qotd: Medicaid and CHIP premiums increase disenrollment

Pediatrics
March 2016
Medicaid and CHIP Premiums and Access to Care: A Systematic Review
By Brendan Saloner, Stephanie Hochhalter, Lindsay Sabik

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.

http://pediatrics.aappublications.org/content/137/3/1.24

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Comment by Don McCanne

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./
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