- Conclusion
This paper has reviewed the experiences of nine states that used either Medicaid
expansions or developed stand alone programs to expand health insurance for children prior
to the enactment of Title XXI. Their decisions regarding benefits and cost-sharing
arrangements reflected the overall program objectives they were trying to achieve and the
cost implications of their choices. The objectives the states considered included:
assuring a comprehensive benefit package through a Medicaid expansion; provision of
primary and preventive services to as many uninsured children as possible; and/or
addressing coverage for a specific population of uninsured children such as transitional
care to children without health benefits. As states consider their options under Title
XXI, these same factors are likely to affect their decision-making.
States' decisions regarding cost-sharing arrangements reflected their overall philosophy
regarding premiums and copayments and trial and error approaches. States considered
cost-sharing mechanisms such as premiums, fees for enrolling in the program, and
copayments for specific services as a means of offsetting cost, a way to instill a sense
of responsibility in participants for their health care, and/or a way to minimize the
welfare stigma associated with public programs. For the majority of states, the cost
recovery features were not a major driving force. Cost-sharing was viewed by some states
as a way to limit potential substitution effects of the public programs and provide a
bridge between public and private programs.
A major issue underlying the states considerations of cost-sharing approaches was price
sensitivity. States emphasized concerns that programs be affordable and not deter
enrollment of targeted populations and their appropriate utilization of services. However,
decisions related to cost-sharing were generally based on anticipated effects and limited
experience. There is presently little evidence or data on the appropriate levels of
cost-sharing and the use of sliding scales and family caps to maintain affordability. As
all states move toward implementation of Title XXI, evaluation and research related to
price sensitivity may provide important information for further decisions.