title: State variability in children's Medicaid/CHIP crowd-out estimates.
abstract: BACKGROUND
  Health insurance crowd-out occurs when individuals enrolled in a public health insurance plan would have enrolled in a private plan but for the public option. The crowding-out of private insurance is often used to criticize state Medicaid and Children's Health Insurance Program (CHIP) expansion, as already insured children move their coverage to the states at the public's expense. A difficulty in discussing crowd-out comes from inconsistent estimates. Previous work focusing on the expansion of public programs has led to estimates ranging from 0% to 50% of the children newly insured on public plans being crowded-out.
  
  
  METHODS
  We apply a regression discontinuity approach to estimate how many children near the state Medicaid/CHIP threshold are crowded-out of private insurance. This approach allows estimates of crowd-out near the eligibility threshold independent of any expansion. Data from the American Community Survey's yearly survey of American households allows for state-level estimates of crowd-out.
  
  
  RESULTS
  We find considerable heterogeneity in the crowd-out that occurs in each state, ranging from no crowd-out to over 18% in states with similar eligibility thresholds. Additionally, we found that as state eligibility thresholds increase, children are less likely to be crowded-out.
  
  
  CONCLUSIONS
  This research indicates that national estimates of crowd-out are inappropriate, as state-specific Medicaid and CHIP programs have state-specific crowd-out. Additionally, it indicates that wealthier families that are eligible for public insurance are less likely to switch from private to public coverage than families earning less. Future work should identify reasons for the heterogeneity among states.
authors.affiliation: The Ohio State University College of Public Health-Division of Health Services Management and Policy.
authors.forename: David B
authors.initials: DB
authors.lastname: Muhlestein
authors.affiliation: The Ohio State University College of Public Health-Division of Health Services Management and Policy.
authors.forename: Eric E
authors.initials: EE
authors.lastname: Seiber
mesh_terms: D002648:Child; D002662:Child Health Services; D004608:Eligibility Determination; D006801:Humans; D007348:Insurance, Health / Q000706:statistics & numerical data; D008396:Maryland / Q000453:epidemiology; D008484:Medicaid / Q000706:statistics & numerical data*; D009657:North Carolina / Q000453:epidemiology; D011203:Poverty / Q000706:statistics & numerical data; D014481:United States / Q000453:epidemiology
keywords: CHIP; Children's Health Insurance Program; Crowd-Out; Health Care Financing; Health Policy; Insurance; Law; Medicaid; Politics; Premiums; Regulation; SCHIP
references.citation: Health Serv Res. 2009 Apr;44(2 Pt 1):593-605
references.pmid: 19040425
references.citation: Future Child. 1996 Spring;6(1):152-61
references.pmid: 8689258
references.citation: Synth Proj Res Synth Rep. 2004 Jun;(5):
references.pmid: 22052210
references.citation: Health Care Financ Rev. 2002 Spring;23(3):65-88
references.pmid: 12500350
references.citation: J Health Econ. 2008 Mar;27(2):201-17
references.pmid: 18206255
references.citation: J Policy Anal Manage. 2004 Summer;23(3):509-30
references.pmid: 15218879
references.citation: Am J Public Health. 2005 Feb;95(2):292-8
references.pmid: 15671467
references.citation: Health Aff (Millwood). 2007 Mar-Apr;26(2):529-37
references.pmid: 17339683
references.citation: Medicare Medicaid Res Rev. 2011 Mar 31;1(1):
references.pmid: 22340771
references.citation: J Health Econ. 2000 Jan;19(1):33-60
references.pmid: 10947571
references.citation: J Health Econ. 2004 Sep;23(5):1059-82
references.pmid: 15353193
references.citation: Inquiry. 2000 Spring;37(1):23-32
references.pmid: 10892355
references.citation: Health Econ. 2012 Sep;21(9):1061-79
references.pmid: 22807287
references.citation: J Health Econ. 2013 May;32(3):599-611
references.pmid: 23579024