Sliding-scale premium health insurance programs: four states' experiences

As publicly funded health insurance shifts more toward coverage of working families of low and moderate incomes, there has been growing interest in beneficiary cost sharing, in the form of sliding-scale premiums. In the 1990s, Hawaii, Minnesota, Tennessee, and Washington initiated expansion programs that used sliding-scale premiums for working-class families. The experience in these states indicates that it is feasible to require cost sharing of premiums, but there are a number of design and operational complexities. A preliminary analysis indicates that, as expected, higher out-of-pocket premium shares were associated with lower participation rates.