The qualitative findings from the focus groups that follow give a flavor of the views of participants in the SCHIP program. However, since they do not represent a statistically selected sample, their representativeness is clearly limited. In the final report to Congress in 2004, results of surveys of enrollees and disenrollees will provide quantitative evidence about the effects of cost sharing on SCHIP enrollment and service use.
In states that require a premium or enrollment fee, most case study respondents (including child advocates) reported that they have not heard that cost sharing poses a barrier to enrollment. They reported that premium amounts are considered reasonable and that, compared with the cost of alternative private-sector options, premium levels adopted by most states appear to be quite affordable. Front-line staff in Texas had heard families describe the premium as "too good to be true," and "the deal of the century." Furthermore, premium requirements were often described as making the program more appealing to some families. As an informant in one state put it, "I think that if we had made this program free, families would have probably been more skeptical of it, or dismissed it as welfare."
Few focus group participants viewed premiums as a positive attribute of SCHIP, but few considered them burdensome. For example, "It's the lowest check I write the whole month," and "Oh it's a blessing to have this kind of coverage for 15 bucks" (Fort Pierce, Florida). (It is important to note that these findings reflect the opinions of parents who have chosen to participate in SCHIP; they do not tell us how parents who have not enrolled their children view the affordability of premiums.) From the families' perspective, the main problem with premiums was logistical--it was hard to remember to pay premiums every month (hence, some consumers disliked state policies to disenroll children whose parents missed payments). The practical implications of such disenrollment--gaps in coverage and/or "churning" as children lost, and then regained coverage--were widely viewed by focus group participants as negative outcomes of these circumstances.
Privately insured, low-income families in the focus group study had much larger financial payments than SCHIP participants--and some resent both that they have to pay such high premiums and that families in SCHIP do not.
Some case study respondents in Missouri believe that the state's premium could be a barrier to enrollment, although premiums apply only to families with incomes above 225 percent of the FPL. (Focus group participants in Kansas City, Missouri who make premium payments spoke of the challenge of monitoring their incomes closely to avoid jumping to the next tier of payments or above the eligibility level.) Premium amounts are higher in Missouri than in any of the other study states, and they have recently been increased. Since the inception of the program, however, enrollment in this eligibility group has been low, so it is not clear whether the small number of enrollees in this segment of the program (five percent of total enrollment) indicates that premiums are less affordable, that families are not aware of the program, or that the need for the program is less among families at these higher-income levels. The buy-in premium component in New York--which also has a higher premium ($115) and applies to families with incomes above 250 percent of the FPL--also constitutes a small part (two percent) of total SCHIP enrollment in that state.
Colorado experienced problems with its premium program and ultimately dropped it. The state initially required all families to pay premiums, including those with incomes between 100 percent and 150 percent of the FPL (a lower threshold than the one used by most states). Unlike most other states, however, Colorado's program did not penalize families for nonpayment of premiums. Delinquency rates escalated over time; and eventually, the state comptroller threatened to send overdue accounts to collection agents. Public opinion of the program then dropped, and with it, enrollment. Ultimately, the state abandoned the premium program and replaced it with an annual enrollment fee that did not apply to families with incomes under 150 percent of the FPL. Some months later, enrollment growth rates returned to earlier levels. The availability of free or low-cost care through a well-known indigent care program operating in the most populous regions of the state seems to have influenced families' perceptions of whether SCHIP offered a "good deal," especially for families in the lowest-income groups.
In all states, case study respondents reported that copayments are considered reasonable, that families are happy to make copayments, and that this type of cost sharing does not reduce the use of services--views that were echoed by focus group participants. Case study respondents in several states noted that higher copayment amounts, especially for emergency room care, may in fact reduce inappropriate emergency room use. While it was not widespread, case study respondents noted that some families do not meet their copayment obligations. This seemed to happen more often in areas where families are accustomed to accessing free care through programs for the medically indigent. Providers had varying views of unpaid copayments. While some reported that they absorbed the cost when copayments were not paid, providers in one state saw this as a reason to limit their SCHIP caseload. In several states, case study respondents noted that providers with a tradition of providing charity care often resist collecting copayments.
A consistent finding across the study states was that cost sharing is not considered a "revenue maker." State officials reported that premium programs cost more to administer than they bring in given the low value of the premiums compared with cost of monthly invoicing, payment processing, and reminder systems. Costs may decrease as states explore using payroll deduction systems, quarterly or semiannual billing cycles with incentives, and other ways of reducing administrative costs. Despite the administrative costs, however, states find cost sharing beneficial because of the positive image it engenders for the program among participants, politicians, and the general public.