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The Effects of Premiums and Cost Sharing on Low-Income Populations: Updated Review of Research Findings

Table 1: Effects of Premiums

National Studies
State Studies

Table 1: Effects of Premiums
Citation Data Study Population(s) Study Focus and Major Findings
National Studies
Gery P Guy, et. al., “The Role of Public and Private Insurance Expansions and Premiums for Low-Income Parents: Lessons from State Experiences,” Medical Care 55, 3 (March 2017):236-243. 2000-2013 Current Population Survey (CPS) and Medical Expenditure Panel Survey (MEPS) data Nonelderly parents with incomes at or below 300% FPL
  • Estimates effects of different types of coverage expansions and premiums on parent coverage.
  • Higher public premiums were associated with a reduction in public insurance, and increased the likelihood of private insurance or being uninsured. A $500 increase in annual public premiums decreased the probability of public insurance by 1.9 percentage points, increased the probability of private insurance by 1.2 percentage points, and increased the probability of being uninsured by 0.6 percentage points.
  • Public premiums were a significant deterrent to coverage for parents in non-worker households and had effects on public coverage that were over 10 times as large as the effects among families with a worker. Among parents without a worker in the household, a $500 increase in annual public premiums decreased the probability of public insurance by 9.8 percentage points, increased the probability of private insurance by 2.9 percentage points, and increased the probability of being uninsured by 6.9 percentage points. Among parents with a worker in the household, both public and private premiums had a significant impact on insurance status.
Salam Abdus, et. al., “Children’s Health Insurance Program Premiums Adversely Affect Enrollment, Especially Among Lower-Income Children,” Health Affairs 33, 8 (August 2014): 1353-1360. 1999-2010 Medical Expenditure Panel Surveys (MEPS) data Children eligible for Medicaid or CHIP with incomes above 100% FPL
  • Simulates the relationship between premiums and coverage by income level and by parental access to employer coverage.
  • Among eligible children in families with incomes between 101-150% of poverty, a $10 increase in monthly premiums is associated with a 6.7 percentage point reduction in having Medicaid or CHIP coverage and a 3.3 percentage point increase in being uninsured. The increase in likelihood of being uninsured is larger among children whose parents lack offers of employer coverage.
  •  Among eligible children in families with incomes above 150% of poverty, a $10 increase in monthly premiums is associated with a 1.6 percentage point reduction in Medicaid or CHIP coverage. In this income range, the increase in being uninsured may be higher among children whose parents lack an offer of employer sponsored coverage than among those whose parents have an offer.
Silviya Nikolova and Sally Stearns, “The Impact of CHIP Premium Increases on Insurance Outcomes among CHIP Eligible Children,” BMC Health Services Research 14 (March 2014):101-107. 2003 Medical Expenditure Panel Surveys (MEPS) data in 19 states Children assumed eligible for CHIP in the income range subject to premiums
  • Simulates the effect of premium differences for children in states that have a tiered premium structure for CHIP, in which families at higher incomes pay higher premiums than families in a lower income group.
  • A $1 increase in premium for those in the higher income group was associated with a 1.7 to 2.2 percentage point increase in the likelihood of being privately insured.
  • Premium increases were not associated with uninsurance rates.
Carole R Gresenz, Sarah E Edgington, Miriam J Laugesen and Jose J Escarce, “Income Eligibility Thresholds, Premium Contributions, and Children’s Coverage Outcomes: A Study of CHIP Expansions,” Health Services Research 48:2, Part II (April 2013):884-902. 2002-2009 Current Population Survey data Children with family incomes 200%- 400% FPL
  • Simulates effects of varying premium schedules (no, low, medium, and high premiums) for individuals with incomes between 200-400% FPL.
  • Across the examined income levels, premiums decrease enrollment in public coverage and increase enrollment in private coverage, with greater effects as premium contributions increase. Changes in uninsured rates are less sensitive to premiums at these income levels, particularly among those with incomes at 300% and 400% FPL, likely reflecting the greater availability of employer coverage at these income levels.
Gery P Guy, Jr., E. Kathleen Adams, and Adam Atherly, “Public and Private Health Insurance Premiums: How do they Affect Health Insurance Status of Low-Income Childless Adults?,” Inquiry 49 (Spring 2012):52-64. 2000-2008 Current Population Survey data Low-income childless adults (age 19-64) eligible for public coverage expansions or premium assistance programs in 16 states and DC
  • Estimates effects of public and private health insurance premiums on insurance status of low-income childless adults eligible for public coverage or premium assistance programs.
  • Higher public premiums are associated with a decrease in the probability of having public insurance and an increase in the probability of being uninsured. A $1,000 increase in annual public premiums was associated with a 14.2 percentage-point reduction in the probability of public insurance and an 8.2 percentage point increase in the probability of being uninsured.
  • Increased private premiums decrease the probability of having private insurance. A $1,000 increase in annual private premiums was associated with a 3.3 percentage point reduction in the probability of private insurance.
  • Eligibility for premium assistance programs and increased subsidy levels are associated with lower uninsured rates. A $1,000 increase in the annual subsidy level for premium assistance was associated with a 3.4 percentage point reduction in the likelihood of being uninsured.
Jack Hadley, et. al., “Insurance Premiums and Insurance Coverage of Near-Poor Children,” Inquiry 43, 4 (Winter 2006/2007). 1996-2003 Community Tracking Study Household Survey data Children in families with incomes between 100%-300% FPL
  • Estimates the effects of premiums on children’s coverage.
  • Higher public premiums are significantly associated with a lower probability of public coverage and higher probabilities of private coverage and being uninsured. An increase in the public premium that leads to a 1% decrease in public coverage increases the probability of private coverage by .62%, while the probability of being uninsured increases by .38%.
  • Higher private premiums are significantly related to a lower probability of private coverage and higher probabilities of public coverage and being uninsured. If the probability of private coverage decreases by 1%, the probability of public coverage will increase by .55% and the probability of being uninsured will increase by .45%.
Genevieve Kenney, Jack Hadley, and Fredric Blavin, “Effects of Public Premiums on Children’s Health Insurance Coverage: Evidence from 1999 to 2003,” Inquiry 43 (Winter 2006/ 2007):345-361. 2000-2004 Current Population Survey data Children with family incomes between 100% to 300% FPL and who meet the eligibility requirements for either Medicaid or CHIP coverage
  • Simulates the effects of premiums on children’s coverage.
  • Raising public premiums reduces enrollment in public programs, and increases the odds of having private coverage or being uninsured relative to having Medicaid or CHIP coverage. Public premiums have larger effects on lower income families.
  • For children with family incomes between 100%-300% FPL, increasing per-child public premiums by an average of $120 annually reduces public coverage by 1.4 percentage points, increases private coverage by 1.1 percentage points, and increases uninsured rates by .3 percentage points.
  • Larger reductions in public coverage were found among lower income eligible children whose family incomes are between 100%-200% FPL. For these children, a $120 annual increase in public premiums would result in a 4.2 percentage point reduction in public coverage, a 3.2 percentage point increase in private coverage, and a 1.0 percentage point increase in the share uninsured.
  • Data also suggest that increases in public premiums may have more pronounced effects on uninsured rates when applied to Black or Hispanic children, whose families have lower levels of educational attainment.
  • A 10% increase in private coverage costs would lower private coverage by 1.4 percentage points, raise public coverage by .6 percentage points, and increase the share uninsured by .8 percentage points.
State Studies   Back to top
The Lewin Group, Healthy Indiana Plan 2.0: POWER Account Contribution Assessment, Prepared for Indiana Family and Social Services Administration (FSSA), (Washington, DC: Lewin Group, March 2017). December 2016-January 2017 Surveys of enrolled, disenrolled, and not enrolled individuals, February 2015-December 2016 Indiana Family and Social Services Administration (FSSA) enrollment data and administrative data, and January-September 2016 data from 3 managed care entities (MCE) Indiana: Medicaid expansion enrollees with incomes between 0-138% FPL
  • Assesses the affordability of the Healthy Indiana Plan (HIP) 2.0’s POWER Account Contribution (PAC) policy, which contains contributions that range from $1-$100 per month, depending on income.
  • Between February 1, 2015 and November 30, 2016, 55% of the 590,315 individuals eligible to pay PAC either never made a first payment or missed a payment during their enrollment. Individuals with incomes at or below poverty were more likely to not make a payment that those with incomes above poverty.
  • 15% of survey respondents reported that they are always or usually worried about having enough money to pay their PAC.
  • 44% of those who missed a payment cited not being able to afford to pay the contribution as the main reason for nonpayment and 17% indicated confusion regarding the payment process. Among those who never made a payment, 22% cited not being able to afford the contribution and 22% cited being confused about the payment process.
  • Individuals who disenrolled due to nonpayment or those who never enrolled because they did not make their first payment were less likely than those enrolled in HIP to report making appointments for both routine and specialty care. They were also less likely to report filling a prescription in the past six months or since leaving HIP.
  • 47% of those who disenrolled due to nonpayment and 41% of those who never enrollment because they did not make their first payment reported that they had insurance coverage, which was most commonly employer sponsored coverage.
MaryBeth Musumeci, et. al., An Early Look at Medicaid Expansion Waiver Implementation in Michigan and Indiana, (Washington, DC: Kaiser Family Foundation, January 2017), http://kff.org/report-section/an-early-look-at-medicaid-expansion-waiver-implementation-in-michigan-and-indiana-key-findings/. State administrative data Michigan and Indiana: Adults enrolled in the Medicaid expansion waiver programs
  • Examines early implementation experiences of Michigan and Indiana Section 1115 Medicaid expansion waivers to low-income adults.
  • State data show that premium costs may deter eligible adults from enrolling in coverage. Particularly for very low-income adults, even very low premiums may be unaffordable.
  • In Michigan, from October 2014-July 2016, about 38% of beneficiaries who owed premiums had paid them. As of July 2016, over 112,000 Michigan beneficiaries owed past due premiums or copayments; about 44,200 (less than 40%) of these were in “consistent failure to pay” status, subjecting them to garnishment of their state income tax refunds.
  • 37% of Healthy Indiana Plan (HIP) 2.0 enrollees with incomes below poverty were not paying monthly premiums and, therefore, were enrolled in HIP Basic, the more limited benefit package with point-of-service copayments, as of October 2016. To date, a limited number of Indiana beneficiaries with incomes above poverty have been locked out of coverage for failure to pay monthly premiums. Between August and October 2016, 4,621 HIP 2.0 beneficiaries were disenrolled and locked out of coverage for 6 months for failing to pay premiums.
James Marton et. al., “Estimating Premium Sensitivity for Children’s Public Health Insurance Coverage: Selection but No Death Spiral,” Health Services Research 50, 2 (April 2015): 579-598. State administrative data, 2003-2006 Georgia: Children enrolled in PeachCare, Georgia’s CHIP program
  • Estimates the effects of premium increases on the probability that near-poor and moderate income children disenroll from public coverage.
  • A $1 increase in per child premium is associated with a 7.7-7.83% increase in the probability of a child disenrolling from CHIP.
  • The data suggest that families with children in poor health do not respond much differently than families with children in medium or good health to premium increases, despite having a lower baseline probability of disenrolling from coverage.
Laura Dague, “The Effect of Medicaid Premiums on Enrollment: A Regression Discontinuity Approach,” Journal of Health Economics 37 (May 2014): 1-12. State administrative data, 2008-2010 Wisconsin: Children and parents enrolled in BadgerPlus, Wisconsin’s Medicaid and CHIP program
  • Estimates the effects that premiums in Medicaid have on the length of enrollment.
  • A monthly premium increase from $0 to $10 results in 1.4 fewer months of continuous enrollment for both adults and children and increases the probability of disenrollment by 12-15 percentage points.
  • No or relatively small effects are found for other large discrete changes in premiums, suggesting that the premium requirement itself, more than the specific dollar amount, discourages enrollment.
Michael Hendryx, et al., “Effects of a Cost-Sharing Policy on Disenrollment from a State Health Insurance Program,” Social Work in Public Health 27, 7 (2012):671-686. Survey of adults who stayed enrolled and disenrolled following premium changes. Washington State: Low-income adults in Washington’s Basic Health Plan
  • Examines the effects of increased premiums and cost sharing in Washington’s state-funded coverage program for adults on enrollment and possible health care consequences of disenrollment. Effective January 2004, Washington made policy changes that increased average monthly premiums for adults from $27 to $35 and average monthly out-of-pocket costs from $29 to $52.
  • About 5% of enrollees disenrolled after the policy changes. Disenrollees were more likely to be younger adults, male, and have fewer children. Among all disenrollees, 39% indicated that they left because they obtained other coverage, 35% reported that they were no longer eligible, while 21% indicated that they left the program because they could not afford it. Middle-income enrollees were the most likely to have left because they had trouble paying for coverage.
  • 63% of disenrollees were aware of the changes in premiums and cost sharing. Among all disenrollees who were aware of the changes, 26% cited the changes as a reason for disenrolling. Among disenrollees who were aware of the changes and left voluntarily, 34% cited the changes as a reason for disenrolling. Among those citing the changes as a disenrollment reason, the increase in the monthly premium was the most important change that affected their decision.
  • Overall, 37% of disenrollees had no health insurance when surveyed. Disenrollees reported less access to care, greater subsequent out-of-pocket costs, and more difficulty providing coverage for children than people who stayed enrolled.
Michael M Morrisey, et.al., “The Effects of Premium Changes on ALL Kids, Alabama’s CHIP Program,” Medicare & Medicaid Research Review 2,3 (2012):E1-E17. State administrative data, 1999 and 2009 Alabama: Children enrolled in ALL Kids, Alabama’s CHIP program
  • Examines the effects of an annual premium increase as well as increases in copayments on enrollment and renewal in Alabama’s CHIP program, ALL Kids. In October 2003, premiums for individual coverage increased by $50 per year and copays by $1-$3 per visit.
  • The increases in premiums and copays are estimated to have reduced renewals that are completed within 12 months by 6.1% annually. This reduction is over one-third larger—up to 8.3%—if only immediate renewals are considered.
  • Families with a child who has a chronic condition were more likely to renew coverage overall. However, those with chronic conditions, African Americans, and those with lower family incomes were more sensitive to the premium increase.
Bill J Wright, et. al., “Raising Premiums and Other Costs for Oregon Health Plan Enrollees Drove Many to Drop Out,” Health Affairs 29, 12 (December 2010):2311-2316. State administrative data and a mail survey, November 2003, 2004, and 2005 Oregon: Adults enrolled in Medicaid with income below 100% FPL
  • Examines effects of premium and cost sharing increases for poor adults enrolled in Oregon’s Medicaid program. In 2003, Oregon made a range of policy changes to its Medicaid program, the Oregon Health Plan (OHP), which included benefit reductions, increased premiums and cost sharing and stricter premium payment policies for adults enrolled in its OHP Standard program. Enrollees in OHP Plus continued to receive benefits similar to the original OHP.
  • During the study period between 2003 and2005, only 33% of OHP Standard plan enrollees remained continuously enrolled following the policy changes, compared to 69% of OHP Plus enrollees. Most disenrollment occurred in the first six months following the changes, when 44% of OHP Standard enrollees left the program.
  • Premium increases and rigid premium payment deadlines were a major reason why members reported disenrolled from the OHP Standard plan, accounting for nearly half of the disenrollment over the first six months.
  • At the end of the study, 32% of those who had left OHP Standard had become uninsured compared to 8% of those who had left OHP Plus.
Michael R Cousineau, Kai-Ya Tsai, and Howard A Kahn, “Two Responses to a Premium Hike in a Program for Uninsured Kids: 4 in 5 Families Stay In as Enrollment Shrinks by a Fifth,” Health Affairs 31, 2 (February 2012):360-366. L.A. Care Health Plan enrollment data, 2009-2011 California: Children enrolled a health insurance program for low-income immigrant children in Los Angeles County and those whose income exceeded 250% FPL
  • Examines the effects of premium increases on disenrollment from a health insurance program for low-income immigrant children in Los Angeles County. In July 2010, L.A. Care Health Plan increased premiums for older children (age 6-18) to $15 per month for each child, with a maximum of $45 per family. Premium increases did not apply to younger children (ages 0-5).
  • After premiums increased, the retention rate among older children dropped by nearly five percentage points from an average of 98.1% to 93.8%. Much of the decline occurred in the first two months after the premium increase. As a result, monthly enrollment among older children declined by 39% after the premium increase. In contrast, the average retention rate for younger children did not change over the period.
  • At the end of the study period, 59% of the older children subject to the premiums were still enrolled. Without the premium increase, it was expected that 80% of the children in this group would still be enrolled. As such, it is estimated that the increase resulted in an enrollment decline of 20%.
James Marton, Patricia G Ketsche, and Mei Zhou, “SCHIP Premiums, Enrollment, and Expenditures: A Two State, Competing Risk Analysis,” Health Economics 19 (2010):772-791. State administrative data for Kentucky, 2001-2004 and Georgia, 2003-2005

 

Kentucky and Georgia: Children enrolled in Medicaid and CHIP in Kentucky and Georgia
  • Compares the effects of introducing new premiums and increasing premiums for children enrolled in CHIP in two states on enrollment in public coverage through CHIP or Medicaid. Kentucky introduced a $20 monthly premium for children in CHIP for the first time in 2003. In mid-2004, Georgia increased existing premiums in its CHIP program from $10 per family to sliding scale premiums ranging from $20-$40 for one child and $35-$70 for two or more children.
  • In both states, premium increases lead to increases in children leaving CHIP and having no public health insurance in the two months immediately following the premium changes. In both states, data also show increases in the probability of children moving to lower income eligibility categories of CHIP that have lower premiums following the premium increase. In Kentucky, there also was an increase in the likelihood of children moving to Medicaid in the two months following the increase; however, this was not observed in Georgia.
  • Not all changes persisted over the longer term. However, in Kentucky, children continued to be more likely to exit to no public health insurance in the remaining seven months of the study period.
James Marton and Jeffery C Talbert, “CHIP Premiums, Health Status, and the Insurance Coverage of Children,” Inquiry 47, 3 (Fall 2010):199-214. State administrative data 2001-2005 and a survey of families that disenrolled from CHIP due to premium nonpayment Kentucky: Children enrolled in CHIP
  • Examines whether the effects of new premiums in Kentucky’s CHIP program on enrollment varied by children’s health status and the extent to which children find alternative coverage after disenrolling due to premium nonpayment. In late 2003, Kentucky introduced a $20 per family per month premium for children in CHIP with family incomes between 151%-200% FPL.
  • Overall, the data show that children with a chronic condition are significantly less likely to disenroll from CHIP than children without a chronic condition.
  • The data suggest that introduction of the premium reduces the duration of CHIP coverage for the average child. However, the data suggest little differential impact of the premium increase by health status of children.
  • Survey results find 56% of families report alternative private or public health coverage for their children after losing CHIP coverage, while 44% had no insurance for their children following disenrollment.
Stephen Zuckerman, Dawn M Miller, and Emily Shelton Page, “Missouri’s 2005 Medicaid Cuts: How Did they Affect Enrollees and Providers?,” Health Affairs 28, 2, (2009):w335-w345. State administrative data; Current Population Survey (CPS) data, 2005-2007; provider utilization and financial reports; and structured interviews Missouri: Nonelderly adults and children in Medicaid and CHIP
  • Examines the effects of a broad range of policy changes in Missouri Medicaid and CHIP coverage, including new monthly premiums for CHIP. In 2005, Missouri adopted large policy changes to Medicaid and CHIP, including new monthly premiums of 1-5% of family income for children in CHIP with incomes above 150% FPL.
  • CHIP enrollment fell 30% between June 2004 and June 2006. In contrast, nationally, CHIP enrollment rose 3.4% over the same time period.
  • The share of low-income children in Missouri with Medicaid or CHIP coverage fell from 50.2% in 2004 to 40.5% in 2006, but increases in other types of insurance coverage prevented an increase in the share that were uninsured.
Jill B Herndon, W Bruce Vogel, Richard L Bucciarelli and Elizabeth A Shenkman, “The Effect of Premium Changes on SCHIP Enrollment Duration,” Health Services Research 43, 2 (April 2008):458-477. State administrative data, 2002-2004 Florida: Children enrolled in CHIP
  • Examines the impact of premium changes in Florida’s CHIP program on enrollment duration. Florida increased CHIP premiums for enrollees with incomes between 101-200% FPL by $5 per family per month in July 2002. These increases were reversed in October 2003 for those with incomes between 101-150% FPL, but maintained for those with incomes above 150% FPL.
  • Enrollment lengths decreased significantly immediately following the premiums increase, and the decrease was larger among lower income children (61%) than higher income children (55%). Enrollment lengths partially recovered in the longer term for both the temporary and permanent policy changes.
  • Children with significant acute or chronic health conditions had longer enrollment lengths and were less sensitive to premium changes than healthy children. Among lower income children, healthy children experienced a 61% decline in enrollment within the first three months compared to a 39% decline for children with significant acute conditions.
James Marton, “The Impact of the Introduction of Premiums into a SCHIP Program,” Journal of Policy Analysis and Management 26 (2007):237-255. State administrative data, 2001-2004 Kentucky: Children enrolled in CHIP
  • Examines the impact of new premiums on enrollment duration for CHIP children in Kentucky. Kentucky introduced a $20 premium for children in CHIP with family incomes between 151-200% FPL in December 2003.
  • Results suggest that a premium reduces the length of enrollment, with the impact concentrated in the first three months after the introduction of the premium.
Genevieve Kenney, et. al., “Assessing Potential Enrollment and Budgetary Effects of SCHIP Premiums: Findings from Arizona and Kentucky,” Health Services Research 42, 6 Part 2 (2007):2354-2372. State administrative data, 2001 to 2004/2005 Arizona and Kentucky: Children enrolled in CHIP with family incomes between 101-150% FPL in Arizona and 151-200% FPL in Kentucky.
  • Assesses whether new premiums in CHIP affect rates of disenrollment and reenrollment in CHIP and whether they have spillover enrollment effects on Medicaid. In July 2004, Arizona introduced CHIP premiums ranging from $10-$15 per month for families with incomes between 101-150% FPL. In December 2003, Kentucky introduced a premium of $20 per month per family for children in CHIP with family incomes between 151-200% FPL.
  • In both states, the premiums increased the rate of disenrollment among children subject to the premiums. The rate of disenrollment increased by 52% in Kentucky and by 38% in Arizona. All of the increases in disenrollment occurred during the first two or three months after introduction of the premium. Almost all the disenrollment is caused by children leaving public insurance rather than moving to Medicaid or other non-premium paying categories of CHIP. Findings also indicate a relatively small reduction in the rate of re-enrollment in both states.
  • In both states, the premiums were associated with a decline in overall enrollment among children subject to the premiums. The premium reduced enrollment in the premium paying group by 18% in Kentucky and by 5% in Arizona, with some of the children leaving public coverage all together. Unlike the impacts on disenrollment, these effects are not limited to the first 2–3 months following the introduction of the premium, suggesting that the premium may have dampened new enrollment into the premium-paying category over a longer period of time.
Gina A Livermore, et. al., “Premium Increases in State Health Insurance Programs: Lessons from a Case Study of the Massachusetts Medicaid Buy-in Program,” Inquiry 44 (Winter 2007):428-442. 2002-2003 Medicaid Management Information System (MMIS) and administrative data Massachusetts: Enrollees in the Massachusetts CommonHealth-Working (CH-W) Medicaid buy-in program for people with disabilities
  • Evaluates the impact of premium increases on disenrollment from a state-funded Medicaid buy-in program for people with disabilities in Massachusetts. In 2003, monthly premiums for the Massachusetts CommonHealth-Working (CH-W) program increased from $37 to $51.
  • After a period of steady growth, CH-W enrollment decreased marginally (.5% decrease) in the months surrounding the premium change (February-August 2003) compared with 12.4% increase during the same period in the previous year.
  • The premium increase increased the likelihood of enrollees leaving Medicaid (MassHealth) altogether, but had no effect on the likelihood of moving to another Medicaid (MassHealth) eligibility category. Although statistically significant, the effect is rather modest. All else held constant, a $10 increase in the premium would increase the odds of leaving Medicaid (MassHealth) by 3%.
  • The analysis suggests that the premium changes had a relatively small impact on disenrollment and alone cannot explain the decline observed between February and August 2003. Authors suggest that several aspects of the program may contribute to the limited impact on disenrollment, including it being a longstanding program, the changes increasing existing premiums rather than introducing new premiums, the exemption of enrollees with incomes under 150% FPL from premiums, the analysis accounting for the movement of enrollees to other categories of Medicaid coverage, and administrative procedures, including processes designed to minimize disenrollment due to nonpayment. Further, people with disabilities may be less price-sensitive to premiums given their significant health care needs.
Genevieve Kenney, et. al., “The Effects of Premium Increases on Enrollment in SCHIP Programs: Findings from Three States,” Inquiry 43, 4 (Winter 2006-2007):378-92. State administrative data, 2001-2004/2005. Kansas, Kentucky, and New Hampshire: Children enrolled in CHIP with incomes between 150-200% FPL in Kansas and Kentucky and with family incomes between 185-300% FPL in New Hampshire.
  • Examines the effects of new and higher premiums on CHIP enrollment in Kansas, Kentucky, and New Hampshire. In 2013, Kansas and Kentucky increased premium levels, while Kentucky introduced new premiums. Kansas increased premiums from $10 to $30 per family per month for families with incomes between 151-175% FPL and from $15 to $45 per family per month for those with incomes between 176-200% FPL. New Hampshire increased premiums for families with incomes between 185% to 249% FPL from $20 to $25 per child per month and from $40 to $45 for families with incomes between 250-300% FPL. Kentucky introduced a $20 premium per family per month for 151-200% FPL.
  • In all three states, caseload growth rates in the six months prior to the premium increase were consistently higher than those in the six months after the increase. In Kentucky, the caseload of children subject to premiums decreased by 16.4% following the premium’s introduction. The caseload stabilized after several months but did not return to pre-premium levels nine months after the premium was introduced. In Kansas and New Hampshire, small declines in the caseload occurred immediately following the premium increase. The caseload resumed growing three to five months after the premium increase, though at lower rates than before the increase. In contrast, caseloads among other categories of public coverage without premiums grew over the period.
  • Premiums were found to reduce new enrollment by 10.1% and 17.7% in Kansas and New Hampshire, respectively. They also led to faster disenrollment in Kentucky and New Hampshire.
  • In Kentucky, larger disenrollment effects were found for nonwhite children relative to white children while in New Hampshire, disenrollment effects were concentrated among children at the lower end of the income group subject to premiums.
Tricia J Johnson, Mary Rimsza, and William G Johnson, “The Effects of Cost-Shifting in the State Children’s Health Insurance Program,” American Journal of Public Health 96, 4 (April 2006):709-715. Yuma HealthQuery (YHQ) community health data, 2001 Arizona: Children in Yuma County, Arizona who received non-traumatic care at an emergency room who were enrolled in CHIP or uninsured
  • Simulates the effects of increasing CHIP premiums on health care use and public costs using data for children in Yuma, Arizona.
  • Estimates that a $10 increase in monthly premiums for CHIP would induce 10% of CHIP children to disenroll.
Bill J Wright et. al., “The Impact of Increased Cost Sharing on Medicaid Enrollees,” Health Affairs 24, no. 4 (Jul/Aug 2005):1106-1116. Survey of enrollees, 2003 and analysis of Medicaid eligibility files Oregon: Adults enrolled in Medicaid
  • Examines longitudinal effects on enrollees of a range of policy changes that were made in Oregon’s Medicaid program. In 2003, Oregon made a range of policy changes to its Medicaid program, the Oregon Health Plan (OHP), which included benefit reductions, increased premiums and cost sharing and stricter premium payment policies for adults enrolled in its OHP Standard program. Enrollees in OHP Plus continued to receive benefits similar to the original OHP.
  • Nearly half (44%) of the OHP Standard members disenrolled in the six months after the program changes were implemented.
  • The increased premiums and cost sharing disproportionately affected the most economically vulnerable OHP members; for the vast majority of those who disenrolled, leaving OHP meant becoming uninsured. This was particularly true for those who left because of the increased costs.
  • Those who left OHP because of cost were more likely than those who left for other reasons not to have received needed care in the previous six months. Similarly, those who left because of cost were more likely to have skipped buying prescription medicines because of cost and were significantly less likely than those who left for other reasons to have a usual source of care.
  • Those who left because of cost were significantly less likely than those who left for other reasons to have had a least one primary care visit in the past six months and significantly more likely to have had at least one emergency department visit in those same six months.
  • Those who left OHP because of cost were significantly more likely to owe $500 or more in medical debt than those who left for other reasons. The increased debt burden may have negatively affected their access to care.
Matthew J Carlson and Bill Wright, “The Impact of Program Changes on Enrollment, Access, and Utilization in the Oregon Health Plan Standard Population,” Prepared for the Office for Oregon Health Policy and Research, Sociology Faculty Publications and Presentations, Paper 14 (March 2005). Survey conducted between November 2003 and February 2004 Oregon: Adult Medicaid enrollees with incomes below 100% FPL
  • Assesses the impact of policy changes made to Oregon’s Medicaid program on enrollment, health care access, and use. In 2003, Oregon made a range of policy changes to its Medicaid program, the Oregon Health Plan (OHP), which included benefit reductions, increased premiums and cost sharing and stricter premium payment policies for adults enrolled in its OHP Standard program. Enrollees in OHP Plus continued to receive benefits similar to the original OHP.
  • 44% of individuals who disenrolled from OHP Standard following the changes reported that increased costs, including premiums, copays, and back-owed premiums, contributed to disenrollment; OHP Standard disenrollees with incomes between 0-10% FPL were significantly more likely to report difficulty paying premiums and copays than those with higher incomes.
  • Two-thirds of OHP Standard disenrollees became uninsured.
  • Disenrollees with very low incomes (43%) were more likely to have an emergency department visit than those still covered (35%); the difference was larger for those with chronic conditions.
Rachel Solotaroff, et. al., “Medicaid Programme Changes and the Chronically Ill: Early Results from a Prospective Cohort Study of the Oregon Health Plan,” Chronic Illness 1, (2005): 191-205. Mail survey of OHP beneficiaries, October 2003 Oregon: Nonelderly adults enrolled in Medicaid
  • Assess the impacts of policy changes in Oregon’s Medicaid program on individuals living with chronic illness. In 2003, Oregon made a range of policy changes to its Medicaid program, the Oregon Health Plan (OHP), which included benefit reductions, increased premiums and cost sharing and stricter premium payment policies for adults enrolled in its OHP Standard program. Enrollees in OHP Plus continued to receive benefits similar to the original OHP.
  • Nearly half (46.3%) of OHP Standard beneficiaries disenrolled in the 10 months after the policy changes. Rates of disenrollment were lower among the chronically ill (42.8%) than those without chronic illness (49.6%). However, 68% of the chronically ill that did disenroll remained uninsured at the time of the survey.
  • When asked why they disenrolled, 45% of the chronically ill and 43% of those without a chronic illness identified a reason related to the increase in cost sharing, such as inability to afford the new premiums or copays and/or owing premiums.
  • Increased costs disproportionately affected enrollment for those with lower incomes. Among those who lost coverage, 68.2% of those with zero income indicated cost sharing as the major reason for their loss, compared to 38.7% of those with incomes between 26%-100% FPL and 23.9% of those with income above 100% FPL.
  • Chronically ill persons who became uninsured after leaving OHP fared worse in terms of access to care, use of care, and financial burden than those who became uninsured but did not have a chronic illness.
Gene LeCouteur, Michael Perry, Samantha Artiga and David Rousseau, The Impact of Medicaid Reductions in Oregon: Focus Group Insights, (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, December 2004). Focus groups, 2004 Oregon: Medicaid adults with incomes under 100% FPL.
  • Assesses the impact of policy changes made to Oregon’s Medicaid program on poor adults who were subject to benefit reductions and premium and cost sharing increases. In 2003, Oregon made a range of policy changes to its Medicaid program, the Oregon Health Plan (OHP), which included benefit reductions, increased premiums and cost sharing and stricter premium payment policies for adults enrolled in its OHP Standard program. Enrollees in OHP Plus continued to receive benefits similar to the original OHP.
  • Increased premiums and stricter payment policies led many to face difficult decisions such as paying other bills late or skipping meals. For many, the new premiums and the stricter payment policies led to loss of coverage, and they had significant problems accessing care after losing coverage.
Utah Department of Health Center for Health Data, Utah Primary Care Network Disenrollment Report, (Salt Lake City, UT: Utah Department of Health Center for Health Data, Office of Health Care Statistics, August 2004). State administrative and survey data, July and September 2003 Utah: Adults with incomes below 150% FPL who disenrolled from Medicaid
  • Examines the effect of an enrollment fee and cost sharing on adults enrolled in a Medicaid limited benefit waiver program in Utah. In 2003, Utah implemented an annual enrollment fee and cost sharing in its Primary Care Network (PCN) waiver program for low-income adults.
  • During July-September 2003 (renewal period after first year), 27% were disenrolled. A survey of disenrollees found that 63% were uninsured at the time of the survey. Nearly half of surveyed disenrollees indicated that they were still eligible for the PCN program.
  • Nearly 30% of survey respondents indicated financial barriers to reenrollment. Most of those reporting financial barriers cited the $50 reenrollment fee as the barrier (63%) and 26% cited the copays. Over 75% of respondents who reported financial barriers to reenrollment reported being uninsured after exiting the program.
  • Of those indicating they did not reenroll because the program did not meet their health needs, 20% reported copays were too high to use services.
  • About half of all respondents who disenrolled, regardless of reason for disenrollment, indicated not having seen a health care provider in the previous 12 months. Many disenrollees reported difficulty accessing needed care, particularly mental health care, alcohol/drug treatment, and dental services.
Mark Gardner and Janet Varon, Moving Immigrants from a Medicaid Look-Alike Program to Basic Health in Washington State: Early Observations, (Washington, DC: Kaiser Family Foundation, May 2004). State administrative data, key informant interviews, a focus group, and interviews, September 2002-September 2003 Washington State: Immigrant families moved from Medicaid to Basic Health in Washington State
  • Assesses the impact of changes in coverage options for low-income immigrants in Washington State. In 2002, Washington State eliminated three state-funded programs for individuals whose immigration status prevented them from qualifying for Medicaid. Instead, “slots” were set aside for them in the state’s Basic Health program, which charges premiums and has more limited benefits than Medicaid.
  • 48% of families in the transition population did not make the transition and disenrolled during the first few months of the transition.
  • Premiums were a significant barrier to families obtaining and maintaining Basic Health coverage; 35.9% of those from the transition group who disenrolled from Basic Health in the first 11 months did so because they did not pay premiums.
  • Most (61%) of the group that successfully transitioned to Basic Health relied on assistance from third parties to pay premiums.
Maryland Department of Health and Mental Hygiene, Maryland Children’s Health Insurance Program: Assessment of the Impact of Premiums, (Baltimore, MD: Department of Health and Mental Hygiene, April 2004). State administrative and survey data, February 2004 Maryland: Children disenrolled from CHIP with incomes between 185-200% FPL
  • Studies the effects of a new monthly premium in Maryland’s CHIP program on program enrollment and health coverage. In 2003, Maryland made several changes to its CHIP program, including requiring families with incomes between 185-200% FPL to pay a new monthly premium of $37 per family.
  • Enrollment data showed about one-quarter of families subject to the new premiums disenrolled.
  • In surveys conducted with parents, the most common reason given was gaining other coverage (41%), but 20% cited a premium related reason.
John McConnell and Neal Wallace, Impact of Premium Changes in the Oregon Health Plan, Prepared for the Office for Oregon Health Policy & Research, (Portland, OR: Oregon Health & Science University, February 2004. State administrative data, January 2002 – October 2003 Oregon: Adults with incomes below 100% FPL who disenrolled from Medicaid in Oregon
  • Examines the effects of changes to Oregon’s Medicaid program on enrollment and highlights the effects for enrollees at different income levels. In 2003, Oregon made a range of policy changes to its Medicaid program, the Oregon Health Plan (OHP), which included benefit reductions, increased premiums and cost sharing and stricter premium payment policies for adults enrolled in its OHP Standard program. Enrollees in OHP Plus continued to receive benefits similar to the original OHP.
  • OHP Standard experienced a nearly 50% drop in enrollment, with the largest declines experienced by those with no income (58% drop in October 2003 from 2002 levels).
  • Of those that left between May and October, 47% were disqualified for not paying premiums.
Norma I Gavin, et. al., Evaluation of the BadgerCare Medicaid Demonstration, Prepared by RTI International and MayaTech Corp. for the Centers for Medicare & Medicaid Services, (Research Triangle Park, NC: RTI International and MayaTech Corporation, December 2003). Case study, including site visit interviews, focus groups, and document review; administrative enrollment data 1997-2002; and surveys of BadgerCare participating, eligible nonparticipating, and disenrolled families. Wisconsin: Families enrolled in Medicaid/CHIP
  • Evaluates Wisconsin’s BadgerCare Medicaid/CHIP program for low-income families. BadgerCare, includes premiums for families with incomes over 150% FPL who must pay monthly premiums of approximately 3% of their income.
  • Premium paying families were less likely to remain enrolled over time, but the difference from families not subject to premiums was small. Premiums delayed reenrollment of families.
  • Of those disenrolled, 26% listed a problem with paying premiums as a reason for leaving BadgerCare. This was the most common reason for leaving the program.
Monette Goodrich, Joan Alker, and Judith Solomon, Families at Risk: The Impact of Premiums on Children and Parents in Husky A, Policy Brief (Washington, DC: Georgetown Center for Children and Families, November 2003), http://ccf.georgetown.edu/wp-content/uploads/2012/03/Far%20-%20impact%20of%20premiums.pdf. State administrative data, August 2003 Connecticut: Children and adults enrolled in Medicaid
  • Models potential effects of adding new premiums to Connecticut’s Medicaid program. In 2003, Connecticut was planning to charge premiums for families with monthly incomes ranging from 50%-185% FPL for a family of three enrolled in Medicaid.
  • Estimates that premiums would contribute to an enrollment decline of by 86,744 adults and children. Of these persons who could be expected to lose coverage, 59,638 – approximately 69% – would be children; the remaining 27,106 would be parents or pregnant women.
  • Of the adults that could be expected to lose coverage, 1,006 would be pregnant women.
  • Just under half of those who could be expected to lose coverage would be children and parents whose income falls below the poverty level – 26,212 children and 15,070 adults – with monthly incomes ranging from $604 to $1,196 a month.
  • The remaining 33,426 children and 12,036 adults who could be expected to lose coverage come from families whose incomes range from 100-184% of the poverty line.
Elizabeth Shenkman, et. al., “Disenrollment and Re-Enrollment Patterns in a SCHIP Program,” Health Care Financing Review 23, 3 (Spring 2002:47-63. Census of all children enrolled in CHIP program for at least 1 month from October 1, 1997-September 30, 1999. Florida: Children enrolled in CHIP
  • Examines the impact of four policy changes made to Florida’s CHIP program on enrollment and re-enrollment, including a reduction in premiums. Prior to 1998, families paid $5-$27 per child per month (depending on the county where they lived) and family income while families above 186% FPL paid $55-$65 per child per month. In 1998, Florida changed its CHIP program, including extending subsidized premiums which reduced premiums to $15 per family per month for those 185%-200% FPL. Families above 200% FPL paid about $75 per child per month.
  • Larger decreases in monthly premiums had larger effects on reducing the likelihood of disenrollment. While an average of $5 per month decrease in premiums resulted in families being only 2% less likely to disenroll their children from the program, a $45 per month reduction in premiums meant that families were 17-20% less likely to disenroll their children from the program.
  • Families experiencing the mean premium change were slightly more likely to re-enroll their children following a disenrollment episode. For example, families experiencing the mean premium change were 6-7% more likely to re-enroll post- versus pre-April 1998.
Leighton Ku and Teresa A Coughlin, “Sliding-Scale Premium Health Insurance Programs: Four States’ Experiences,” Inquiry 36, 4 (Winter 1999/2000). Interviews with state officials, review of state documents, and 1995 state data Washington, Tennessee, Hawaii, and Minnesota: Medicaid/CHIP enrollees
  • Examines the experiences in four states that implemented Medicaid expansion programs that include sliding-scale premiums for families. In the 1990s, Washington, Tennessee, Hawaii, and Minnesota initiated Medicaid expansion programs using sliding-scale premiums.
  • Participation in public health programs fell from 57% when premiums were equal to 1% of family income to 35% when premiums grew to 3% of family income. Participation continued to fall to 18% when premiums rose to 5% of family income.

 

Study Tables Table 2: Effects of Cost Sharing

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