In an illuminating new study published in JAMA Health Forum, researchers from the University of Pittsburgh, University of South Carolina, and Emory University have revealed critical insights into the dynamics of health insurance coverage retention and plan switching among Americans utilizing the HealthCare.gov Marketplace. Their extensive analysis, spanning enrollment data from 2022 through 2024, uncovers the substantial consequences of administrative changes on insurance continuity, highlighting a nearly 7% drop in reenrollment rates connected to the loss of automatic reenrollment options for zero-premium plans.
The Affordable Care Act (ACA) has been pivotal in transforming the American health insurance landscape, enabling over 24 million previously uninsured individuals to access coverage via the Health Insurance Marketplace. This achievement, further bolstered by the American Rescue Plan and Inflation Reduction Act since 2021, dramatically expanded affordability, particularly through broad availability of zero-premium plans for low-income enrollees. Under these provisions, Americans earning less than approximately 175% of the federal poverty level—around $27,000 for individuals or $56,000 for families of four as of 2025—could access comprehensive coverage without monthly premium obligations.
However, the study reveals that this progress is vulnerable to policy shifts. When insurers exit the Marketplace or alter plan offerings, returning enrollees are often defaulted into new plans that require active selection or payment initiation. Specifically, the research shows that in counties where individuals were transitioned from zero-premium plans to those with positive premiums, many faced a new barrier: the necessity to start paying a premium in the subsequent year or find an alternative zero-premium plan if available. This shift eliminated the previous benefit of automatic reenrollment, introducing administrative burdens that led to a significant erosion in continuous coverage.
Dr. Coleman Drake, the study’s lead author and an associate professor in the Department of Health Policy and Management at the University of Pittsburgh’s School of Public Health, articulates the gravity of these findings. He emphasizes that administrative complexity—such as initiating payments after a period without premium obligations—can pose insurmountable challenges for many Marketplace enrollees. The problem is acute given that many of these individuals are relatively inexperienced with navigating the intricacies of health insurance, often comprising populations with limited prior exposure to financial and bureaucratic healthcare processes.
The analysis leverages a robust dataset encompassing 36.7 million HealthCare.gov enrollees across 29 states during the post-2021 period. This massive-scale investigation elucidates enrollment patterns year-over-year, particularly focusing on the impact of insurer plan withdrawals and the associated necessity for enrollees to actively engage in the selection or payment process. The data vividly illustrate how the removal of passive reenrollment options acts as a significant disruptor, contributing to disenrollment spikes and increased uninsured rates.
Administrative burdens—defined as complexities in paperwork, payment initiation, and plan selection—introduce friction that disproportionately affects populations with lower socioeconomic status or limited health insurance literacy. The research underscores that such barriers not only diminish coverage retention but also exacerbate health inequities by pushing vulnerable populations into uninsured status. The estimated fallout from these procedural changes is stark: approximately 250,000 Americans likely lost their Marketplace coverage in 2024 due to the requirement to transition to positive-premium plans and the loss of automated reenrollment.
The policy implications of these findings are substantial. David Anderson, Ph.D., assistant professor at the University of South Carolina Arnold School of Public Health and a co-author of the study, warns that upcoming budget resolutions in the House of Representatives may exacerbate this trend. The proposed changes, mandating premium payments by all Marketplace enrollees beginning in the year, would codify the administrative hurdles studied, potentially resulting in coverage losses on a far larger scale by 2027, thereby hindering the progress achieved in recent years.
Interestingly, while the requirement for active reenrollment or payment initiation introduces clear downsides, the researchers acknowledge potential benefits in some contexts. For example, forcing enrollees to make plan selections annually can act as a behavioral “nudge,” encouraging beneficiaries to reassess their healthcare needs and potentially select plans better aligned with their current circumstances. Nevertheless, the study finds that for many, the overall effect of increased administrative burden overwhelmingly results in coverage gaps rather than optimization.
This research contributes a granular understanding of the mechanics underpinning insurance coverage continuity and highlights the delicate balance between policy design and actual enrollment outcomes. The integration of data/statistical analysis allows for a nuanced decomposition of enrollment flows, offering policymakers evidence-based insights into unintended consequences arising from seemingly straightforward procedural changes. These findings underscore the necessity of designing insurance Marketplaces that minimize friction and promote seamless coverage transitions.
The study also situates its findings within the broader landscape of U.S. health policy, where affordability and access remain persistent challenges. While the ACA and subsequent legislative enhancements have succeeded in expanding coverage, the findings highlight that even well-intentioned reforms can falter if administrative hurdles impede retention. As such, the research offers a cautionary tale that underscores the importance of maintaining and potentially expanding features like automatic reenrollment for zero-premium plans to protect the gains made in reducing uninsured rates.
Reflecting on these developments, the researchers call for careful scrutiny of forthcoming legislative measures that threaten to increase administrative burdens. They recommend that policymakers prioritize mechanisms that preserve ease of coverage renewal and reduce the need for active decision-making, particularly for low-income populations who are most sensitive to such barriers. Avoiding unnecessary enrollment disruptions can have downstream effects on health outcomes, healthcare utilization, and financial security among vulnerable groups.
In sum, this study delivers an urgent wake-up call regarding the fragility of health insurance gains in the face of administrative complexity. By rigorously documenting that the elimination of zero-premium plan automatic reenrollment leads to coverage losses affecting hundreds of thousands of Americans, it provides a compelling case for reevaluating policy proposals that would impose premium payment requirements on all Marketplace enrollees. Protecting and enhancing the usability of the Marketplace is critical in sustaining advances made in reducing the uninsured population and ensuring equitable access to healthcare.
The comprehensive nature of the data evaluated and the careful methodological approach position this analysis as a seminal contribution to health policy research. This work bridges the gap between statistical enrollment trends and the lived realities of millions of Americans navigating the often-confounding health insurance system. As such, it stands to shape policy discourse and inform reforms aimed at maintaining health coverage accessibility amidst evolving Marketplace conditions.
Subject of Research: Not applicable
Article Title: Coverage Retention and Plan Switching Following Switches From a Zero- to a Positive-Premium Plan
News Publication Date: 23-May-2025
Web References:
JAMA Health Forum Article
University of Pittsburgh Department of Health Policy and Management
University of Pittsburgh School of Public Health
University of South Carolina Arnold School of Public Health
References:
Drake, C., Anderson, D., Nagy, D., Avina, S., Ludwinski, D. (2025). Coverage Retention and Plan Switching Following Switches From a Zero- to a Positive-Premium Plan. JAMA Health Forum. DOI: 10.1001/jamahealthforum.2025.1424.
Keywords: Health insurance, HealthCare.gov, Affordable Care Act, Marketplace enrollment, Zero-premium plan, Administrative burden, Coverage retention, Health policy, Insurance disenrollment, Health equity
Tags: administrative changes in health coverageAffordable Care Act impactAmerican Rescue Plan benefitscoverage retention strategiesenrollment data analysis 2022-2024health insurance continuity issueshealth insurance Marketplace dynamicshealthcare coverage riskHealthCare.gov reenrollment challengesInflation Reduction Act effectslow-income health insurance accesszero-premium health insurance plans