If you've ever had Medicaid coverage, you might know the anxiety of checking your mailbox. A routine income bump—a few extra shifts, a small raise, a one-time bonus—can suddenly make you ineligible. Then, months later, you might qualify again. This back-and-forth has a name: Medicaid churn.

For millions of Americans, this isn't a bureaucratic inconvenience. It's a healthcare crisis in slow motion. Churn disrupts medications, derails treatment plans, and forces people to start over with new providers. Understanding why this happens reveals something important about how our safety net actually works—and why continuous coverage matters more than most people realize.

Medicaid eligibility is tied to income thresholds, often set around 138% of the federal poverty level in expansion states. For a single adult, that's roughly $20,000 a year. The math sounds straightforward, but real life isn't. Income fluctuates constantly—seasonal work picks up, overtime becomes available, a side gig pays out. Even modest changes can push someone over the line.

Here's where it gets complicated. States typically verify income monthly or quarterly. A good month can make you appear wealthier than you actually are across the year. Someone earning $1,600 one month and $1,200 the next might average below the threshold, but that single high-earning month could trigger disenrollment. The system measures snapshots, not the full picture.

The paperwork burden compounds this. Missing a renewal notice—easy to do if you've moved or your mailbox is unreliable—means automatic termination. Getting back on requires reapplying from scratch. Many people who lose coverage actually still qualify; they just couldn't navigate the administrative maze in time. The system wasn't designed for how low-income Americans actually live.

Takeaway

Income thresholds create cliff effects where small, temporary gains can cost you healthcare access. Eligibility systems often measure moments rather than circumstances.

Chronic conditions don't pause when your insurance lapses. Diabetes still requires monitoring. Hypertension still needs medication. Mental health conditions still demand consistent treatment. But coverage gaps force people to ration insulin, skip appointments, and abandon therapy midstream. The consequences compound over time.

Research consistently shows that people who churn in and out of Medicaid have worse health outcomes than those with continuous coverage. Emergency room visits increase. Hospitalizations become more common. Preventable complications develop into expensive crises. A person with well-controlled diabetes can spiral into kidney problems within months of interrupted care.

The provider relationship matters too. Each coverage gap often means finding a new doctor who accepts your new plan—assuming you can get coverage again. New providers don't know your history. They might order redundant tests or miss warning signs your previous doctor would have caught. Medical care works best as an ongoing relationship, but churn forces people into a series of disconnected encounters.

Takeaway

Healthcare works through continuity. Interrupted coverage doesn't just delay care—it unravels the accumulated benefit of consistent treatment and trusted provider relationships.

Some states have experimented with solutions. Twelve-month continuous eligibility guarantees coverage for a full year regardless of income fluctuations within that period. It's simple: once you qualify, you're covered until your annual renewal. This approach recognizes that monthly income swings shouldn't constantly reshuffle someone's healthcare status.

The COVID-19 pandemic offered an unintentional experiment. Federal rules temporarily prohibited states from disenrolling Medicaid recipients. Coverage became stable. Early research suggests this continuity improved health outcomes and reduced administrative costs. When the emergency provisions ended, millions lost coverage in the "unwinding"—many of them still technically eligible but unable to complete paperwork in time.

Other approaches include expanding income thresholds, simplifying renewal processes, and creating bridge coverage for people transitioning between Medicaid and marketplace plans. The underlying principle is consistent: healthcare systems work better when people don't repeatedly fall through gaps. Administrative efficiency and health outcomes both improve when coverage remains stable.

Takeaway

Continuous eligibility isn't just compassionate policy—it's efficient policy. Keeping people covered costs less than repeatedly processing their exits and reentries while their health deteriorates.

Medicaid churn reveals a fundamental tension in how we design safety nets. We want to target resources toward those who need them, but rigid eligibility rules create instability for the very people we're trying to help. The result is a system that spends significant resources managing paperwork while people lose access to care they still qualify for.

Understanding churn matters because it shapes how you might advocate—for yourself, for family members, for policy changes in your state. Stable coverage isn't a luxury. It's what makes healthcare actually work.