Researchers from the University of Pittsburgh, University of South Carolina and Emory University have published findings in JAMA Health Forum from a recent study on coverage retention and plan switching among Americans who obtain their health insurance through HealthCare.gov.

Looking at data from 2022 through 2024, the authors found that losing the option to automatically reenroll into a zero-premium plan reduced enrollment. Reenrollment decreased by about 7% among those affected, indicating that an estimated quarter of a million Americans likely lost their Marketplace health insurance coverage and became uninsured in 2024.

“Administrative burdens can critically undermine people’s ability to maintain health insurance coverage. That includes needing to start making a premium payment on January 1 after not having to in the previous year, as we study here. This is especially problematic for people enrolling in Marketplace coverage, who often have relatively little prior experience with the complexities of health insurance,” said lead author Coleman Drake, Ph.D., associate professor in the Department of Health Policy and Management at Pitt’s School of Public Health.

The Affordable Care Act has enabled 24.2 million uninsured Americans to obtain coverage through the Health Insurance Marketplace (HealthCare.gov). Since 2021, the American Rescue Plan and Inflation Reduction Act has increased affordability and coverage for low-income households, making zero-dollar premium plans broadly available to HealthCare.gov enrollees with incomes below 175% of the federal poverty level (approximately $27,000 for an individual or $56,000 for a family of four in 2025).

The researchers analyzed data from 36.7 million HealthCare.gov enrollees across 29 states from 2022 to 2024 (following the 2021 American Rescue Plan Act), examining year-to-year changes in enrollment resulting from enrollees being defaulted to new plans as insurers exited the Marketplace.

In counties where returning enrollees were defaulted from zero-premium plans to plans with premiums with a new insurer, enrollees had to start making a premium payment or switch to a different zero-premium plan, if available, or lose their coverage altogether. Being forced to either reenroll or select a new plan can have positive impacts, such as giving participants the nudge they may need to choose a plan that better fits their household’s health needs. However, in many cases, the administrative burdens required to actively enroll each year can result in a total loss of coverage, the study showed.

“Increasing administrative burdens on Marketplace enrollees will lead to loss of coverage and an increase in uninsurance. The current budget resolution in the House of Representatives would require all Marketplace enrollees currently in zero-premium plans to make a premium payment at the start of the year,” said David Anderson, Ph.D., assistant professor at the University of South Carolina Arnold School of Public Health

“This would expose millions more Marketplace enrollees to the administrative burdens we study here, and as such, lead to substantial coverage losses in 2027.”

Other authors of the study were Dylan Nagy and Sarah Avina, of Pitt; and Daniel Ludwinski, Ph.D., of Oxford College of Emory University.