CHIP Premiums, Health Status, and the Insurance Coverage of Children

Article excerpt

This study uses the introduction of premiums into Kentucky's Children's Health Insurance Program (KCHIP) to examine whether the enrollment impact of new premiums varies by child health type. We also examine the extent to which children find alternative coverage after premium nonpayment. Public insurance claims data suggest that those with chronic health conditions are less likely to leave public coverage. We find little evidence of a differential impact of premiums on enrollment among the chronically ill. Our survey of nonpayers shows that 56% of responding families found alternative private or public health coverage for their children after losing CHIP.

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The Children's Health Insurance Program Reauthorization Act (CHIRPA) was signed into law by President Obama in early 2009 and extends the Children's Health Insurance Program (CHIP) over a four-and-a-half-year period, until September 2013 (Horner et al. 2009). CHIP was created in 1997 as a federal-state partnership to initiate and expand health insurance coverage for uninsured, low-income children (Kenny and Chang 2004). The CHIRPA legislation was designed to build upon this success by targeting uninsured children, most of whom are eligible for CHIP coverage under current eligibility rules, but not enrolled. To encourage states to enroll these children, CHIRPA provides incentives to streamline eligibility processing and increases CHIP financial allotments to states.

Increased emphasis on outreach and enrollment implies a need to better understand programmatic barriers to enrollment and retention such as CHIP premiums. The net impact of reducing the complexity of the CHIP enrollment process may be negligible if such a policy change is financed in part by increases in CHIP premiums (Ross and Cox 2005). Thus the introduction of (or increases in) CHIP premiums raises many important policy questions. For example, do premiums reduce enrollment in CHIP? If so, how is this related to the health of the children in the program? In other words, are children with chronic conditions more or less likely to exit as a result of changes in premiums? Do the children who exit CHIP obtain other insurance coverage, either through other public programs (Medicaid) or the private market?

The purpose of this paper is to address these questions by examining the impact of the introduction of a $20 per family per month premium in Kentucky's CHIP in late

2003. We estimate Cox proportional hazard models to measure the impact of this policy change on the duration of premium-paying CHIP enrollment spells. Using linked claims data to identify children with chronic health conditions, we extend the literature by addressing whether child health influences the family decision to drop CHIP coverage when faced with changes in premiums. In order to complement the hazard analysis, we present the results from a survey of families with children that dropped CHIP coverage as a result of premium nonpayment in the first four months after the introduction of the premium (December 2003-March 2004). The survey results also extend the literature by allowing us to examine whether children who leave CHIP as a result of premium nonpayment find other sources of insurance coverage.

The results of our hazard analysis suggest that the introduction of the premium reduces the duration of CHIP coverage for the average child (as is typically found in the literature). In addition, children with chronic health conditions, such as diabetes, asthma, or one of a variety of mental health conditions, are less likely to leave CHIP coverage than children without one of these health conditions. Unlike Herndon et al. (2008), we find little evidence of a differential impact of premiums on the enrollment status of children with chronic conditions. Our survey results suggest that 56% of responding families report having some form of private (25%) or public (31%) health coverage after losing CHIP coverage for their children. …