Medicaid and CHIP premiums increase disenrollment

Medicaid and CHIP Premiums and Access to Care: A Systematic Review

By Brendan Saloner, Stephanie Hochhalter, Lindsay Sabik
Pediatrics, March 2016

BACKGROUND: Premiums are required in Medicaid and the Children’s Health Insurance Program in many states. Effects of premiums are raised in policy debates.

OBJECTIVE: Our objective was to review effects of premiums on children’s coverage and access.

RESULTS: Four studies examined population-level coverage effects by using national survey data, 11 studies examined trends in disenrollment and reenrollment by using administrative data, and 2 studies measured additional outcomes. No eligible studies evaluated health status effects. Increases in premiums were associated with increased disenrollment rates in 7 studies that permitted comparison. Larger premium increases and stringent enforcement tended to have larger effects on disenrollment. At a population level, premiums reduce public insurance enrollment and may increase the uninsured rate for lower-income children. Little is known about effects of premiums on spending or access to care, but 1 study reveals premiums are unlikely to yield substantial revenue.

CONCLUSIONS: Public insurance premiums often increase disenrollment from public insurance and may have unintended consequences on overall coverage for low-income children.



By Don McCanne, M.D.

Most individuals are relatively sensitive to the health insurance premiums they pay. This particular analysis of multiple studies shows that the rate of low-income children enrolling in the Medicaid or CHIP programs declines as the premium increases. Since an important objective is to try to ensure that all low-income children have insurance coverage, charging premiums for the government programs is an unwise policy as it results in the opposite outcome.

In fact, health insurance premiums are a deterrent to enrollment for all populations. A goal of health reform was to have everyone covered (though that was abandoned when it was acknowledged that the Affordable Care Act model could not accomplish this). Thus we still have 29 million people who remain uninsured without much of a prospect that we can significantly decrease the numbers simply because of the administrative complexity of the ACA model. Many of these 29 million people are disqualified for the public programs or cannot afford even subsidized premiums and thus will remain uninsured.

A single payer system is not funded through insurance premiums but rather is funded through equitable taxes based on the ability to pay. Taxes are automatic. An individual does not have the option of not paying them, unlike the option of declining to pay insurance premiums, thus forgoing coverage. True, some people fail to pay their taxes. Although that might cause problems with the IRS, it does not result in the revocation of the right to enjoy the fruits of government funded services. If we funded an improved Medicare for All program through the tax system, nobody would lose his or her coverage for non-payment. Health care coverage would always be there for everyone.

We should be supporting effective policies that would bring health care to all of us rather than being distracted by peripheral issues such as protecting the the interests of the inefficient private insurers. Switching from insurance premiums paid to private plans to equitable taxes to fund a more efficient public insurance program is exactly the type of public policy that we should be considering if we really do want everyone to have health care.

Physicians for a National Health Program (PNHP) is a nonpartisan educational organization. It neither supports nor opposes any candidates for public office.