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CHIP OVERVIEW
Basic Access Issues Basics of Cost-Sharing Designing Premiums Crowd-outSource: HCFA web page –
presentations by Shuster, Ullman and Weinick.
IMPACT ON ACCESS TO HEALTH CARE
Usual Source of Health Care
Level of Services
Quality, Continuity, and Satisfaction With Care
HEALTH INSURANCE AND ACCESS TO CAREPercent with No Usual Source of Care
20.2
10.0
5.6
0
5
10
15
20
25
Uninsured Public Private
HEALTH INSURANCE AND USUAL SOURCE OF CARE SITE
Percent with Office-Based Usual Source of Care
68.574.8
86.7
0
25
50
75
100
Uninsured Public Private
Source: Weinick, Weigers, and Cohen, 1998 (1996 MEPS)
HEALTH INSURANCE AND BARRIERS TO CARE
Percent of Families Experiencing Barriers to Care
23.4
12.2
7.0
0
5
10
15
20
25
30
One or more membersuninsured
All members publicinsurance
All members privateinsurance
Source: Weinick, Zuvekas, and Drilea 1997 (1996 MEPS)
HEALTH INSURANCE AND PHYSICIAN CONTACT
Percent of Children with Any Physician Contact
54.0
72.677.3
0
25
50
75
100
Uninsured Public Private
Source: Monheit and Cunningham, 1992 (1987 NMES)
HEALTH INSURANCE AND WELL-CHILD VISITS
Percent of Children with Well-Child Visits
48.556.4
64.7
31.438.0
47.5
0
25
50
75
Uninsured Public Private
Any visits Recommended visits
Source: Short and Lefkowitz, 1992 (1987 NMES)
IMPACT ON USE AND EXPENDITURES
Uninsured Children Use Fewer Health Care Services Than Insured Children
Uninsured People Spend a Greater Proportion of Their Income on Health Care Services Than the Privately Insured (Taylor and Banthin 1994)
IMPACT ON HEALTH STATUS AND HEALTH OUTCOMES Adverse Health Outcomes Appear to Be
Related to Being Uninsured
Avoidable Hospitalizations for a Variety of Conditions Are More Common Among the Uninsured Than the Privately Insured
Uninsured Newborns Are More Likely to Have Adverse Outcomes Than the Privately Insured
Source: Office of Technology Assessment, 1992; Weissman, Gastonis, and Epstein, 1991
IMPACT ON HEALTH STATUS AND HEALTH OUTCOMES The Uninsured Are More Likely to
Experience avoidable hospitalizations
Be diagnosed at later stages of disease
Be hospitalized on an emergency or urgent basis
Be more seriously ill upon hospitalization
Die upon hospitalization
Source: Office of Technology Assessment, 1992
HOW MANY CHILDREN ARE UNINSURED?
Health Insurance Status ofChildren Under Age 18
63.8%
15.4%
20.8%
Uninsured
Public
Private
HEALTH INSURANCE AND AGE
Percent Uninsured by Age
13.215.5
17.9
0
5
10
15
20
25
Less than 6 6-12 13-17
Source: Weinick, Weigers, and Cohen 1998 (1996 MEPS)
HEALTH INSURANCE AND RACE
Percent Uninsured
27.7
17.6
12.3
0
5
10
15
20
25
30
Hispanic Black White
HEALTH INSURANCE AND FAMILY STRUCTURE
Single-Parent Families
38.7%
19.8%
41.5%
Uninsured
Public
Private
Two-Parent Families
73.7%
13.6%
12.7%
HEALTH INSURANCE AND PARENTS’ EDUCATION
Percent Uninsured by Parents' Education
28.5
17.9
10.1
0
5
10
15
20
25
30
35
<12 years 12 years >12 years
Source: Weinick, Weigers, and Cohen 1998 (1996 MEPS)
HEALTH INSURANCE AND PARENTS’ EMPLOYMENT
Percent Uninsured by Parents' Employment
15.819.1
11.4
0
5
10
15
20
25
0 1 2Number of parents employed
Source: Weinick, Weigers, and Cohen 1998 (1996 MEPS)
HEALTH INSURANCE AND WHERE CHILDREN LIVE
Percent Uninsured by Metropolitan Statistical Area Status
14.0
20.7
0
5
10
15
20
25
30
MSA Non-MSA
Source: Weinick, Weigers, and Cohen 1998 (1996 MEPS)
BACKGROUND
Traditionally, Public Insurance (Medicaid) Was for the Poor and Was Free
As Government Programs Expand to Serve Uninsured People in Working Class Families, Then Issues of Cost-Sharing Become More Relevant
Premiums Have Been Used in Family-Based Expansion Programs, Like Tenncare or Washington's Basic Health Plan, and Are Now Being Permitted in CHIP Programs
Sliding Scale Premium: Reduces participation and government share of cost
Copayment: Amount Paid by the Person to Get Specific Medical Services (e.g., Office Visit or Prescription Drugs) Copayments affect whether an insured person
gets a specific service, affect health care utilization
Reduces cost per covered person
BASICS OF COST-SHARING
Reduces Government Cost, Both by Sharing Burden and Lowering Participation
Targets Assistance and Subsidies to the Poorest
May Reduce Problems of Welfare and Medicaid Dependency
May Reduce Crowd-Out May Reduce Stigma
ADVANTAGES OF PREMIUMS
Lowers Participation Might Lead to Adverse Selection Requires More Administrative
Effort Might Break Up Coverage, If
People Enter and Exit When They Can Afford
DISADVANTAGES OF PREMIUMS
May Reduce Unnecessary Medical Care Use
Can Be Tailored to Accomplish Specific Purposes, e.g., High Copayment for ER, but None for Preventive Services
Can Supplement Provider Payments
ADVANTAGES OF COPAYMENTS
Barrier to Care Can Reduce Use of Cost-Effective
Services Harder for Provider, Could Reduce
His/Her Payment
DISADVANTAGES OF COPAYMENTS
RAND Health Insurance Experiment: Generally, Copayments Reduced Medical Utilization and Expenditures, but Did Not Affect Health Status except among poor
Prescription Drugs: Copayments Reduce Drug Use, Could Increase Hospitalization Costs
Tenncare: Many Went Without Medication Because of Drug Copayments
RESEARCH ON COPAYMENTS
DESIGN OF PREMIUM STRUCTURES
How Low and How High? Progressivity Stairsteps Fixed Dollars or Fixed
Percentages? Equity for Individuals and
Families
Tenncare: Sliding Scale Premiums Between 100 and 400% of FPL, Full Premiums Above 400%; Copayments
Hawaii QUEST: Sliding Scale Premiums Between
100 and 300% of FPL
Washington Basic Health Plan: Sliding Scale Premiums Between 0 and 200% of Poverty, Free for Children Thru Medicaid Expansion (State Funded)
Minnesotacare: Sliding Scale Premiums for Families With Children Between 0 and 275% of Poverty, for Childless Adults Between 0 and 135% of Poverty
FOUR STATES WITH FAMILY EXPANSIONS - 1995
ESTIMATED PARTICIPATION FUNCTION, BASED ON THREE STATES, 1995
As Premiums Rise, Participation Levels Fall
Even When Free, Some Do Not Participate
There Is No "Right" Level for Premiums
Trade-Off Between Budget and Participation Goals, As Well As Perception of What Seems "Fair"
MAIN FINDINGS OF ANALYSIS
Includes Children Only, People May Be More Willing to Insure Children
Other Factors Matter Too: Publicity, Ease of Application, Type of Benefit Package
Interactions With Medicaid Federal Rules on Premiums and
Copayments Constrain Choices
CHIP MIGHT BE DIFFERENT
If Medicaid Expansion, Then Follow Medicaid Rules, Essentially Banning Cost-Sharing
If CHIP-Only, Then Premiums in Families Below 150% of Poverty Must Not Exceed "Nominal" Levels, Related to Medically Needy Rules …Modest copayments permitted
If CHIP-Only, Then Total Cost-Sharing in Families Above 150% of FPL Must Not Exceed 5%… No copayments on preventive services
WHAT ARE COST-SHARING RULES IN CHIP?
PRIVATE INSURANCE: OFFER RATES
Percent of All Workers Offered Employment-Related Coverage
72.475.4
50
55
60
65
70
75
80
1987 1996
Source: Cooper and Schone 1997 (1987 NMES and 1996 MEPS)
PRIVATE INSURANCE: TAKE-UP RATES
Percent of Workers Offered Insurance who are Policyholders
88.3
80.1
75
80
85
90
95
1987 1996
Source: Cooper and Schone 1997 (1987 NMES and 1996 MEPS)
PUBLIC INSURANCE: ELIGIBILITY 29.5% of All Children Are
Estimated to Be Medicaid Eligible 33.7% of children ages 0-12 are
estimated to be eligible 20.2% of children ages 13-18 are
estimated to be eligible
Source: Selden, Banthin, and Cohen 1998 (1996 MEPS)
INSURANCE COVERAGE OF CHILDREN ELIGIBLE FOR MEDICAID
Private25.9%
Medicaid51.9%
Uninsured22.2%
Source: Selden, Banthin, and Cohen 1998 (1996 MEPS)
MEDICAID TAKE-UP RATES AMONG ELIGIBLE CHILDREN
Percent of Children Without Private Coverage who Enrolled in Medicaid
70.0 73.2
59.1
0
20
40
60
80
100
All children Ages 0-12 Ages 13-18
Source: Selden, Banthin, and Cohen 1998 (1996 MEPS)
INSTITUTE OF MEDICINE
DEFINITION OF QUALITY (1990) The degree to which health services for individuals and populations * increase the likelihood of desired health outcomes and * are consistent with current professional knowledge
SUMMARY Quality Assessment Can
Help screen out bad providers
Help with improving all providers
Show effects of changes or variations BUT – DIFFICULT TO MEASURE AND
ENFORCE
The Substitution of Public Coverage for Private Coverage (the “woodwork effect”) May Lead To:
Fewer improvements in access to care and health status than expected
Greater increases in public expenditures than expected
Lower cost effectiveness of the program than expected
POLICY IMPORTANCE OF CROWD-OUT
Low-Income Children Gain Access to Affordable, Comprehensive, Health Insurance That Always Covers Preventive Care
Low-Income Families Who Have Been Paying for Insurance Coverage Get Financial Relief
Employers Who Have Historically Provided Health Insurance Coverage to Their Low Wage Employees May Have Lower Health Insurance Costs
WHO BENEFITS FROM CROWD-OUT?
Almost Nothing
WHAT CAN STATES THAT EXPAND THEIR MEDICAID PROGRAMS UNDER CHIP DO TO PREVENT CROWD-OUT?
Institute Waiting Periods Subsidize Employer-Sponsored Coverage Make Coverage and Premiums
Comparable to Employer-Sponsored Coverage
Monitor Crowd-Out and Implement Prevention Strategies If Crowd-Out Is a Problem
WHAT CAN STATES THAT CREATE SEPARATE CHIP PROGRAMS DO TO PREVENT CROWD-OUT?
CROWD-OUT PREVENTION STRATEGIES
Strategy States
3 Month Waiting Period CA, CO, ME, MT, UT
6 Month Waiting Period CT, KS, MD, MI, MO, NV,NC, OR, WI
12 Month Waiting Period NJ
Denial of Coverage if Accessto Insurance
IN, MI, MN, RI, WI
Subsidize EmployerCoverage
MA, MD, NY, NC
Premium Contributions(Above 150% FPL)
MI, RI, NC, FL, GA, NJ, NV,CA, KT, MA, NY, ME, CO,TN, WI
Note: Most states requiring waiting periods make exceptions under certain conditions.
Source: Children’s Defense Fund
May Prevent Crowd-Out May Create Inequities in the Program May Be Difficult to Administer May Reduce Participation Among the
Uninsured
ADVANTAGES AND DISADVANTAGES OF CROWD-OUT PREVENTION
Any Equitable and Administratively Workable Program Will Crowd-Out Private Coverage
Children Will Come Out Ahead With Greater Insurance Security and Coverage That Always Includes Preventive Care
There Will Be Benefits of Financial Relief to Families Who Had Previously Purchased Health Insurance
The Focus on Crowd-Out, While Important From a Budget Perspective, Draws Attention Away From Other Challenges States Face Under Both Their Medicaid and CHIP Programs
Offering Health Insurance Alone Is Not Sufficient
Programs Must Get Uninsured Children to Participate and Provide Access to High-Quality, Effective Medical Care in Order to Realize Improvements in Child Health
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