About one in four low-income adults in three U.S. states have experienced changes in their health insurance coverage—known as “churning”—since the Affordable Care Act (ACA) was passed in 2014, according to a new study from Harvard T.H. Chan School of Public Health. The study suggests that, while the ACA has expanded health coverage to millions, maintaining stable coverage over time remains a challenge.

The study also found that churning has resulted in negative effects on health care.

“We found that the ACA has not worsened the problem of churning, as some had predicted, but it hasn’t fixed it either,” said Benjamin Sommers, assistant professor of health policy and economics and lead author of the study. “People who switched coverage reported frequent periods when they didn’t have any insurance, as well as high rates of skipping medications, having to switch doctors, and receiving low-quality care.”

Previous research suggested that churning was common, particularly among lower-income individuals, even before the ACA’s expanded health coverage in 2014. To find out what happened after the expansion, the Harvard Chan researchers surveyed more than 3,000 low-income adults in late 2015 in Arkansas, Kentucky, and Texas—three states that have responded in three different ways to the ACA’s option of expanding eligibility for Medicaid—and they compared that information with 2013 survey data from low-income adults in those states. Kentucky chose a traditional expansion of Medicaid; Arkansas chose an expansion that enrolled Medicaid beneficiaries in private plans through the federal health care marketplace; and Texas chose not to expand.

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