It has happened every fall, for five years in a row. After spending months figuring out her insurance deductibles, doctor networks, drug lists and other fine print, Cyndee Weston has received notice that her policy will be canceled as of Dec. 31 — and she must start over.
“It’s agonizing going through all the plans and trying to compare,” said Ms. Weston, 55, whose job doesn’t come with insurance and who has diabetes and a history of melanoma. “Every year it’s the same scenario: ‘We’re not going to renew your policy.’”
Under the market-based system set up by the Affordable Care Act, individuals are encouraged to shop around each year to find the insurance that best suits their medical needs and income. But the reality is that many people — among them Ms. Watson, a trade-association executive in Sulphur, Okla. — end up being forced to shop around, again and again, when insurance plans drop out of the local market or eliminate preferred hospitals and doctors from the network.
The Affordable Care Act has increased the number of Americans with health insurance by 20 million, and cut the uninsured rate to 9 percent. But the task of finding new insurance annually can complicate care for some people, particularly those with continuing medical needs or chronic conditions. This issue became complex in new ways this year given the uncertainty introduced by the administration of President Donald Trump, whose threats to repeal or rein in the law have spurred turmoil in many state and local insurance markets.
“There’s quite a number of people who are either temporarily uninsured or they move into different plans” each year, said Marianne Udow-Phillips, head of the Center for Healthcare Research and Transformation at the University of Michigan. “And I’m guessing this year that will be much greater, given all the changes that are happening in the marketplace plans.”
Fewer than half the people with marketplace insurance in 2014 stayed in the same plan the next year, according to a Michigan survey done by Ms. Udow-Phillips and colleagues. Nearly a third of marketplace enrollees for 2017 were new customers, meaning they had other kinds of coverage previously or were uninsured. For the 2018 enrollment season, which began on Nov. 1 and ends Dec. 15 in most states, millions of people will switch coverage.
The imperative to shop for insurance affects mostly those who buy it for themselves, for instance small-business owners and people who are self-employed. Enrollment for 2018 through online marketplaces has been particularly complicated because of premium increases for some plans, the mistaken belief that the health law was fully or partly repealed, and the administration’s decision to terminate $7 billion in subsidies.
There were no projections for this kind of turnover when the law was designed. And because people often buy individual plans to fill gaps in job-based insurance or other coverage, that market had high turnover even before the law took effect. But recent turmoil has made steering through the system particularly challenging, even as coverage rates have gone up, analysts said.
Many of the plans that people relied on for 2017 are being canceled because insurers are exiting the marketplaces or redesigning coverage to try to keep premiums down. Aetna and Humana stopped selling individual marketplace plans for 2018 after losing money on the products. UnitedHealthcare has sharply pulled back.
Hundreds of counties have only one marketplace insurer next year, although competition is higher in metropolitan areas. The average number of carriers selling individual marketplace plans has fallen to 3.6 per state next year from 5.0 in 2014.
“I wouldn’t call it ideal. It’s what we have,” said Sabrina Corlette, who studies insurance for Georgetown University’s Health Policy Institute. “Ultimately the consumers have to read the fine print and probably expect that things are going to change from year to year.”
Such instability impedes what was supposed to be the Affordable Care Act’s other big goal beside coverage expansion. Former President Barack Obama talked of fixing a “broken system” that neglected preventive care; could result in costly, unneeded medical procedures; and sometimes shuffled patients among doctors who didn’t communicate efficiently with one another.
The idea, in other words, was to push insurers to help diabetics improve their diets, keep patients on their blood-pressure medications, prevent asthma flare-ups and otherwise improve care, while also controlling costs. Investing in prevention up front, the thinking went, would pay off for insurance companies over time as people needed fewer costly emergency-room visits or hospital stays.
That equation fails, though, when people have a new policy or a new insurance company each year.
Insurance churn “is a longstanding problem in the U.S. health care system,” said Benjamin Sommers, a physician and health economist at Harvard’s Chan School of Public Health. “But there’s a concern that with the A.C.A. you’ve added a whole new layer.” Insurance turnover is especially frequent among lower-income families and those with irregular work.
For example, unemployed people might be eligible for a plan under Medicaid, which the health law expanded to most low-income adults in most states. But getting a job, and a salary, might make them ineligible for Medicaid, bumping them up to a subsidized marketplace plan — and a coverage change.
Medicaid, which often comes with its own confusing menu of managed-care plans, generally covers people with the lowest incomes. Subsidized marketplace plans are for medium-income households.
In a 2015 survey by Dr. Sommers and colleagues, about a fourth of low-income adults reported that they had changed coverage during the previous 12 months. That was lower than expected, but still problematic, Dr. Sommers said.
That’s partly because more than half the switchers had coverage gaps between policies, causing many to report skipped medications and poorer health. Even people who didn’t have a coverage gap were more likely to swap doctors, have trouble booking appointments and seek treatment in the emergency room.
Even with laws in some states allowing patients in active treatment to keep doctors from one plan to the next, that’s not a recipe for stable medical relationships or long-term treatment strategies.
“Coming up with the right balance and right approach to a patient’s condition takes time,” Dr. Sommers said. “If you wind up with a new set of doctors and new coverage every year, it’s going to make that much harder.”
Ms. Weston has navigated the shifting ground. For years, she has had the same insurer, Blue Cross Blue Shield of Oklahoma, which has dominated that state’s market for individual plans and is the only marketplace player for 2018.
But even though the carrier is the same and the health law requires insurers to take all comers, canceled plans each year force her to learn a new coverage design, file new paperwork with doctors and worry that her primary physician will be dropped from the network.
One year, Blue Cross “automatically enrolled us into a bronze plan, which we didn’t want, so we chose another gold plan,” Ms. Weston said.
Even when insurers stay in a market, they often redesign plans from year to year, changing drug coverage or raising out-of-pocket costs, Ms. Corlette said. As in Ms. Weston’s case, that often requires canceling the old plan and having subscribers switch.
“Each year, we assess our plan offerings and make any necessary adjustments to best meet our members’ anticipated health care needs,” a Blue Cross Oklahoma spokeswoman, Melissa Clark, said in an email.
After Ms. Weston’s primary physician left the plan’s network this year, she has had trouble finding a new one, although the insurer said its physician list had not changed significantly.
“I take some medications, and I worry that if I go to a new doctor they’ll change my medication or it won’t be covered,” she said.
A few weeks ago, Blue Cross notified her that it will cancel her current plan Dec. 31. So Ms. Weston is shopping again.