With states under acute fiscal pressure because of falling revenues, policy efforts have also focused on finding ways to maintain Medicaid coverage and prior public program expansions. Medicare's failure, until recently, to include coverage of prescription drugs, as well as its imposition of a long waiting period before disabled adults can gain coverage, has contributed to fiscal pressures on states. Two reports^(17) (18) on the interaction between Medicare and Medicaid by Stacy Berg Dale and James M. Verdier estimate that expanding Medicare to include drugs and eliminating the two-year waiting period would reduce state Medicaid costs by $6.8 billion and $1.8 billion, respectively. Applied to the Medicaid program, the savings could help maintain coverage for millions of low-income adults and families. Elimination of the waiting period would also expand coverage to an estimated 400,000 disabled people who are currently uninsured and provide new insurance security for all 1.2 million now in the waiting period.

Task Force-sponsored work also documented the potential of helping people remain enrolled in their existing coverage. In a recent Fund report,⁽¹⁹⁾ Leighton Ku and Donna Cohen Ross of the Center on Budget and Policy Priorities calculated that the numbers of low-income children and adults without health insurance would decline significantly — by roughly 40 percent for children and 25 percent for adults — if everyone with insurance coverage at the beginning of a year could retain it over the next 12 months. The authors argue that improving insurance retention is cost-effective and could be accomplished through rule changes in Medicaid and CHIP.

National surveys that track insurance over time reveal that one of four Americans under age 65 — more than 60 million people — have been uninsured during all or part of the previous year. To draw attention to the problem of insurance instability, the Task Force sponsored a panel of grantees to present recent work at the annual meeting of AcademyHealth. In addition to the previously mentioned findings, the panel featured a case study⁽²⁰⁾ by Deborah Bachrach on the negative effects of insurance instability, or "churning," for low-income beneficiaries in New York and new analysis⁽²¹⁾ by Pamela Farley Short on the dynamics of insurance over a four-year period.

Insurance instability and churning impose high costs on the nation's health care system and the people it serves. In invited testimony⁽²²⁾ before the Senate Special Committee on Aging, Fund president Karen Davis highlighted problems associated with complexity, gaps in coverage, and churning — including barriers to participation in public insurance programs — and outlined the potential benefits of simplification and insurance expansions. Underscoring the need for simplification and more automatic enrollment, an article⁽²³⁾ by Dahlia Remler and Sherry Glied, both at the Mailman School of Public Health at Columbia University, pointed out that participation is much greater — sometimes twice as high — in programs using automatic enrollment mechanisms than in programs requiring several steps, including documentation, to enroll.