Dataset Information

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

ABSTRACT:

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.

SUBMITTER: Gresenz CR

PROVIDER: S-EPMC3626333 | biostudies-literature | 2013 Apr

REPOSITORIES: biostudies-literature

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Publications

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

Gresenz Carole Roan CR Edgington Sarah E SE Laugesen Miriam J MJ Escarce José J JJ

Health services research 20130210 2 Pt 2

<h4>Objective</h4>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.<h4>Data sources</h4>2002-2009 Annual Social and Economic Supplements of the Current Population Survey linked to data from multiple secondary data sources.<h4>Study design</h4>We use a selection correction model to simultaneously estimate program eligibility and coverage outcomes conditio ...[more]

PMID: 23398477

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Project description:ImportanceThe Affordable Care Act created 2 new coverage options for uninsured adults: Medicaid expansion, which in most states provides comprehensive coverage without premiums and deductibles; and private marketplace coverage, which requires a premium contribution and cost-sharing, though with generous federal subsidies at lower incomes. How enrollment rates compare in the marketplace vs Medicaid is an important policy question as states continue to weigh alternative coverage options such as Medicaid buy-in programs, enrolling Medicaid-eligible populations into marketplace plans, or creating a public option.ObjectiveTo assess the association between income eligibility for Medicaid vs marketplace coverage and insurance enrollment among low-income adults in Colorado.Design setting and participantsUsing 2014 and 2015 all-payer claims data from Colorado and detailed income eligibility information, we used a regression discontinuity design to assess the difference in Medicaid and marketplace enrollment just below and just above 138% of the federal poverty level (FPL), the eligibility threshold between the 2 programs. The sample included nonpregnant adults aged 19 to 64 years with incomes between 75% to 400% FPL. We stratified our analysis by age, sex, chronic condition status, and urban vs rural residence. Analysis was conducted from January to October 2020.Main outcome and measuresThe main outcome was total enrollment in either Medicaid or marketplace coverage during marketplace's Open Enrollment period. Income-based health insurance eligibility was assessed as a percentage of FPL at the time of initial application for coverage.ResultsThe primary analytical sample included 32 091 enrollees in 2014 and 55 451 in 2015, with incomes ranging from 120% to 156% FPL. Most enrollees were women (59.26% in 2014, 59.20% in 2015), resided in urban areas (70.36% in 2014, 73.08% in 2015), and had no chronic conditions (74.66% in 2014, 76.11% in 2015). For age, in 2014 and 2015, respectively, 13.22% and 13.93% were aged 19 to 25 years, 27.85% and 28.54% were aged 26 to 34 years, 23.58% and 24.34% were aged 35 to 44 years, 18.35% and 17.75% were aged 45 to 54 years, and 17.00% and 15.44% were aged 55 to 64 years. Marketplace enrollment was 81.3% (95% CI, -86.0% to -75.0%) lower than Medicaid enrollment in 2014 and 88.6% (95% CI, -90.8% to -86.0%) lower in 2015 among those close to the 138% FPL eligibility threshold. The drop-off in marketplace enrollment was largest among younger adults, aged 26 to 34 and 35 to 44 years: relative drop off -88.7% (95% CI, -93.3% to -80.8%) and -87.8% (95% CI, -90.8% to -83.9%) in 2014, and relative drop off -91.9% (95% CI, -94.5% to -87.9%) and -93.0% (95% CI, -94.5% to -91.1%) in 2015, respectively.Conclusions and relevanceIn this cross-sectional study using a regression-discontinuity analysis, meaningful gaps in insurance enrollment may have existed for those with incomes just above the eligibility threshold for Medicaid expansion, especially among younger adults. Policies expanding Medicaid income eligibility or zero-dollar premium marketplace plans are likely to be more effective at inducing enrollment than subsidized private plans with premium requirements.

Project description:ObjectiveTo evaluate the effect of the Oregon and New Mexico Health Insurance Flexibility and Accountability (HIFA) demonstrations. HIFA is an optional state Medicaid expansion targeted at adults and children with incomes below 200 percent of the federal poverty level (FPL). The study has five research questions: What type of health insurance do HIFA enrollees self report in surveys? What are the demographic characteristics of these enrollees? What type of health insurance coverage, if any, did HIFA enrollees have just prior to enrollment in the HIFA program? Among those with prior coverage, what prompted participation in the HIFA program? What type of health insurance, if any, would HIFA enrollees have in the absence of HIFA?MethodsData were collected via telephone interviews with a total of 406 enrollees from Oregon and 409 enrollees from New Mexico. The survey was conducted between July 7 and September 20, 2009, for both states. The sample frame for the survey was based on administrative records of adults enrolled in June 2009. After completion of the survey, active enrollment status as of the date the telephone interview was confirmed. Respondents no longer enrolled at the time of the survey (7 cases in NM and 14 in OR) were excluded from the analysis. The final sample size was 794 verified HIFA enrollees.ResultsHIFA enrollees tended to be middle-aged, male, and relatively unhealthy. Employment status varied tremendously from the self-employed to retired to unable to work. HIFA enrollees were reasonably well educated with 80 percent having at least a high school education. Most HIFA enrollees (90 percent) reported being uninsured just prior to participation in HIFA. Of those who were uninsured, most reported having been uninsured for an extended time-a year or more. Most enrollees joined HIFA because they lacked access to health insurance or could not afford insurance on the private market. The overwhelming majority (76 percent) of respondents believed that they would be uninsured in the absence of HIFA, with few considering either an employer plan or private purchase to be a viable option. Over 90 percent of enrollees correctly indicated they had insurance coverage. However, characterization of the type of coverage was problematic, particularly in the absence of the program-specific name.ConclusionsHIFA enrolled a relatively sick, male, middle-aged population that tended to have been long-term uninsured--the kind of enrollees for which the programs were designed--with little apparent crowd-out of private insurance. The reported health status coupled with low incomes suggests that individual purchase is unlikely, a sentiment echoed by the respondents. In the absence of HIFA, most enrollees believed they would rejoin the ranks of the uninsured from where they came.

Dataset Information

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

Objective

Data sources

Study design

Principal findings

Conclusions

Publications

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

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