t have a “Churn Notice” headline without a pic of Gabrielle Anwar and her pokeys.

    1. That poor girl’s boyfriend needs to take her out for a steak.

      1. Yeah, I didn’t know who the hell she is until I googled her, but based on the pics I saw the only pokeys she has are her collarbones poking out of her skin.

      2. Oh, no question, she needs to eat a couple of boxes of doughnuts.

  4. In other words, it’s more of what we’ve come to expect from ObamaCare: More bureaucratic busywork for states, and more hassles for those trying to get care.

    But they’re well-intentioned hassles.

    And thing of the bureaucrats saved or created. Why do you hate America, Peter?

  5. Someone should do a study on elective surgeries and procedures vs. technically equivalent covered procedures. Like compare a facelift to an insured face-fix resulting from a car-wreck or something.

    That will open some eyes to the difference between truly private systems at work in medical care vs. the insured mess.

    Also, saw a great piece on 60 Minutes about tourist hospitals in places like Thailand and India. Truly shocking how much better and cheaper the care was in those places. That will be new frontier for insurance companies because its literally getting cheaper to buy a ticket and go half-way-around the world for a surgical procedure than costs of filling out the paperwork and CYA’s for lawyers here at home. Just pathetic.

    1. My hospital isn’t terribly far from Mexico, although not near any of the larger crossing metropoli. I have proposed that we start putting in a hospital just over the border, to cash in on regulatory and payment arbitrage, which will only get worse.

  6. No one could possibly have foreseen any of this. It’s just un-possible.

    We’ve got to give the system time to work. It’s only been a year or so. All the good stuff comes in 2014 anyway.


  7. Leave lifeboat ethics in the lifeboat, people.

    Every lifeboat should be supplied with a fire axe.

  8. Like schools, universal healthcare could be fixed if we just pumped more money into it.

    “By George, I think you’ve got it.”

  9. I like it very much, thank you

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