Insurance Churn And Diabetes Outcomes In Low-Income Patients

The video explores the “churn” of insurance and its negative effects on the daily lives of people with diabetes who are of low income and how it impacts their diabetes outcomes in the long run.

The Clinical Impact of Insurance Churn

Research indicates that health insurance churn for individuals with diabetes has numerous negative health effects. In a study of 39,000 patients from 14 community health centers in Massachusetts, patients with diabetes who experienced “churn” (two or more consecutive uninsured visits) had poor clinical outcomes. Specifically, patients with diabetes who experienced churn had a 4.0% higher prevalence of uncontrolled HbA1c levels (defined as >9.0%) compared to the non-churn group. The negative health effects of health insurance churn experienced by individuals with diabetes are likely the result of challenges that individuals with diabetes face when attempting to access diabetes-related care and services during periods of health insurance coverage loss.

Why It Matters

The cycle of managing diabetes is challenging enough, but when a patient with diabetes has low income and unstable insurance, managing diabetes can be extremely difficult. When a person with diabetes has insurance, they are able to access the necessary medications and supplies to manage their diabetes, as well as regular contact with their healthcare provider. Their healthcare provider is able to keep them on track with treatment, manage their blood sugar levels, and make any necessary changes to their treatment. When a person with diabetes has unstable insurance, however, it can be difficult for them to receive the care and services that they need to manage their diabetes. Even small changes in treatment can be difficult to implement when a patient has unstable insurance. For example, a patient’s diabetes medication may not be refilled on time because of problems with the patient’s insurance coverage. The patient may not be able to take their prescribed medications on time and as a result experience high blood sugar levels. A person with diabetes and unstable insurance may not have access to necessary diabetes education or services to help prevent complications of diabetes such as nerve damage or kidney failure.

Real Life Harm

Insurance churn causes a lot of harm to patients and families, even when that harm is not so obvious. For example, when a patient’s new health insurance plan has a different formulary than did the patient’s old health insurance plan, the patient may not immediately have access to prescribed medications. When a patient’s health insurance requires prior authorization or step therapy for a prescribed medication, that can interfere with the patient’s timely receipt of needed medications. Each time a patient with unstable insurance experiences a period of time without insurance, the patient must pay a new deductible for health care services that are provided when the patient again has health insurance. A patient with unstable insurance may find that the patient’s new health insurance plan has a smaller network of health care providers and facilities than did the patient’s old health insurance plan. For many patients with diabetes who have very unstable work, housing, and family situations, many patients will skip a diabetes medication refill or a diabetes health care provider visit from time to time because of the “friction” that is caused by the process of dealing with insurance churn. Skipping refills of and visits for diabetes health care can cause increased use of expensive ED care for preventable diabetes complications, and increased rate of preventable hospitalizations for patients with diabetes. In the long term, the process of dealing with insurance churn can cause patients with diabetes to experience a faster progression of diabetes complications that require expensive and chronic health care for years to come (e.g. dialysis, amputation, specialty health care providers).

Financial Impact

Preventable illnesses are those that can be managed through constant monitoring, typically inexpensive when the individual has adequate insurance. Diabetes is the most common chronic illness, and with proper management of prescription drugs and monitoring tools (such as blood glucose meters and test strips), individuals can have relatively low healthcare costs when they are on insurance. However, when an individual with diabetes loses his or her insurance, they immediately become candidates for very expensive care that will be paid for by the taxpayers or by the hospital where the care is delivered. Why should the poor have to purchase insurance that can be taken away at any time? Insurance churn in insurance affects the poor more than others and has a greater negative effect on them when it occurs the same number of times as it does for wealthier individuals.

What the Research Says: Escalation of Complications and Costs

The cycle of health coverage loss, change, and recovery has the potential to cause negative health impacts and create increased costs of care for people with chronic conditions during the time of health coverage change. In the case of people with diabetes who have low incomes, their experience of diabetes complications is reported by 3.0% more individuals with diabetes who have low incomes than by individuals with diabetes who have stable health insurance (p<.01). These problems with diabetes that have negative health impacts and that increase cost of care can be managed as an outpatient with a team of health care providers and with medications and supplies to manage the health condition, but instead these problems with diabetes are addressed as health crises that require expensive and often life altering inpatient and emergency care when a person with diabetes who has low incomes experiences a period of health coverage loss, change, and recovery. The increased cost of care for people with diabetes who have low incomes with diabetes complications during periods of health coverage loss, change, and recovery creates additional costs to the health care system for the care of individuals with diabetes.

In addition to increasing the degree of needed care, churn also can increase the cost of care that is needed. As an example, while only 2.2% of the non-churn patients were on insulin, 4.4% of the churn patients required this medication for glycemic control. This is due to the HbA1c levels of patients who are uninsured fluctuating while the patient is uninsured and the primary care manager increasing the degree of glycemic control with insulin when the patient becomes insured.

Who It Affects

Patients

The individuals most affected by this problem are those with low incomes and diabetes or their family members. These individuals and their family members are most likely to be covered by public health insurance or short-term employer sponsored health insurance. As a result, individuals with diabetes and their families are more likely to receive care at community health centers and free clinics, the safety nets of care provided to individuals with limited resources. Insurance churn can create a number of gaps in care for individuals with diabetes including: (1) lack of access to essential diabetes medications; (2) lack of access to essential diabetes supplies (e.g. insulin, oral medications for diabetes, test strips for measuring blood glucose); and (3) lack of access to adequate diabetes education.

Clinicians and Care Teams

Additionally, people with diabetes who have low income face many negative impacts from their clinicians and their practices. First, patients with diabetes who have low income face increased complexity and variability in their diabetes care due to their clinicians and their practices. The biggest barrier is that the patient’s insurance coverage often changes, which makes it difficult for clinicians and their practices to provide effective diabetes care to their patients. Even simple aspects of patient care such as medication management are negatively impacted by a patient’s insurance coverage. For example, a patient with diabetes may be prescribed a certain medication by his or her clinician. However, when the patient enrolls in a new health plan, the medication may not be covered. As a result, the patient’s clinician must spend time and resources to try to reconcile the patient’s new medication list with what medications the patient’s new insurance coverage will pay for. Clinicians and their practices also must verify coverage of any prescribed medications for their newly enrolled patients. If a patient has low income, it is possible that the staff at the patient’s clinician’s and practice’s facility will not have the time and the resources to deal with the complexities of the patient’s insurance coverage. As a result, many people with low income and diabetes experience many negative impacts from their clinicians and their practices. These negative impacts can include negatively impacted patient relationships and even clinician burnout.

Payers, Healthsystems & Health Policy

Chronic problems in healthcare today stem from the outside of the health care system. The issue of coverage of individuals with diabetes can affect other outside parties as well. High rates of insurance churn in individuals with diabetes creates an avoidable use of expensive resources for acute complications and therefore, it is in the best financial interest for payers, for health systems, and for health care policy makers to decrease the insurance churn of individuals with diabetes in order to reduce costs. For hospitals, however, the greatest impact will be for those hospitals that serve large proportions of uninsured and underinsured individuals. These patients visit the hospitals for needed care and then the hospitals are left to collect unpaid or underpaid debts for services rendered to those patients while they had been covered by insurance. Public agencies and state Medicaid programs will have to strike a balance between maximizing Medicaid enrollment, to cover more people with needed services, preventing and detecting fraud, and efficiently managing a budget to provide the health care coverage for individuals with diabetes while the rules for Medicaid enrollment and for the provision of health care services may cause some gaps in the needed services for individuals with diabetes.

Similar effects of insurance instability are experienced by health centers that provide care to a large percentage of low-income individuals and families with diabetes. Nine out of ten patients with diabetes served in community health centers (CHC) have incomes at or below 100% of the federal poverty level (FPL). A large proportion of individuals with diabetes experience periods of time when they are uninsured and have chronic symptoms of diabetes. Therefore, changes in Medicaid policy have the potential to have negative effects on the health of low-income individuals with diabetes as well as on the health centers that serve them. The health centers could experience a loss of revenue when patients lose Medicaid coverage but the greater loss would be to the patient’s health and to the quality of care that the health center is able to provide to its community of patients with diabetes. The One Big Beautiful Bill Act would have the effect of creating unstable insurance coverage for individuals with diabetes and their health centers.

Community Safety Nets

Additional challenges in diabetes care can be mitigated by various community organizations that function as part of the diabetes care safety net of care. For example, diabetes and healthy fitness programs, retail pharmacies and community and retail pharmacists can assist individuals and their families with several tasks including assistance in obtaining appropriate insurance coverage, help in identifying the most cost-effective diabetes medications, fill prescriptions for people who are without coverage for a period of time, and help individuals and educate individuals and their families regarding the proper use of oral and injectable diabetes medications and management of diabetes. Several barriers to the various tasks of diabetes care provided by these individuals and groups exist. The lack of resources available to complete various tasks to be of aid to individuals and their families with diabetes are several of the several challenges. Other challenges of individuals and groups in the safety net of care of diabetes include the lack of reimbursement for several of the various completed tasks of diabetes care. Reducing the rate of time that patients with diabetes are uninsured is essential to manage to prevent diabetes complications and to reduce costs associated with treatment of people with diabetes. Providing people with continuous coverage is a crucial step in this process.

What Changes

• Make coverage more continuous. Policies that lengthen continuous eligibility for public programs reduce churn. For clinicians, that means fewer abrupt treatment interruptions and more predictable care plans.
• Design care around transitions. Clinics can build practical workflows: screen patients for coverage instability, give longer prescriptions when appropriate, and connect patients immediately to enrollment navigators or community health workers. These steps reduce missed doses and missed visits.
• Match medications and supplies to likely coverage. When changing plans is common, clinicians and pharmacists should prioritize affordable, widely covered options and provide prescriptions for 90-day supplies when feasible. That lowers the chance a patient will be left without insulin or glucose testing supplies.
• Invest in data and coordination. Better data sharing between payers and clinics can flag coverage lapses earlier. That lets care teams act before a gap becomes a medical emergency. The alternative is reactive, expensive care.

Why Practical Fixes Matter

Administrative solutions to insure that people maintain coverage during the time of greatest instability have great potential to have significant clinical implications for improving the health of people with diabetes. Continuing eligibility during periods of fluctuating income (as is the case with the Medicaid policy of ‘continuing eligibility’) could keep patients with diabetes on coverage and in touch with their health care providers and their diabetes treatment during the time when they are most vulnerable to loss of coverage. Administrative simplifications, such as simplifying the processes for current beneficiaries to renew their coverage, automating the eligibility process (using information that the program already has in its databases), mailing required documentation to the most current address of record for the beneficiary, and avoiding of unnecessary mailings to find a current address can prevent coverage disruptions due to incomplete or misplaced documentation.

Patients with diabetes and poor or low incomes have the potential to be stable patients on diabetes medications (oral and/or insulin) and supplies (such as test strips) and diabetes education when they have insurance through a public program (such as Medicaid), a short-term employer-based insurance plan, and/or safety-net system of clinics and providers. Patients with diabetes who have these sources of insurance, however, can experience “churn” or “shifting” in their insurance as they experience small fluctuations in their income, and/or in their family circumstances. These insurance “churn” can have “patchy” effects on a patient’s access to and use of their diabetes medications and supplies as well as their access to and receipt of their diabetes education. The diabetes care in primary care clinics can be affected by the “churn” as well when a clinician or diabetes care team attempts to deliver and coordinate a patient’s treatment, but is negatively affected by the lack of continuity of care due to the patient’s “churn” and the clinic’s staff time to verify and complete the patient’s insurance enrollment.

Trade-offs And Real-World Constraints

More than simple solutions are needed to address these health issues and their prevention will require more than just changes in health care delivery. Some of the health systems that have implemented solutions for managing patients with chronic illnesses have created “pockets of excellence” in order to address the special needs of these patients. One of the models that have been used by many of the health systems that are successfully managing the care of patients with chronic illnesses is Continuum Care. In order to successfully manage the care of patients with chronic illnesses a payment system is needed that rewards the prevention of hospitalizations for acute complications of their chronic condition. In addition, there is a need to invest in staff and programs in order to stabilize the coverage of patients with chronic conditions.

The current US system of coverage— employer-based coverage, Medicaid, Medicare, and the health insurance marketplaces— has different rules for different types of coverage. Thus, patients may experience different formularies, in- and out-of-network providers, and patient cost sharing as they move from one type of coverage to another. Simple clinical fixes— such as prescribing an inexpensive generic for diabetes, or writing a 90-day supply of a necessary medication— are not always possible. Many medications are approved for only a single indication, and some have formulations that are not suitable for wide dissemination.

Looking Ahead

The best way to address the impact of insurance churn is to find a way to make insurance coverage more stable for patients with diabetes. If currently eligible individuals are able to remain enrolled in Medicaid and other programs during periods of fluctuating income, newly eligible individuals could be reduced in their likelihood of experiencing gaps in coverage as they transition into Medicaid and other programs. For those that do experience a lapse in coverage, measures can be put in place to reduce the duration of time for which that individual is uninsured. Efforts can also be made to simplify the process of applying for, and determining eligibility for, coverage, as well as to create structures within and between programs to facilitate a smooth transition for individuals moving between programs or types of coverage.

Rather than simply tracking whether or not a patient with diabetes has had stable insurance, measuring and tracking the negative health effects of coverage instability, or the negative health effects of having to manage their diabetes through periods of time when they had no insurance, or when they had inadequate or unaffordable insurance, would be more precise. For example, tracking the number of preventable emergency room visits for hyperglycemia or hypoglycemia, or for other diabetes-related complications, would measure the effects of having to manage diabetes through periods of time when a patient had no insurance, or when they had insurance that was inadequate or unaffordable. Similarly, tracking patient adherence to prescribed diabetes medications would serve as an indicator of the negative health effects of having to manage diabetes through periods of periods of time when a patient had no insurance, or when they had insurance that was inadequate or unaffordable. And, finally, tracking the rate at which patients with diabetes develop serious complications of the disease, such as diabetic retinopathy, end stage kidney disease, and heart disease, would serve as an indicator of the negative health effects of having to manage diabetes through periods of time when a patient had no insurance, or when they had insurance that was inadequate or unaffordable. By quantifying the number of and the rate at which which patients with diabetes experience these types of negative health effects as a result of having to manage their diabetes through periods of time when they had no insurance, or when they had insurance that was inadequate or unaffordable, clinicians and policymakers will have a more precise sense of the scope and of the issues that need to be addressed in order to improve the quality of diabetes care provided to patients with diabetes who are uninsured, underinsured, or experience periods of time when they are uninsured or underinsured.

We cannot view insurance churn solely through a fiscal lens, as the problem is not an equal opportunity problem and will have different effects on individuals with different determinants of health. Thus improving the stability of insurance coverage for people with diabetes is a health equity intervention as well as a very simple intervention to improve the care of people with diabetes who are of low income and are treated by clinics and providers.

Reference

1. Huguet N, Dinh D, Larson A, et al. Insurance Churn and Diabetes Outcomes Among Patients With Low Income. JAMA Health Forum. 2026;7(3):e260034. Published 2026 Mar 6. doi:10.1001/jamahealthforum.2026.0034