A comprehensive new study led by Oregon Health & Science University (OHSU) has uncovered a troubling dynamic impacting low-income adults living with diabetes: a heightened risk of health insurance instability, often referred to as “insurance churn.” This research, published in the Journal of the American Board of Family Medicine, analyzed patterns of insurance coverage loss among a large sample of more than 300,000 adults aged 19 to 64. These individuals received care at community-based health centers between 2014 and 2019, with a particular focus on those who experienced interruptions in insurance coverage. The findings offer critical insights into the vulnerabilities faced by patients managing chronic conditions in an evolving healthcare landscape.
The study utilized a retrospective analysis of electronic health records to extract detailed information about insurance status. Insurance churn was operationalized as a sequence whereby patients who were previously insured experienced at least two consecutive clinical visits during which they lacked coverage. This method enabled researchers to identify not just momentary lapses but more persistent gaps in insurance that could undermine continuous access to medical care. Approximately 39,500 individuals within the cohort lost their health insurance at some point during the study period, providing a robust dataset for evaluating risk factors associated with coverage loss.
One of the study’s key revelations was that patients diagnosed with diabetes were 25% more likely to lose health insurance coverage compared to their non-diabetic counterparts. Moreover, among those with diabetes, individuals with more complex disease profiles—characterized by poor glycemic control, multiple medication regimens, or diabetes-related complications—faced an even greater risk of becoming uninsured. These findings challenge prior assumptions about healthcare engagement, as conventional wisdom would suggest that patients managing chronic illness might be more motivated or supported in maintaining insurance coverage.
The corresponding author of the study, Dr. Nathalie Huguet, an associate professor of family medicine at OHSU, expressed surprise at this result. “We had hypothesized that people with diabetes, given their higher medical needs and presumably greater interaction with healthcare systems, would maintain more stable insurance coverage,” she said. Instead, the data revealed significant instability, pointing to systemic barriers that disproportionately impact vulnerable populations with chronic diseases. This instability poses a threat not only to individual health outcomes but also to broader public health objectives.
Insurance churn carries profound implications for the continuity of care, a cornerstone of effective diabetes management. The episodic loss of coverage can lead to interruptions in medication adherence, delayed clinical interventions, and increased reliance on costly emergency services. These disruptions may exacerbate disease progression and heighten the risk of complications such as cardiovascular events, neuropathy, and renal failure. The study’s evidence underscores the urgency of designing policies that promote sustained insurance coverage, particularly for populations with complex medical needs.
Alarmingly, the study also demonstrated that many patients who experienced insurance loss did not regain coverage. Nearly half (46%) of diabetic patients who lost Medicaid insurance failed to re-enroll or obtain alternative coverage, while 61% of those disenrolled from private insurance remained uninsured. This phenomenon of prolonged uninsurance compromises access to preventive and routine care, undermining disease control and increasing downstream healthcare costs. The persistence of such gaps highlights critical deficiencies in existing safety nets and enrollment systems.
The research gains added urgency in light of recent historical events. Following the expiration of the public health emergency declaration related to the COVID-19 pandemic in May 2023, approximately 25 million people were disenrolled from Medicaid nationwide. Policymakers had anticipated that most of these individuals would transition seamlessly to other forms of insurance. However, the study’s findings suggest that these expectations may be overly optimistic given the documented challenges of re-enrollment, particularly for individuals with chronic illnesses like diabetes.
The dataset analyzed in this study encompasses years prior to the pandemic, yet Dr. Huguet plans to extend the research to evaluate post-pandemic trends, including the outcomes of the mass Medicaid disenrollment. Her ongoing work aims to probe whether insurance instability has worsened for high-risk groups and to identify mechanisms through which healthcare systems can better track and support these transitions. Advanced statistical modeling and health informatics will likely play key roles in uncovering these dynamics.
Importantly, some states’ strategies during the post-pandemic period provide potential models for mitigating insurance churn. Oregon, for instance, opted not to immediately disenroll eligible individuals from Medicaid, thus preserving more consistent coverage. According to Dr. Huguet, maintaining continuous enrollment through targeted policy interventions can stabilize healthcare access, reduce preventable hospitalizations, and ultimately control public healthcare expenditures. Insights from such policy experiments may inform national approaches to health insurance administration.
Going forward, Dr. Huguet advocates for improvements both in enrollment processes and patient navigation. Slower, more deliberate disenrollment procedures combined with personalized support systems could help individuals quickly identify and obtain alternative insurance plans, minimizing periods of uninsurance. Policymakers and healthcare providers must collaborate to design streamlined transitions and proactive outreach that prioritize patients with chronic conditions. Such reforms have the potential to reduce costly gaps in coverage and improve long-term health trajectories.
This study represents an important contribution to the literature on healthcare inequities by quantitatively demonstrating the link between diabetes and insurance loss risk. The large-scale, longitudinal electronic health record data adds rigor to the field’s understanding of insurance dynamics among socioeconomically disadvantaged populations. It also challenges simplistic assumptions that chronic illness automatically secures insurance stability, revealing instead a nuanced reality shaped by socioeconomic, medical, and policy factors.
In conclusion, as health systems continue to grapple with post-pandemic disruptions and evolving healthcare financing models, it is imperative to recognize that insurance instability disproportionately undermines continuity of care for people with diabetes. Ensuring uninterrupted insurance coverage is essential not only for individual well-being but also for the sustainability of healthcare delivery and cost control. This study signals urgent policy priorities and offers a research framework to evaluate and improve insurance stability for vulnerable patients nationwide.
Subject of Research: People
Article Title: Insurance Instability Among Community-Based Health Center Patients with Diabetes Post-Affordable Care Act Medicaid Expansion
News Publication Date: 16-Apr-2025
Web References: https://www.jabfm.org/content/early/2025/03/28/jabfm.2024.240186R1
Image Credits: Credit: OHSU
Keywords: Diabetes; Public health; Health insurance; Adults; Family medicine; Disease control; Drug costs
