I've talked about the use of premiums in Medicaid programs across the United States in previous Healthcare Triage episodes. But, a new study in pediatrics collects the evidence, and it's worth a look. Medicaid and CHIP Premiums and Access to Care: a systematic review. This is Healthcare Triage News.

[Intro]

Researchers wanted to look at all the published studies that examined the effects of premiums on children's coverage by Medicaid and CIP and their access to health care. They found four studies that looked at population-level coverage effects using national survey data.

Overall, increases in premiums were associated with increases in disenrollment. One study found that increasing premiums by about $10 (in 2003 dollars) was associated with a 3% decrease in public insurance enrollment among children eligible for CHIP. Moreover, about one-third of the children who lost CHIP became uninsured. The other studies reported similar findings.

Eleven more looked at trends in disenrollment and re-enrollment using administrative data, and two more examine additional outcomes. Most of the premium increases were between 5 and 20 dollars, and overall, premium increases were associated with disenrollment.

One study looked at premium spending as an outcome. It found that premium revenues account for little savings to government programs. Any savings to CHIP are likely balanced by increased Medicaid enrollment as well. 

One study also looked at how access was affected. It found that premium reductions were associated with a 20% to 113% increase in the chance of well-child visits occurring.

Premiums for CHIP and Medicaid are not a lot of money in the scheme of things. Even so, they act as a disincentive for enrollment and result in more children leaving the program. Small increases result in significant numbers of people leaving the plans, and many of those children wind up being uninsured. Moreover, premium increases are associated with lower levels of well-child visits and other desired health outcomes.

What are the premiums for? If they're only 10 or 20 dollars a month, then they constitute a very small amount of actual healthcare spending. It's hard to imagine premiums are being used to really offset the cost of care. Some believe they might be part of a plan to make patients feel like they have more skin in the game. Given that they result in significantly reduced numbers of children covered by insurance, we really need to question whether it's worth that outcome to achieve this goal. A more cynical view might be that cost savings are being achieved by getting more people to disenroll from these programs. 

Regardless, tiny financial changes have meaningful effects. Medicaid and CHIP are suppose to cover those who need the most assistance and who have the least means to help themselves. Premium increases for those programs don't seem to be in line with their goals. 

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