Effects of Public Premiums on Children's Health Insurance Coverage: Evidence from 1999 to 2003

Do state laws reduce uptake of Medicaid/CHIP by U.S. citizen children in immigrant families: evaluating evidence for a chilling effect

Background

Restrictive state laws aimed at immigrants can have unintended consequences for health insurance coverage of United States citizens in immigrant families due to both actual barriers created by the laws and perceived barriers among immigrants. Increasing numbers of children in the U.S. are part of immigrant families, and these children are more likely to be living in poverty than their counterparts in native families. Immigrant restrictive policies could lead to reduced access to Medicaid and CHIP even for citizen children in immigrant families.

Methods

Using data from the Current Population Survey's (CPS) March Supplement, linear probability models with difference-in-differences (DD) estimates compare probability of enrollment in Medicaid/CHIP among low-income U.S. citizen children in immigrant families and low-income children in native families and U.S. citizen children in immigrant families in states that did not adopt restrictive legislation, in order to estimate the impact of restrictive state laws aimed at immigrants. An additional model explores the effect of mother’s citizenship on enrollment among all immigrant families in states with and without restrictive legislation.

Results

Results suggest a significant chilling effect where the magnitude of the effect varies according to family demographics and by the types of laws being passed. Immigrant restrictive social welfare laws being adopted have a strong negative effect on U.S. citizen children in immigrant families’ enrollment in Medicaid/CHIP, a 5.5 percentage point reduction in coverage. Among the subsample of only immigrant families, results point toward a global chilling effect created by an overall restrictive policy environment. All immigrant restrictive related laws, including those aimed at education, job restriction, identification access, and social welfare restrictions have a significant and negative impact on access to public insurance for U.S. citizen children with non-citizen mothers.

Conclusions

This research shows that the unintended consequence of restrictive state legislation aimed at immigrants is the reduction in access to Medicaid and CHIP by low-income U.S. citizen children living in immigrant families. Reduced access to health insurance can increase unmet medical needs for an already vulnerable group.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-022-01651-2.

Children's Health Insurance Program Expansions: What Works for Families?

We examine the impact of Children’s Health Insurance Program (CHIP) eligibility expansions 1999 to 2012 on child and joint parent/child insurance coverage. We use changes in state CHIP income eligibility levels and data from the Current Population Survey Annual Social and Economic Supplement to create child/parent dyads. We use logistic regression to estimate marginal effects of eligibility expansions on coverage in families with incomes below 300% federal poverty level (FPL) and, in turn, 150% to 300% FPL. The latter is the income range most expansions targeted. We find CHIP expansions increased public coverage among children in families 150% to 300% FPL by 2.5 percentage points (pp). We find increased joint parent/child coverage of 2.3 pp (P = .055) but only in states where the public eligibility levels for parent and child are within 50 pp. In these states, the CHIP expansion increased the probability that both parent/child are publicly insured (2.5 pp) among insured dyads, but where the eligibility levels are further apart (51-150 pp; >150 pp), CHIP expansions increase the probability of mixed coverage—one public, one private—by 0.9 to 1.5 pp. Overall, families made decisions regarding coverage that put the child first but parents took advantage of joint parent/child coverage when eligibility levels were close. Joint public parent/child coverage can have positive care-seeking effects as well as reduced financial burdens for low-income families.

Medicaid Versus Marketplace Coverage For Near-Poor Adults: Effects On Out-Of-Pocket Spending And Coverage

In states that expanded Medicaid eligibility under the Affordable Care Act, nonelderly near-poor adults-those with family incomes of 100-138 percent of the federal poverty level-are generally eligible for Medicaid, with no premiums and minimal cost sharing. In states that did not expand eligibility, these adults may qualify for premium tax credits to purchase Marketplace plans that have out-of-pocket premiums and cost-sharing requirements. We used data for 2010-15 to estimate the effects of Medicaid expansion on coverage and out-of-pocket expenses, compared to the effects of Marketplace coverage. For adults with family incomes of 100-138 percent of poverty, living in a Medicaid expansion state was associated with a 4.5-percentage-point reduction in the probability of being uninsured, a $344 decline in average total out-of-pocket spending, a 4.1-percentage-point decline in high out-of-pocket spending burden (that is, spending more than 10 percent of income), and a 7.7-percentage-point decline in the probability of having any out-of-pocket spending relative to living in a nonexpansion state. These findings suggest that policies that substitute Marketplace for Medicaid eligibility could lower coverage rates and increase out-of-pocket expenses for enrollees.

Effects of Premium Increases on Enrollment in SCHIP: Findings from Three States

This study examines the effects of new and higher premiums on SCHIP enrollment in Kansas, Kentucky, and New Hampshire—three states that implemented premium changes in 2003. We used state administrative enrollment records from 2001 to 2004–2005 to track changes in total caseloads, new enrollments, and disenrollment timing in premium-paying categories of SCHIP before and after the premium changes were implemented. Premium hikes were associated with lower caseloads in all three states and with earlier disenrollment in Kentucky and New Hampshire. Premium increases appeared to have greater disenrollment effects for lower-income children in New Hampshire and for nonwhite children in Kentucky.

Annual Economic Burden of Productivity Losses Among Adult Survivors of Childhood Cancers

BACKGROUND AND OBJECTIVES

Although adult survivors of childhood cancers have poorer health and greater health limitations than other adults, substantial gaps remain in understanding the economic consequences of surviving childhood cancer. Therefore, we estimated the economic burden of productivity losses among adult survivors of childhood cancers.

METHODS

We examined health status, functional limitations, and productivity loss among adult survivors of childhood cancers (n = 239) diagnosed at ≤14 years of age compared with adults without a history of cancer (n = 304 265) by using the 2004-2014 National Health Interview Survey. We estimated economic burden using the productivity loss from health-related unemployment, missed work days, missed household productivity, and multivariable regression models controlling for age, sex, race/ethnicity, education, comorbidities, and survey year.

RESULTS

Childhood cancer survivorship is associated with a substantial economic burden. Adult survivors of childhood cancers are more likely to be in poorer health, need assistance with personal care and routine needs, have work limitations, be unable to work because of health, miss more days of work, and have greater household productivity loss compared with adults without a history of cancer (all P < .05). The annual productivity loss for adult survivors of childhood cancer is $8169 per person compared with $3083 per person for individuals without a history of cancer.

CONCLUSIONS

These findings underscore the importance of efforts to reduce the health and economic burden among adult survivors of childhood cancer. In addition, this study highlights the potential productivity losses that could be avoided during adulthood from the prevention of childhood cancer in the United States.

Children's health insurance program premiums adversely affect enrollment, especially among lower-income children

Both Medicaid and the Children's Health Insurance Program (CHIP), which are run by the states and funded by federal and state dollars, offer health insurance coverage for low-income children. Thirty-three states charged premiums for children at some income ranges in CHIP or Medicaid in 2013. Using data from the 1999-2010 Medical Expenditure Panel Surveys, we show that the relationship between premiums and coverage varies considerably by income level and by parental access to employer-sponsored insurance. Among children with family incomes above 150 percent of the federal poverty level, 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 uninsurance may be higher among those children whose parents lack an offer of employer-sponsored insurance than among those whose parents have such an offer. Among children with family incomes of 101-150 percent of poverty, a $10 increase in monthly premiums is associated with a 6.7-percentage-point reduction in Medicaid or CHIP coverage and a 3.3-percentage-point increase in uninsurance. In this income range, the increase in uninsurance is even larger among children whose parents lack offers of employer coverage.

Health Expenditure Concentration and Characteristics of High-Cost Enrollees in CHIP

Devising effective cost-containment strategies in public insurance programs requires understanding the distribution of health care spending and characteristics of high-cost enrollees. The aim was to characterize high-cost enrollees in a state’s public insurance program and determine whether expenditure inequality changes over time, or with changes in cost-sharing policies or program eligibility. We use 1999-2011 claims and enrollment data from the Alabama Children’s Health Insurance Program, ALL Kids. All children enrolled in ALL Kids were included in our study, including multiple years of enrollment (N = 1,031,600 enrollee-months). We examine the distribution of costs over time, whether this distribution changes after increases in cost sharing and expanded eligibility, patient characteristics that predict high-cost status, and examine health services used by high-cost children to identify what is preventable. The top 10% (1%) of enrollees account for about 65.5% (24.7%) of total program costs. Inpatient and outpatient costs are the largest components of costs incurred by high-cost utilizers. Non-urgent emergency department costs are a relatively small portion. Average expenditure increases over time, particularly after expanded eligibility, and the share of costs incurred by the top 10% and 1% increases slightly. Multivariable logistic regression results indicate that infants and older teens, Caucasian children, and those with chronic conditions are more likely to be high-cost utilizers. Increased cost sharing does not reduce cost concentration or average expenditure among high-cost utilizers. These findings suggest that identifying and targeting potentially preventable costs among high-cost utilizers are called for to help reduce costs in public insurance programs.

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

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.

DATA SOURCES

PubMed was used to search academic literature from 1995 to 2014.

STUDY SELECTION

Two reviewers initially screened studies by using abstracts and titles, and 1 additional reviewer screened proposed studies. Included studies focused on publicly insured children, evaluated premium changes in at least 1 state/local program, and used longitudinal or repeated cross-sectional data with pre/postchange measures.

DATA EXTRACTION

We identified 263 studies of which 17 met inclusion criteria.

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.

LIMITATIONS

Effect sizes were difficult to compare across studies with administrative data.

CONCLUSIONS

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

The impact of recent CHIP eligibility expansions on children's insurance coverage, 2008-12

Following the reauthorization of the Children's Health Insurance Program (CHIP) in 2009, fifteen states raised their CHIP income eligibility thresholds to further reduce uninsurance among children. We examined the impact of these expansions on uninsurance, public insurance, and private insurance among children who became newly eligible for CHIP after the expansions. Using a difference-in-differences approach, we estimated that the expansions reduced uninsurance by 1.1 percentage points among the newly eligible, cutting their uninsurance rate by nearly 15 percent. Public coverage increased by 2.9 percentage points, with variations in take-up among the states. A better understanding of these state-level differences in take-up could inform efforts to enroll children who remain uninsured but are eligible for CHIP. CHIP is up for reauthorization in 2015, and further funding will be needed to maintain the program, which provides insurance to children who might not have access to affordable private coverage.

The impact of CHIP premium increases on insurance outcomes among CHIP eligible children

Background

Within the United States, public insurance premiums are used both to discourage private health policy holders from dropping coverage and to reduce state budget costs. Prior research suggests that the odds of having private coverage and being uninsured increase with increases in public insurance premiums. The aim of this paper is to test effects of Children’s Health Insurance Program (CHIP) premium increases on public insurance, private insurance, and uninsurance rates.

Methods

The fact that families just below and above a state-specific income cut-off are likely very similar in terms of observable and unobservable characteristics except the premium contribution provides a natural experiment for estimating the effect of premium increases. Using 2003 Medical Expenditure Panel Survey (MEPS) merged with CHIP premiums, we compare health insurance outcomes for CHIP eligible children as of January 2003 in states with a two-tier premium structure using a cross-sectional regression discontinuity methodology. We use difference-in-differences analysis to compare longitudinal insurance outcomes by December 2003.

Results

Higher CHIP premiums are associated with higher likelihood of private insurance. Disenrollment from CHIP in response to premium increases over time does not increase the uninsurance rate.

Conclusions

When faced with higher CHIP premiums, private health insurance may be a preferable alternative for CHIP eligible families with higher incomes. Therefore, competition in the insurance exchanges being formed under the Affordable Care Act could enhance choice.

Income eligibility thresholds, premium contributions, and children's coverage outcomes: a study of CHIP expansions

OBJECTIVE

To understand the effects of Children's Health Insurance Program (CHIP) income eligibility thresholds and premium contribution requirements on health insurance coverage outcomes among children.

DATA SOURCES

2002-2009 Annual Social and Economic Supplements of the Current Population Survey linked to data from multiple secondary data sources.

STUDY DESIGN

We use a selection correction model to simultaneously estimate program eligibility and coverage outcomes conditional upon eligibility. We simulate the effects of three premium schedules representing a range of generosity levels and the effects of income eligibility thresholds ranging from 200 to 400 percent of the federal poverty line.

PRINCIPAL FINDINGS

Premium contribution requirements decrease enrollment in public coverage and increase enrollment in private coverage, with larger effects for greater contribution levels. Our simulation results suggest minimal changes in coverage outcomes from eligibility expansions to higher income families under premium schedules that require more than a modest contribution (medium or high schedules).

CONCLUSIONS

Our simulation results are useful counterpoints to previous research that has estimated the average effect of program expansions as they were implemented without disentangling the effects of premiums or other program features. The sensitivity to premiums observed suggests that although contribution requirements may be effective in reducing crowd-out, they also have the potential, depending on the level of contribution required, to nullify the effects of CHIP expansions entirely. The persistence of uninsurance among children under the range of simulated scenarios points to the importance of Affordable Care Act provisions designed to make the process of obtaining coverage transparent and navigable.

Public and Private Health Insurance Premiums: How Do They Affect the Health Insurance Status of Low-Income Adults? Childless

The Patient Protection and Affordable Care Act (ACA) will substantially increase public health insurance eligibility and alter the costs of insurance coverage. Using Current Population Survey (CPS) data from the period 2000–2008, we examine the effects of public and private health insurance premiums on the insurance status of low-income childless adults, a population substantially affected by the ACA. Results show higher public premiums to be associated with a decrease in the probability of having public insurance and an increase in the probability of being uninsured, while increased private premiums decrease the probability of having private insurance. Eligibility for premium assistance programs and increased subsidy levels are associated with lower rates of uninsurance. The magnitudes of the effects are quite modest and provide important implications for insurance expansions for childless adults under the ACA.

Premium increases in state health insurance programs: lessons from a case study of the Massachusetts Medicaid buy-in program

In March 2003, Massachusetts increased the premiums it charges to most enrollees in its CommonHealth-Working (CH-W) program. This study evaluates the impact of the premium change on disenrollment using a comparison group methodology. The findings indicate that the premium change had only a small, but statistically significant impact on program exits. The CH-W experience differs from other state programs that saw substantial enrollment declines in response to new or increased premiums. This is likely due to factors that make CH-W different from other programs, key of which are administrative procedures intended to minimize disenrollment due to premium nonpayment.

Children's eligibility and coverage: recent trends and a look ahead

We used data from the 1996-2005 Medical Expenditure Panel Survey to track changes in children's public insurance eligibility and coverage. During the 2001-2005 "postexpansion" period, eligibility was approximately constant, while public enrollment increased rapidly and uninsurance declined. Nevertheless, as of 2005, 62 percent of all uninsured children (5.5 million) continued to be eligible but not enrolled. We present detailed estimates of their characteristics by age, income, race/ethnicity, health status, and nativity/citizenship. We also examine the impact of potential changes in SCHIP income thresholds--both an expansion and a rollback--and estimate the number and characteristics of the children potentially affected.

Insurance premiums and insurance coverage of near-poor children

States increasingly are using premiums for near-poor children in their public insurance programs (Medicaid/SCHIP) to limit private insurance crowd-out and constrain program costs. Using national data from four rounds of the Community Tracking Study Household Surveys spanning the seven years from 1996 to 2003, this study estimates a multinomial logistic regression model examining how public and private insurance premiums affect insurance coverage outcomes (Medicaid/SCHIP coverage, private coverage, and no coverage). Higher public premiums are significantly associated with a lower probability of public coverage and higher probabilities of private coverage and uninsurance; higher private premiums are significantly related to a lower probability of private coverage and higher probabilities of public coverage and uninsurance. The results imply that uninsurance rates will rise if both public and private premiums increase, and suggest that states that impose or increase public insurance premiums for near-poor children will succeed in discouraging crowd-out of private insurance, but at the expense of higher rates of uninsurance. Sustained increases in private insurance premiums will continue to create enrollment pressures on state insurance programs for children.