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This commentary details how Oregon’s state employee health plan is implementing multiple approaches to contain high costs and ensure a level of predictability for its public employees and their health plan.
This issue brief presents a sustainable, hybrid coverage and funding approach for mobile crisis services in light of the new federal funding opportunities for states to improve access to behavioral health crisis services.
This recording features highlights from NASHP's 34th Annual Conference.
This commentary presents strategies for state-based marketplaces to improve consumer outreach, provide enrollment assistant and clearly communicate with consumers with what health coverage options are available for them in 2022.
This expert perspective summarizes the provisions of the No Surprises Act relating to air ambulances and notes particular implications for state regulators and marketplace officials.
This resource page compiles the latest Robert Wood Johnson funded research on the benefits of closing the Medicaid coverage gap.
This blog post examines how the American Rescue Plan Act affected the affordability, choice, and coverage stability of health plans on 12 different state-based marketplaces.
This commentary examines state action during the 2021 legislative session to address rising drug costs.
This report examines the effect the COVID-19 pandemic has had on the small group insurance market.
This commentary explains how since March 2020, many states have rapidly leveraged federal and state flexibilities under the public health emergency to expand telehealth capabilities and reimbursement through both public and private payers.
This blog highlights how state-based Marketplaces are launching integrated and innovative outreach campaigns—including tapping into existing public health and COVID-19 vaccination efforts—to reach residents and alert them to the fact that the American Rescue Plan Act provides more people than ever before with access to financial help to pay for health insurance.
This article highlights NASHP’s Center for State Rx Drug Pricing five years of state action to lower drug costs.
This commentary reviews provisions of the U.S. Departments of Health & Humans Services and Treasure final 2022 Notice of Benefit & Payment Parameters of particular import to the state-based marketplaces and state insurance regulators.
This brief seeks to show the maximum potential impact of the American Rescue Plan Act's (ARPA) enhanced marketplace subsidies on health insurance coverage by modeling the new subsides as if they were permanent changes.
This toolkit outlines template language that state-based marketplaces can adapt and use in consumer-facing communications regarding new Internal Revenue Service (IRS) information about how consumers can receive relief from repayment of excess advance premium tax credits for 2020 under the American Rescue Plan Act.
This series of policy briefs include evidence-based recommendations to help people through the immediate health and economic crises and longer-term recommendations to ensure a fair and just opportunity for health.
This webinar addresses key provisions of the American Rescue Plan package, the $1.9 trillion budget reconciliation package signed into law by President Biden on March 11.
This report assesses awareness of and experiences with publicly subsidized coverage options among adults who were uninsured in September 2020.
The ten most-visited resources on StateNetwork.org during 2020.
This report describes the methodology of the Health Insurance Policy Simulation model and presents the model’s 2020 current-law baseline, which reflects health care and coverage after 2020 Open Enrollment and before the COVID-19 pandemic.
This commentary explores the high levels of profitability insurers have seen in 2020.
This commentary focuses on several provisions of the proposed 2022 “Notice of Benefit & Payment Parameters" that have implications for state oversight of insurance markets and the state-based marketplaces.
This brief explores the shares of a typical nongroup insurance premium attributable to essential health benefits and estimates the financial implications should they be eliminated from the nongroup insurance benefit package.
This commentary examines state-based health insurance marketplaces' efforts to actively connect consumers to health insurance coverage during the annual open enrollment period that launched Nov. 1.
This brief explores the ways in which public and private health insurance coverage options bolstered by the Affordable Care Act are mitigating the impact of employer-sponsored insurance losses during the COVID-19 pandemic.
This map current state activity related the Affordable Care Act’s Section 1332 waivers.
This commentary considers ways states could potentially redirect insurers’ extra cash to benefit policyholders and the public.
This guide provides answers to frequently asked questions about selecting and using health insurance coverage and applying for financial help for 2021's open enrollment period.
This commentary explores the importance of clearly communicating to consumers what health coverage options are available for the remainder of 2020 and heading into 2021.
This brief reviews the evidence on how the Affordable Care Act has affected individual and family health care coverage, access, affordability, hospital finances and national health expenditures.
This brief considers how a Supreme Court ruling overturning the Affordable Care Act would affect average people and illustrative, hypothetical families in different circumstances.
This commentary highlights several strategies states can pursue to help ensure a successful open enrollment period this year amid the COVID-19 pandemic.
This report examines activity across six states that are exploring social insurance initiatives to help finance long-term services and supports.
This commentary discusses how state Medicaid, children’s health insurance programs, and health insurance marketplaces prepare for an expected increase in demand due to COVID-19, an economic downturn and ensuing budget crises, and unpredictable federal relief efforts.
Two webinars on open enrollment period 2021 explore COVID-19 implications and effective strategies to consider as states design their outreach and education campaigns in a shifting health care environment.
This webinar highlighted how states should adapt their strategies during COVID-19 as they plan their open enrollment outreach and education campaigns, and how to ground these efforts in terms of audience targeting and messaging.
This commentary considers five frequently heard worst-case scenarios related to the Affordable Care Act and provides research evidence that these fears did not come to pass.
This commentary outlines how state legislative sessions took a hit this year from the novel coronavirus pandemic.
This report provides the first nationally representative estimates of changes in coverage during the initial months of the recession induced by the COVID-19 pandemic.
This commentary features insights from state health agencies and health insurance marketplaces that have actively identified opportunities to conduct outreach in communities disproportionately affected by COVID-19.
Stakeholders in six states assess the impact of Medicaid insurers increasing dominance in the ACA marketplaces.
This commentary compiles thoughts from navigators across five states using the federally-facilitated marketplace about how they are faring during the COVID-19 pandemic.
This commentary outlines how continuity between Medicaid and the marketplace is more important than ever.
This commentary gauges the potential effects on coverage and cost if public options become available in the country's health insurance exchanges, based on observations from a RAND COMPARE microsimulation model.
This commentary examines strategies that successfully drove enrollment in state-based marketplaces during the COVID-19 pandemic.
This commentary provides an overview of strategies that states can consider to help address gaps in coverage to ensure as many people as possible get access to comprehensive care as the country continues to respond and recover from the COVID-19 health and economic crisis.
This commentary discusses state employee health plans (SEHPs) and the rapid changes they are making to address the COVID-19 pandemic.
This report estimates the extent to which workers in industries most vulnerable to pandemic-related unemployment and their family members would be eligible for Medicaid, the Children’s Health Insurance Program, or marketplace subsidies if workers lose their jobs.
This commentary discusses the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) and the potential eligibility challenges it creates for both individuals and states.
This report assesses market trends in seven states—Colorado, Georgia, Iowa, Mississippi, New Hampshire, Texas, and Utah—through a review of insurer participation, premiums, and enrollment data and through structured interviews with health insurance brokers.
This commentary discusses new federal and state laws that are making significant steps to eliminate consumer cost-sharing for coronavirus (COVID-19) testing, diagnosis, and prevention.
This commentary includes a list of the unique special enrollment periods (SEPs) available in state-based marketplaces, including life-changing events, unexpected health plan changes, or enrollment in dental coverage.
This commentary features recommended communication strategies and examples for how states can elevate coverage options and help ensure that more residents can access health insurance during these uncertain times.
This brief includes communication examples to help states answer questions on how health insurance covers COVID-related testing and treatment, encourage consumers to enroll in coverage, and engage with providers to keep them informed.
This commentary examines state strategies to promote health insurance enrollment to protect consumers from potentially exorbitant medical bills during the COVID-19 pandemic.
This report assesses the cost of Medicaid relative to private insurance in the health insurance landscape under the Affordable Care Act (ACA).
This brief is a compilation of state marketplace communications examples during the novel coronavirus outbreak.
This brief provides a template for states to inform residents of health insurance options during the COVID-19 pandemic.
In this webinar, experts explore the key health care provisions in the Families First Coronavirus Response Act and the implications for states.
This brief is a compilation of communication examples from state departments and agencies during the COVID-19 pandemic.
This Special Enrollment Period (SEP) Reference Chart is a tool for those who are helping people enroll in health coverage through a special enrollment period.
This brief provides some answers about who is eligible to enroll in coverage as many seek new health coverage, or help paying for coverage, during the novel coronavirus outbreak.
This blog posts pulls together frequently asked questions about the novel coronavirus to help guide Navigators, brokers, assisters, and consumers through this complex and trying time.
This report shows the changes in average lowest silver premiums from 2017 to 2020 by state and in the lowest silver premiums offered by each insurer in selected markets.
This resource identifies areas where states are doing well and areas where they can improve on healthcare affordability.
This report identifies the states and people who would face the largest coverage losses if the Affordable Care Act were repealed, including estimates by city.
These were the ten most-visited resources on StateNetwork.org during 2019
This report examines preferences between a public option for health insurance and Medicare for All among nonelderly adults.
This perspective outlines benefits and risks of health plan standardization, raises critical questions that states will need to consider, and offers a decision roadmap for states implementing a standardized benefit design requirement.
This piece investigates each of the non-ACA-compliant plan types and provides a brief description along with current estimates of enrollment or projected enrollment.
This guide is a practical, hands-on resource to help assisters and consumers navigate this enrollment season.
This report analyzes commercial insurers’ experiences competing in marketplaces with managed care organizations, which only offered coverage within public programs prior to ACA implementation.
This report investigates what is motivating states to transition to full state-based marketplace status, assesses the benefits and risks of such a switch, and identifies considerations for other states considering a similar move.
This brief explores state variation in health insurance coverage changes during implementation of the primary health insurance coverage reforms of the Affordable Care Act (ACA) using data from the 2013 and 2017 American Community Survey.
This brief describes interviews with 10 Medicare Advantage plans, Medicare Advantage experts, and social service providers to discuss new benefits added under the Centers for Medicare & Medicaid Services' increased flexibility in plan year 2019.
This report updates previous analysis of the coverage and health spending implications of Healthy America and analyzes two additional options: one without an individual requirement and one that would lead to universal coverage for all legal residents of the US.
This report assesses public support for Medicare for All proposals, as well as some incremental reforms for expanding health insurance coverage, using data from the March 2019 round of the Health Reform Monitoring Survey.
This analysis examines how people with different characteristics would be affected if the Texas v. United States decision invalidates the Affordable Care Act.
This brief presents an analysis of targeted reforms to the Affordable Care Act.
This report examines ACA marketplace participation by insurers that participated in Medicaid but not in private insurance markets prior to the ACA.
This analysis examines some of the consequences should a case pending before the U.S. Court of Appeals for the Fifth Circuit be decided in favor of the plaintiffs, who argue that the entire Affordable Care Act (ACA) be eliminated.
This brief found that ACA markets have become more competitive between 2018 and 2019, but have not regained the level of competition they had in 2017.
This article estimates the costs of implementing state-based reinsurance programs in four large states whose size provides a useful cost-projection base for other state policymakers considering reinsurance programs.
This analysis examines the use of 1332 State Innovations Waivers to stabilize individual health insurance markets, comparing the use of this strategy in three states; assessing how they navigated the process; identifying lessons learned; and discussing future concerns.
The brief provides a roadmap of policy, program design, and financing considerations for states that are contemplating development of a state-based reinsurance program under 1332 waiver authority.
This webinar walked through key components of the proposed annual Notice of Benefit and Payment Parameters for 2020, and discussed potential state considerations for states.
This study assesses short-term plan insurers’ marketing tactics in the wake of new federal rules and how regulators have prepared for this new market.
The Urban Institute conducted interviews with marketplace administrators and insurers selling marketplace coverage in ten states. They analyze marketplace insurer participation and pricing decisions, as well as several related topics.
This analysis examine four policy scenarios meant to improve the ACA, which, taken together, could reduce the number of uninsured by 12.2 million people and to 7.3 percent uninsured.
These were the five most-visited resources on StateNetwork.org during 2018.
This webinar discusses the implications of the proposed regulations easing the rules governing health reimbursement arrangements (HRA) and other account-based, tax-preferred health care benefits; and possible state responses.
Alaska, Minnesota and Oregon were the first to gain approval and federal funding to implement their own reinsurance programs under a 1332 waiver. This issue brief assesses their progress and lessons learned to date.
This monitoring and tracking project will document changes to the implementation of national health reform to help states, researchers and policymakers learn from the process as it unfolds.
Using data from the American Community Survey and the Current Population Survey, this report assesses whether coverage gains from 2010 to 2016 were associated with changes in labor market outcomes across occupations.
The brief provides a roadmap of policy, program design, and financing considerations for states that are contemplating development of a state-based reinsurance program under 1332 waiver authority.
The Trump administration finalized regulations for short-term limited duration policies in early August 2018, which increase the maximum length of short-term, limited-duration insurance policies to just less than one year. This report provides updated tables taking these state legislative changes into account.
This report examines brokers’ evolving role in the individual market, consumer purchasing decisions, and brokers’ observations about how the market and consumers are responding to recent federal policy adjustments to the ACA.
This report explores options for states as they consider oversight of risk-bearing organizations (RBOs), with a focus on states that have elected to act to protect against provider insolvency. The State Health Policy Highlight reviews specific state considerations when overseeing RBOs; case studies examine approaches in California, Massachusetts, New York and Texas.
To understand the marketplace enrollment gains and losses observed in 2018 relative to 2017, the Urban Institute interviewed key stakeholders in Rhode Island, Washington, and New York, which saw marketplace enrollment increases, and in West Virginia and Louisiana, which saw enrollment drops. This report explains the different features of the five states, presents cross-state findings, and discusses important factors in next year’s open enrollment period.
The Trump Administration is expanding the availability of alternatives to Affordable Care Act-compliant health insurance. Rules to expand association health plans and short-term limited duration health plans are imminent. This webinar explores what options states have to respond to these developments, featuring experts from Georgetown University’s Center for Health Insurance Reform.
This webinar untangles HHS's annual Notice of Benefit and Payment Parameters and its many implications for states. The rule is a collection of policies governing the ACA’s marketplaces, insurance reforms, and premium stabilization programs. Speakers include Sabrina Corlette and Justin Giovannelli from Georgetown’s Center on Health Insurance Reforms, Joel Ario from Manatt Health, and Jason Levitis.
The Affordable Care Act (ACA) made private nongroup health insurance more accessible to nonelderly adults with chronic conditions through the federal and state-based Marketplaces. As repeal of the ACA individual mandate takes effect in 2019, protecting coverage gains while stabilizing nongroup premiums may depend on state-level efforts to spread the risk of enrollees’ health care costs across a balanced insurance pool.
This article analyzes the impact of the Affordable Care Act on health insurance coverage for verterans in states that chose to expand Medicaid and in non-expansion states using data from the 2013 and 2014 American Community Survey. The analysis found a substantial 24 percent relative decline in the rate of uninsurance for U.S. veterans between 2013 and 2014. Coverage gains in rural areas were due to gains in Medicaid and individual market coverage. The increase in the insured rate was three times larger in Medicaid expansion states versus non-expansion states.
Although congressional efforts to repeal and replace the Affordable Care Act (ACA) did not succeed in 2017, the law continues to face an uncertain future. This brief examines insurers’ participation and pricing decisions for the 2018 and 2019 plan years through structured interviews with 10 insurance companies participating in the individual market in 28 states and the District of Columbia.
Many states continue to encounter challenges in stabilizing their individual health insurance markets, including large premium increases and declining insurer participation. One solution is a state-based reinsurance program similar to the federal program that reduced premiums by more than 10 percent per year from 2014 to 2016. The brief provides a roadmap of policy, program design, and financing considerations for states that are contemplating development of a state-based reinsurance program under 1332 waiver authority.
With effective repeal of the federal individual insurance mandate scheduled for 2019, many state policymakers are exploring ways to stabilize their insurance markets, including creating a state-based mandate similar to one in Massachusetts. This webinar includes a deep dive into Massachusetts’ mandate, and features a Maryland proposal to create an auto-enrollment process for individuals through its marketplace.
In response to President Trump’s October 12 executive order, the U.S. Departments of Health and Human Services, Labor and Treasury have published proposed rules to expand the availability of health coverage sold through short-term, limited duration insurance (STLDI).
This report summarizes findings from the 2017 Minnesota Health Access Survey, focusing on trends in how Minnesotans obtained health insurance coverage, and provides an understanding of how the 2017 climate may have contributed to a contraction of coverage.
This brief provides an analysis of legislation recently introduced in the U.S. Senate that would create a mechanism for states to offer their residents the opportunity to buy a Medicaid-based public insurance option.
This report examines the issue that with no individual mandate and expanded non-comprehensive coverage, the divisions between states will deepen, and market conditions will deteriorate for unsubsidized farmers and others seeking coverage in states that don’t protect their risk pool.
Prior to the passage of the Affordable Care Act in 2010, Minnesota's health insurance market was relatively high-functioning across indicators of health insurance access and quality of care, although the state faced common challenges in the area of health care costs. This report considers Minnesota's health insurance market before and after the passage of the ACA and the outlook for the state's market given the current policy environment.
RWJF’s SHVS together with experts from Manatt Health, host this webinar that highlights and defines potential policy options, including the “Medicaid Buy-in,” that states may consider to leverage Medicaid to achieve their goals with respect to coverage availability and affordability. Conditions that make each option more or less favorable for a state, and implementation issues or other considerations in play for states are discussed.
Uncertainty about the future of health insurance options and concern about the ability of Affordable Care Act (ACA) marketplaces to offer adequate competition and choice have spurred states to look for new coverage approaches. Innovative strategies states are proposing include allowing consumers to buy into state Medicaid programs and developing state-specific coverage options within the ACA’s framework.
As Congress barrels toward the end of the year, several bills are in play that will have major and almost immediate ramifications for health insurance markets. They include: Tax Cuts and Jobs Act (H.R. 1); The Alexander-Murray insurance market stabilization bill; The Nelson-Collins reinsurance program bill; and the temporary elimination of the health insurance tax (H.R. 4620).
CMS released two informational bulletins detailing a new, streamlined approach for the review and management of Section 1115 demonstrations and state plan amendments and 1915 waivers. The streamlined approach may enhance states' ability to design innovative health care delivery initiatives in their Medicaid programs. These changes come at a critical time as states develop new approaches to reduce health care costs and stem the opioid epidemic.
HHS released proposed changes in its annual notice that governs standards for issuers and the health insurance marketplaces. The annual notice is one of the most significant tools the Administration wields in shaping the health insurance markets and this proposed notice carries significant implications for markets and states.
Understanding premium increases for individual market plans is more complicated this year. In many states, carriers attempted to recapture that lost revenue by increasing the premium of the silver plan relative to other metals. ‘Silver-loading’ gives subsidized non-cost-sharing reduction (CSR) consumers the opportunity to purchase a relatively more affordable bronze or gold plan.
With three states using Section 1332 waivers to help fund reinsurance programs for the 2018 plan year, many more state officials are considering the model for their state in future years. Having worked directly with the 2018 reinsurance states, State Health and Value Strategies presents a to-do list for states as they consider reinsurance for 2019.
This report examines six states that faced the prospect of bare counties for 2018: Iowa, Nevada, Ohio, Oklahoma, Tennessee, and Washington.
The research included in this panel illustrates both the intended and unintended consequences of state policy decisions on a range of health systems outcomes and highlights the necessity of access to different types of federal surveys for the purposes of health policy evaluation. Federal survey data is especially critical when analyzing variation between states, as when comparing outcomes by Medicaid expansion status. As policy flexibility for states continues to grow, this ability to compare states to one another will continue to be essential.
This brief puts a state lens on emerging proposals in the ACA repeal and replace debate. Over the last decade, 21 states introduced legislation to sell across state lines, only five states enacted such laws, but no insurer has yet to offer.
Sens. Lamar Alexander (TN) and Patty Murray (WA) released a bipartisan bill designed to bring short-term stability to the health insurance market. While there are indications that Alexander and Murray secured the 60 votes needed for passage in the Senate, it faces an uncertain fate in the House and with the President.
The prospects for these new players reflect tensions for the market as a whole. Clearly the massive number of net exits signals a retrenchment by many market participants in 2018, resulting in shrinking of territorial footprints and outright withdrawal by large parts of the industry. For a variety of reasons, including attempts to repeal the ACA, the potential of the individual market has not yet been fully realized. Yet, it still remains the source of coverage for millions of people.
While there are risks to the stability of their markets that states cannot well control, one important route to adverse market outcomes may be state policy decisions. There are frequent calls for more state flexibility, but these data suggest that the exercise of existing state flexibility is one way that states have visited a considerable amount of trouble upon their markets. Yet there is a hopeful note here as well, since this suggests that there are steps that states can take to improve their situation.
This report discusses the scope of state authority and tools available to ensure that consumers living within their borders benefit from the insurance protections promised under federal law. It also discusses specific statutory and administrative options for states in the event of selected possible federal administrative actions, including a: Rollback of the essential health benefits; relaxation of marketplace health plan oversight; re-definition of what constitutes minimum essential coverage; loosening of medical loss ratio standards; and an expansion of off-marketplace enrollment opportunities.
This blog reviews cost-sharing reduction (CSR) programs designed to reduce the cost of insurance for consumers purchasing policies on individual markets.
This chart summarizes major provisions included in the 2010 Affordable Care Act, provisions included in the American Health Care Act passed by the House on May 4, 2017, as well as preliminary analysis of the Senate Better Care Reconciliation Act (BCRA) discussion draft as amended on June 26, 2017, and then revised on July 13, 2017 and July 20, 2017.
The Senate released two bills as part of its efforts to repeal the Affordable Care Act (ACA): A revision to the Better Care Reconciliation Act (BCRA) eliminating the “Ted Cruz Amendment,” which provided funding to create coverage alternatives for high-risk individuals, and the Obamacare Repeal Reconciliation Act (ORRA), which would repeal many of the major provisions of the ACA within a two-year period, but does not offer plans to replace those provisions.
The data thus far suggest that most counties will have at least two insurers offering plans on the exchange, and most people will be able to choose from at least three.
Mental health and substance use coverage could roll back to pre-Affordable Care Act (ACA) levels if the American Health Care Act (AHCA) becomes law. Analysis finds the AHCA could limit access to mental health treatment.
Watch: Webinar discussing the impact of ACA implementation in Kentucky.
The AHCA, which proposes to repeal and replace the ACA, would dismantle the Prevention and Public Health Fund (PPHF). States received over $625 million from the PPHF in fiscal year 2016, and stand to lose more than $3 billion over five years if it is repealed. The bill would repeal all new appropriations for the PPHF starting in fiscal year 2019, and rescind any funds left over at the end of 2018.
HHS Secretary Tom Price issued a letter to governors encouraging them to take advantage of Sec. 1332 State Innovation Waivers under the Affordable Care Act and cited Alaska‘s request as an example. Alaska’s waiver seeks federal funds to support a reinsurance plan to stabilize its individual insurance market.
This chart summarizes how the American Health Care Act, passed out of House committees the day before, differed from the Affordable Care Act. State leaders, representing the diversity of states and breadth of state health policy agencies and officials, met at a summit to discuss those changes and how they might affect states.
Congressional action to repeal and replace the ACA is on the fast track. The administration and GOP leaders have outlined a three-pronged effort to reform healthcare beginning with passage of the American Health Care Act (AHCA). Congress released Manager’s Amendments to the AHCA, inclusive of a series of policy and technical changes to the bill. Here is a full statutory text of policy and technical amendments.
While the focus of debate regarding repeal of the Affordable Care Act (ACA) has been on Marketplaces and the Medicaid expansion, myriad other provisions of the ACA are at risk of repeal—including those that streamline Medicaid eligibility and enrollment systems and implement a national, simplified standard for income eligibility. As of January 2016, 37 states are able to complete an eligibility determination in real time, defined as less than 24 hours, and among these, 11 states report that at least half of their applicants receive an eligibility determination in real time. The future of the ACA’s streamlined eligibility and enrollment-related provisions and the system improvements states have invested in to implement them are the subject of this issue brief.
Recent state waivers can inform the question of whether and how low-income individuals could benefit from health savings accounts (HSAs) with high-deductible health plans. State experiences incorporating health savings accounts into Medicaid can be instructive, as policymakers consider the role of HSAs in proposed health care reforms. This brief looks at health savings and similar accounts in Michigan and Indiana.
Congress began its ACA repeal effort and evolving replacement options are receiving considerable attention. NASHP is tracking issues that appear in multiple proposals and will provide state perspectives, including: How might they impact states? What might they cost? Have they been tried before in states and what did we learn from past initiatives?
This chart provides an overview of ACA provisions and snapshot of the implications for states if the ACA is repealed. States are the primary regulator of insurance and as such had laws in place prior to the enactment of ACA. Some states repealed those laws and replaced them with ACA provisions, while other states revised their laws but left other old, preempted laws on the books.
Health coverage transitions—sometimes referred to as churn—have always existed to some degree, but with the Affordable Care Act there are additional possibilities for churning to occur across multiple coverage sources. This report examines current efforts in some states to measure these coverage transitions and provides broader context on the issue of churn.