The Affordable Care Act (ACA) will expand access to health insurance for nearly all Americans. It also supports longer-term goals of health system transformation, aimed at providing efficient, high-quality health care. That transformation is possible only when people have stable health care coverage; yet for low-income populations, changes in income will result in eligibility churning between Medicaid and coverage options offered by insurance exchanges.

The ACA offers numerous opportunities to stabilize coverage and care for beneficiaries as their incomes fluctuate, and states can reduce the impact of churn with design and purchasing strategies that promote seamlessness. This brief explores the challenges for states in creating seamless health coverage for low-income populations. The brief provides a roadmap for states as they consider options for building seamless health systems. Key issues for states to consider include managing subsidy fluctuations through carefully designed eligibility and enrollment strategies and ensuring stable coverage and care by creating seamlessness across benefits, providers, and health plans.