Only a few states have been allowed to charge premiums to the poorest Medicaid recipients, and all of them did so while also expanding the low-income health benefit under the Affordable Care Act. A renewed proposal from Gov. Paul LePage and his health and human services commissioner, Mary Mayhew, then, comes with a lot of unknowns.

But what we do know, from those states and other initiatives aimed at giving low-income beneficiaries some “skin in the game,” is that it could end poorly for a lot of Mainers. Sure, the financial burden on MaineCare, the state’s Medicaid program, could certainly be diminished, but only at the expense of the health and financial security of low-income residents.

The LePage administration is seeking a waiver to charge premiums to MaineCare recipients who are able to earn income, as well as $20 co-pays for emergency room visits, among other initiatives designed at tightening restrictions on public assistance programs. Indications are that the Trump administration is open to the waiver.

The idea is that not only will such fees limit the amount of public money spent on these programs, but people who have to pay something for their health care are more likely to use it wisely — they’ll take better care of themselves, or they won’t go to ER for some minor illness.

That may apply to co-pays, which are made every time a service is rendered. But those waste-reducing effects may be overblown — research has shown that patients have a hard time distinguishing between high- and low-value visits. They may skip a prostate exam but see a doctor about a bad cold, a dynamic that doesn’t change even if co-pays are waived for preventative tests.

It certainly doesn’t apply to premiums, which beneficiaries pay each month whether they go to the doctor or not, hardly an incentive for using health care efficiently.

Instead, if experience is any judge, the premiums, however small, will discourage people from enrolling. For someone barely getting by, paying what they do have for rent, food and transportation, even a couple of hundred dollars a year extra is too much to swing.

Lower enrollment — a goal of the LePage administration — may be the point. Medicaid premiums elsewhere have not saved money by collecting the fees — in fact, Virginia found that it was spending $1.39 in administrative costs for $1 collected — but through reduced enrollment.

That would mean more Mainers failing to care for chronic diseases or engage in preventative measures, leaving Maine hospitals on the hook when things go bad and costly, uncompensated care is necessary.

Premiums and co-pays for MaineCare, structured correctly, could work under a MaineCare expansion. In that case, such fees could keep people from limiting their income in order to receive benefits, or from leaving an employer-based plan to access MaineCare.

But as it is now, they would only lead to more unhealthy and overburdened Mainers. If the Trump administration grants the waiver, it will be up to the Legislature to stand up for them.

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