While there has been considerable attention of late focused on the Affordable Care Act and the courts, many states, health care providers, and employers are continuing to move forward on the assumption that the Affordable Care Act will stay in effect—at least in its broadest dimensions. While a Supreme Court decision is now expected by the end of the 2012 term, getting ready for implementation of the major provisions of the ACA that go into effect in 2014 cannot wait for that court decision.

Much has been made about provisions in the Affordable Care Act affecting employers: expansions of benefits, affordability provisions, automatic enrollment requirements, and limited penalties for not offering coverage. Surveys abound, predicting what employers will do as a result of the ACA, and they are wildly different: predicting everything from a significant decrease in the number of employers offering coverage post-reform to a significant increase.

The Affordable Care Act is complex, and many employers know only the well-publicized elements of the law. Most surveys to date have been conducted by asking employers about various future scenarios, and human resource directors have responded based on those scenarios. At best, these surveys are highly speculative. And, even with a deeper understanding of the law and its key provisions, we believe most employers won’t jump to decisions about whether or not to continue offering coverage but will rather take a wait and see approach to see how some of the new structures—like health insurance exchanges—develop over time.

When employers respond, for example, that they would likely drop health benefits as a result of the Affordable Care Act, they may be thinking about only one part of the equation: the current cost of premiums and the likelihood that direct penalties for dropping health coverage will be less than the premiums they pay. But that answer doesn’t take into account what the competition will do, how important health benefits are to attracting a skilled work force, and/or what wage pressure might develop if employers that are currently offering health coverage drop it and encourage employees to purchase their coverage on the Exchange. All of these issues are more complex and will take considerable sorting out by employers.

To help employers better understand the relevant provisions of the ACA, we developed and published a guide called The Affordable Care Act for Midsize and Large Employers. This guide highlights some of the nuances employers will need to consider when thinking about changes they might make to their health benefit plans: nuances such as—how many of their employees are part time, how rich are the benefits they offer today, and how health insurance benefits relate to the average compensation levels of their employees. Our hope is that this guide will inform employers and help them begin to think about the relevant questions as they determine their best future direction for employee health benefits.

The Affordable Care Act will set in place a whole series of changes to the health insurance market place that are interrelated and will lead to some fundamental differences from the ways health coverage is purchased today. How those changes affect the employer market will be an unfolding story over many years. Becoming educated on what those changes are is, however, something all employers can and should do starting right now.

Many of those working to improve health care in America have advocated for the use of electronic prescribing as an important tool for improving patient safety and moderating health care cost trends. A recent report released by the U.S. Government Accountability Office (GAO) documents abuses in the Medicare drug benefit that underline the potential value of electronic prescribing tools. According to the GAO report, some beneficiaries were able to obtain more than a year’s worth of narcotics by “shopping” different doctors. Electronic prescribing tools can enable health plans, physicians, and pharmacists to detect doctor-shopping, and assure that multiple prescriptions are not filled for the same condition within a given time period. Such an approach can both protect the health of patients who may receive duplicate prescriptions in error, and prevent fraud and abuse by those who seek prescription drugs for non-medical purposes.

In a recent review of the literature[CHRT E-PRESCRIBING] on e-prescribing, our center noted that despite the evident potential of e-prescribing, use is still very low. In 2010, only 25 percent of eligible prescriptions were prescribed using electronic tools. Indeed, Michigan had the second highest rate of e-prescribing in the country in 2009 – 20 percent – up from 4 percent in 2007. But even though rates are increasing, they are still extremely low relative to the opportunity. In a recent issue brief, the Center for Studying Health Systems Change found that in 2008, 42 percent of physicians in the country had access to e-prescribing, but only one-third were routinely using the technology.

The American Recovery and Reinvestment Act (ARRA) included significant components to promote the use of electronic medical records (EMRs). Starting this year, there are incentives for physicians who document “meaningful use” of EMRs, and starting in 2015, there are disincentives for physicians who don’t. There is already evidence that physicians are responding to these incentives to some degree, and because e-prescribing is included as part of EMR meaningful use standards, these incentives/disincentives may provide impetus for a further increase in e-prescribing. However, there are many who believe that the uptake is too slow and the incentives and disincentives included in the ARRA won’t make a big enough difference in the use of these tools.

So, why is it we can know so well that something will improve quality and safety and yet don’t use it to its potential? One key reason: the increasing availability of information and technology often outstrips the speed at which human systems change. The meaningful use guidelines recognized this by providing not only incentive and disincentive funding but also technical assistance to help physicians make the needed changes. Aligning incentives between public and private payers such that physicians get consistent messages and consistent support to embrace technology will also help.

But technical assistance and aligned incentives will only help to the extent that physicians want that help and are open to change. There is a telling statistic in the study reported by the Center for Studying Health Systems Change: the degree of e-prescribing use by age of physician. Of physicians over age 60 with access to e-prescribing, 66.5 percent used it routinely, compared to 87.2% of physicians between the ages of 29 and 40.

It would be nice if the trend toward adoption of EMR/e-prescribing didn’t rely on the retirement of older physicians. But it does appear that over time, one way or another, we will eventually reach a tipping point, and e-prescribing will become the norm, not the exception.

It is difficult to find an issue that is more politically contentious than health care; particularly the policy changes and programs that are needed to assure that Americans have access to needed care.  The liberal position tends to see health care as a right, and seeks a strong centralized public role in assuring that all Americans have access to the same kinds of benefits and care.  The conservative position sees fiscal and personal responsibility as the top priorities; tending to favor decentralized, private market solutions.

Most would agree central authority does a better job assuring equity of coverage to a defined set of benefits (best evidenced in Medicare, where there is a uniform, national benefit package). There is less agreement on whether centralized or decentralized authority is preferable in terms of health care quality improvement and effective cost control, but there is strong evidence in support of the need for centralized authority to accomplish these goals.

The case for central authority begins with a critique of state/local government authority. The problem with state based approaches is that a significant degree of decision making is delegated to each of the 50 states, making it extremely difficult to achieve uniformity unless there are strict and prescriptive federal guidelines.  Most often it creates a situation where there is success based on anecdote:  we hear about the innovation that occurred in Massachusetts through its health reform initiative, or the single payer system planned for Vermont, or Hawaii’s success in reducing its rate of uninsured.  These glowing stories of success blithely gloss over the fact that these are truly exceptions, in aggregate affecting less than 5 percent of the U. S. population with little or no chance of adoption by other states.

Even when the federal government partners with the states to meet policy objectives, states tend to take advantage of any discretion, thereby creating state to state differences based more on fiscal ability and political priority than on variations in local need.  Take Medicaid as an example.  In 2009, 17 states set eligibility thresholds for working parents at less than 50 percent of the federal poverty line.  Another 17 states set eligibility for working parents between 50 percent and 99 percent of the federal poverty line.  Lastly, 16 states set their eligibility threshold at income greater than the poverty line. What is the policy justification for these differences?  Are working families in Tennessee (greater than 100 percent of poverty) significantly different from working families in North Carolina (less than 50 percent of poverty)?

The differences from state to state in Medicaid are significant, impacting who is eligible, who gets access to care, and the quality of care they receive.  A recent study from the Commonwealth Fund highlights this issue. The study looked at Medicaid managed care and compared the performance of publicly traded health plans with the performance of non-publicly traded plans (mostly provider owned).  It found that publicly traded plans tended to devote a higher percentage of each premium dollar to administrative expense—including profit—and receive lower scores for quality related to preventive care, treatment of chronic conditions, and members’ access to care and customer service.  Again, this leads to disparities among states because for-profit plans tend to be concentrated in certain states.

The major reasons for Medicaid’s profile on cost and quality performance involve two interrelated factors:  states’ political culture and fiscal capacity.  States with the largest poverty populations tend to have less fiscal capacity than more affluent states. So when these poorer states are asked to match federal dollars, they simply do not have the tax base to afford more generous benefits and higher eligibility thresholds.

Secondly, Medicaid is not a popular program in most states.  Legislators would rather allocate incremental tax dollars to other purposes, such as elementary and secondary education, higher education, corrections and/or tax relief.  Even though two-thirds of Medicaid dollars go to pay for care for the elderly and the disabled, these dollars are generally viewed as going into the pockets of providers, who are thought to be well off and not a priority for extra tax dollars.  As a result, in most states there is not an effective political constituency to advocate for the Medicaid program.

In summary, state based accountability tends to result in programs with wide, and unjustified, disparities from state to state.  There are some success stories, but these tend to occur in more progressive and affluent states and represent the exception and not the rule.  Yes, state accountability is better than no accountability, but it is not the way to develop an equitable and effective coverage program for all Americans.  State control can be effective in cost control, but when cost control becomes the overriding policy priority, that success can come at the expense of quality, coverage, and access to care.

Healthcare consultant Kevin Seitz, MSW, is the former executive vice president for Health Care Value Enhancement at Blue Cross Blue Shield of Michigan. Seitz was a founding member of CHRT’s board of directors and served on the board from 2006 to 2010.

In early August, when the debt ceiling agreement was reached, many news reports noted the agreement did nothing to address core reasons for the debt, namely: Social Security, Medicaid and Medicare. Indeed, nearly every article written about the debt ceiling talked about the need to “deal with” (aka: cut) Medicare, Medicaid, and Social Security.

But every time there is a serious proposal on the table to cut federal spending for health care, health care stocks fall—and this is considered a bad thing.

Recent reports from the Office of Chief Actuary noted the rate of increase in health care spending was at a historic low (3.9 percent) in 2010. Now you would think the media would frame this as good news, especially in light the need to reduce health care spending to address the national debt.

Instead, news reports carried headlines like: “Health-Care Use is Sluggish.” These reports cited the “fragile recovery” as the reason fewer people went to the hospital, which had a negative impact on medical suppliers’ earnings reports (though, a positive impact on for-profit health plans). Indeed, the article profiled stock problems at Johnson and Johnson, noting (among other things) the “sluggish sales of replacement hips and knees.”

We rarely talk about the business of health care in those direct terms: “sluggish sales of hips and knees.” We prefer to think of health care in more altruistic terms: care that is patient-centered, care that helps people in need, care that improves population health. Indeed, in the 1990s, there was a brief, consultant-driven movement when patients were called “customers” with the idea that that would focus practitioners more on quality and service. That movement quickly died because those receiving health care services didn’t like being viewed as “customers” or “consumers,” and those providing services didn’t like being viewed as just any other business.

But the reality is, just as is exemplified in the Wall Street Journal article, today much of health care is developed by or delivered through the for-profit world. And, the for-profit world has different incentives than the federal government or, indeed, consumers at large. In fact, the interests of shareholders may require behaviors that are at cross purposes with the public interest as expressed during the debt ceiling debate. This is part of what makes any discussion about cutting Medicare in particular so difficult. After all, Medicare beneficiaries are among the biggest consumers of health care, based both on their demographics and their generally extensive health benefits. So, any cuts to Medicare means cuts to those whose income and returns are dependent on the use of health care services.

It is important to note that this issue is not just about for-profit health care. Though nonprofit providers do not have shareholders, they often develop a parallel goal to for-profit providers: survival of the entity itself, and not just the services they provide. And, as many of those in religious orders running hospitals came to understand, there is no mission without a margin.

So, though many in health care don’t like to view it as a medical-industrial complex with customers instead of patients, in the end, it truly is. And, until we understand the truth behind the financial structures of health care that create conflicting incentives, we really won’t be able to have a realistic conversation about the need to cut health care spending at all.

When I was in graduate school and early in my career, hospices were viewed as one of the most altruistic components of the health care system. With a philosophy of caring holistically for those at the end of life by controlling symptoms, supporting families, and providing a “good” death (preferably at home), hospices seemed to represent the vision of compassion that should be embodied in a caring profession. Hospice care was formalized in Great Britain in the late 1960s, and federally funded in the U.S. for the first time in a 1979 demonstration project. The hospice benefit became a part of the Medicare program in 1982 and fully incorporated in 1986.

Perhaps it was inevitable that, when formalized as an insurance benefit, the nature of hospice care would change. In every aspect of the health care system, as coverage makes it easier to make money by providing a given benefit, entrepreneurs enter the system. After all, this is the American way – with all of its pluses (creating incentives for innovation) and minuses (creating opportunities to make money in ways that don’t actually add value to patient care).

Even if it was inevitable, I find what has happened to the hospice movement to be a sad story in the journey of American health care.

In the early years, hospices saw themselves as part of a movement to give better, more compassionate care to the dying. The overwhelming majority of these organizations were non-profit, often led by charismatic leaders and community boards of directors.

In today’s environment, for-profit hospices are on the rise and non-profits on the decline. In 1990, for profit hospices cared for only 9 percent of hospice patients. By 2009, they cared for 35 percent. In 1986, Medicare reimbursement for hospice care totaled $68.3 million; by 2009, that number had grown to $12 billion. As baby boomers become senior citizens, these numbers will go nowhere but up.

While there is nothing inherently wrong with for-profit hospices, an increasing body of research says their care is less comprehensive and admission criteria more selective (to focus on more profitable patients). Indeed, in 2007, profit margins of for-profit hospices ranged from 12-14 percent while that of non-profit hospices ranged from -2.9 to -4.4 percent.

Recently, the New York Times ran an article about the changing profile of hospices and increasing concerns about the cost of hospice care. An aging population and increases in Alzheimer’s and other forms of dementia account for part of the increase in hospice spending. But the Times article also reported on abusive practices by some hospice providers, and large financial settlements resulting from whistle blower and other lawsuits. As a result of ballooning costs, Congress is now considering a change in the reimbursement methodology for hospice providers.

There is no question that hospice care can improve the end of life journey for many individuals and families—but it is still under-utilized by many who could benefit. The shift from a “movement” to an “industry,” –and publicity around industry abuses—have the potential to discourage patients from seeking the care they need.

Too many times in the history of American health care the “medical-industrial complex” has overrun patient interests. Let’s hope this is one time when Congress can reverse a dangerous trend. Returning to the values of “the movement” would be a truly beneficial “back to the future” moment.

Health care policy happens at many levels, but health care delivery: just one. Policy is made at the federal, state and local levels—but delivery is at the local level: in organized systems of care or with individual or teams of practitioners working with patients and families.

There must be a nexus between policy and practice in order for policy related to medical care to have any real impact on the health of individuals and populations. Though there is some recognition of the importance of the nexus (see the formation of clinical translational research entities—CTSAs—at many universities), policy makers often overlook this important step. To make true change in the way care is delivered in America, this translation of policy to local level implementation must be explicit.

The coverage provisions of the Affordable Care Act (ACA) offer great examples of the importance of this connection, and how the centrality of the local role has been overlooked. The ACA relies heavily on Medicaid and health insurance exchanges to expand health coverage. We know from Massachusetts’ experience that when coverage was expanded, many people tried to find a practitioner to treat them and could not. This meant that those with newly acquired coverage were more likely to get care in the emergency department or other facility settings: high cost and ineffective approaches to primary care.

Where is planning occurring in the rest of the country to prepare for 2014 and avoid what happened in Massachusetts? There does not seem to be a coordinated strategy in any states or with the federal government to address this important issue—but we have a great example right here in Washtenaw County.

In the early fall of 2010, the former CEO of the St. Joseph Mercy Health System in Ann Arbor, Robert Laverty, started talking to a number of community leaders about coming together to identify ways to improve care for the poor in Washtenaw County today (Medicaid recipients and the uninsured), and to begin planning for health care reform long before 2014. He got commitments from the CEOs of the two major health systems in the community to co-sponsor this effort, and enlisted other community leaders to chair and facilitate the work. Ultimately, 40 individuals got involved—on a voluntary basis—representing providers, safety net organizations, the Department of Human Services, county employees, public health, patients and their advocates, and the like. The group worked for 6 months focusing on how to improve care—here and now—as well as to plan for the future.

The first step the group took was to document the current state of affairs and what care in Washtenaw County might look like in the future. For example, the group noted that there were approximately 6,400 people currently eligible for Medicaid but not enrolled and 50,000 uninsured in Washtenaw County. By 2014, an additional 25,000 individuals were expected to be eligible with most (but not all) of the uninsured expected to enroll in private coverage with the help of subsidies.

While there are many primary care providers active today in Washtenaw County, the group estimated that the expansion of coverage would increase demand for primary care services by something like an additional 54,000 visits and more than 33,000 of the uninsured appear not to be connected to primary care at this time.

These numbers should be startling and galvanizing: and they have been in Washtenaw County. The groups are now working together on the strategies needed to fill these gaps and more (dental, mental health, and substance abuse treatment were also areas of focus for the group, along with ways to simplify and improve the Medicaid enrollment process). Working together, the health systems and safety net providers are looking at how to restructure what already exists and bring more capacity to the community to be prepared for the expected increase in demand.

This is where the nexus between policy and practice happen. Washtenaw County is off to a great start in preparing for 2014. How many other communities can say the same?

In the May 18 issue of the New England Journal of Medicine, Rashi Fein and Arnold Milstein tackled the question of why evidence-based care diffuses so slowly. The article is compelling because of its fundamental conclusion: institutionalized interest group pressure against change in health care and consumer misunderstanding of health care financing make it hard to envision how health care spending could be reduced in significant ways.

Fein and Milstein note, as many have, that other countries have addressed this issue much better than we have in the United States. They conclude that if we could do as well as some of these other countries, we could save $640 billion – no small sum, especially with the focus on deficits in today’s environment. But they go on to enumerate the obstacles to getting evidence-based guidelines embraced and used on a routine basis.

Those who are steeped in health policy often focus on macro level trends and impacts. But in the U.S., unlike most developed countries, health policy decisions are not made on the macro level. Health policy in the U.S. is fragmented, with many different actors creating the environment and cost trends. State and federal governments have significant health policy roles but they are not alone in their influence. They are joined by thousands of health plans, hospitals, physicians and other provider entities, device manufacturers, pharmaceutical manufacturers, billing agencies, research entities, and other administrators, all with a stake in the current health care system. This diffuse decision making makes it harder to effect change in the U.S. than in countries where decision making structures are more centralized.

So, what can we do about the environment we are in? Well, the Affordable Care Act has a number of strategies for changing the cost trajectory of health care in the country. But most importantly, it will be essential for groups throughout the country to focus on things that can truly be changed and not get lost in those macro trends.

A great example is the concept of waste in health care. Some people argue that as much as 30 percent of spending on health care is “waste” because so much care doesn’t have good evidence behind it—and that may be true. Others think of waste as process re-engineering: simplifying and streamlining functions for efficiency. These points of view may not be in conflict, but viewing this as a macro issue, encompassing both, can make it hard to tackle any part of the problem.

Looking at waste in health care on a global basis can get us mired into looking at every possible approach to reducing spending. This was the approach taken in the Affordable Care Act. Make no mistake: there are great ideas in the Affordable Care Act and they should all be tested. But, for those not in the federal government, focusing on the laundry list of ideas can actually be paralyzing. Community and even statewide groups can come to the conclusion that “solving” the cost problem is out of their hands.

Perhaps a better way to look at the question of waste in health care is to say: in a highly decentralized system, how do we influence enough individual actors to make a noticeable difference in overall health care spending? Put that way, community and state groups can focus on efforts that can be undertaken to make a difference and build from there. Think of hospitals coming together to work on Lean Engineering to make a difference in the efficiency of health care at the hospital level. Think of health plans and physician organizations sharing data about best practices in certain clinical areas to learn from each other about evidence-based guidelines and ways to do things differently. And, think of communities focused on physical fitness and nutrition in the schools and working with parents to prevent obesity before it happens.

Starting from the community and going up rather than the macro and going down can give us more hope that the promise of reducing waste—and in that process freeing up billions of dollars for other purposes—could be achievable after all.

Sixty-five quality indicators? Retrospectively attributed patient populations? Risk after the fact? Significant management and financial investment required with uncertain payback?

This may not sound like a strategy to win the hearts and minds of providers who are on the fence about whether or not to participate in CMS’ new approach to care: accountable care organizations (ACOs). So, what is going on?

Well, first a little background. Several events coincided to encourage CMS (and some private insurers) to embrace the ACO concept.

To begin with, years of research done in connection with the Dartmouth Health Care Atlas led some researchers to advocate for a model similar to ACOs. For many years, Dartmouth noted the tremendous variation in use of health care services in the country. In this context, they also looked in more detail at the use of services by types of institutions and noted that some systems (generally, academic medical centers) were better at managing care than others – especially when looking at the experience of the entire case and not just the cost per day of care. These institutions had lower rates of complications and readmissions – making the episode of care lower cost than those at other institutions where the quality indicators did not look as good. The idea of rewarding hospitals and physicians who work together in an integrated manner and encouraging others to create such structures became formalized in the ACO framework.

The concept was also attractive to those who had observed that the fee for service structure was not effective at managing the cost of care, but knew that managed care systems – popular with employers in the mid-1990s – were not popular with patients. The ACO concept was designed as a mid-point – a system that attributes patients to provider entities, holds providers accountable for the care of the attributed population, but doesn’t make the patients choose anything. From a patient’s perspective, they get care as they always have – with perfect freedom to choose the provider they want – and all of the “management” occurs behind the scenes.

Finally, the concept also coincided with Don Berwick’s move to head the Centers for Medicare and Medicaid (CMS), bringing a concept he championed at IHI: Triple Aim. In Triple Aim, an entity (a provider, or payer, or government) takes responsibility for population health and tries simultaneously to improve population health and patient experience while lowering health care spending. The ACO concept would seem to be a good model for testing whether or not these goals can be achieved – with the right incentives. And, the already-extant CMS Physician Group Demonstration project would seem to be a good project to build upon.

The challenge of ACOs, however, is that they are an entirely unproven concept and it is completely unclear whether or not they could really be structured in an environment that includes community hospitals and independent physician groups – not just academic medical centers.

There is no question that integrating care across practice settings (hospitals, offices, nursing homes) has the potential to improve both the quality and the efficiency of care. The question is, however, in an environment as fragmented as the one we have today, will a strategy like ACOs (as articulated to date by CMS) really get us there? And, if tightly managed care networks that required patients to select and stick with a primary care physician didn’t work, how likely is it that a loose structure like ACOs can really improve care such that the “juice is worth the squeeze”?

All of this is, of course, unknown. And, perhaps that is why CMS chose a route in its interim regulations that wasn’t very popular with providers. Maybe, in the end, CMS doesn’t really want too many participants as they move down this uncharted path.

But, the optics are important here. Since every provider and their brother announced that they are, in fact, ACOs – long before the term was defined by CMS – having significant providers saying they won’t be (e.g. Mayo), could be a serious setback for the future of this concept.

Only time will tell, of course, and Paul Ginsberg has given an elegant defense of the CMS rules here. But, if I were a betting person, I would say the odds are long that the ACO model articulated to date will have the kind of broad sweeping impact that early proponents hoped it would.

Today we are releasing our Cover Michigan Survey, 2011. Like last year’s survey, this report looks at what Michigan residents say about their access to health care. Different from last year, this survey was designed to look more in-depth at access, along with health status.

Our findings confirm last year’s major finding: Having health insurance coverage is important but not sufficient to assure access to health care.

Those who were uninsured reported that they were less connected to primary and specialty care than those who were insured, and the uninsured were much more likely than the insured to identify the emergency department as their usual source of care. This year, we also noted that those who were uninsured reported significantly poorer health status than those who were insured – 16 percent of those who were uninsured said their health status was “poor” compared to only 5 percent of those who were insured. Notably, almost one-third of the uninsured reported having been diagnosed with depression – more than twice the rate of any insured category and much higher than the national average rate of 10 percent.

But even for those who had insurance, access varied depending on the type of coverage. Last week, the New England Journal of Medicine reported on a study that showed, through a “secret shopper”-type program, that those with Medicaid coverage had a harder time getting appointments with specialists than those with other coverage—further supporting the findings in our survey.

Medicaid recipients reported a significantly harder time getting access to care than those with other coverage—and not just for specialty care. In our survey, 42 percent of those with Medicaid coverage reported having been told their primary care physician would not accept their insurance coverage, compared to only 15 percent or less for those with Medicare, employer, or individual coverage. Twenty-two percent of those with Medicaid coverage reported having been told their specialist wasn’t accepting their coverage compared to 11 percent or less for those with Medicare, employer or individual coverage. And, getting appointments with either primary care physicians or specialists was much harder for those with Medicaid than those with any other kind of health coverage. One quarter of Medicaid recipients reported that they had a very difficult time getting appointments with specialists compared to 10 percent or less for those with Medicaid, employer, or individual coverage.

The Affordable Care Act relies heavily on the Medicaid program to expand coverage to the uninsured. The findings in our survey suggest that the Medicaid program, as structured today, will be sorely challenged as several hundred thousand more people are added to its rolls in Michigan in 2014. While the federal government anticipated this challenge in part, and included a provision to pay primary care physicians at Medicare rates in 2013 and 2014, that provision will go only so far in dealing with the bigger issues in Medicaid. If we want to provide real access to care for Medicaid recipients, we’re going to need some new thinking about how to structure provider networks to care for those newly eligible—and provide better access for those currently enrolled.

Given the breadth of medical needs we found among the uninsured, all programs—public health and Medicaid alike—will have to think about ways to meet the needs of this population, with particular attention to providing better mental health care to Medicaid recipients. Today, mental health care is somewhat fragmented and significantly under-resourced. Given that one-third of the uninsured population noted that they have been diagnosed with depression—many of which will be coming into the Medicaid program—re-thinking how care is structured in this regard is paramount.

While 2014 still seems somewhat far off, the scale and significance of these changes are such that planning must begin now. And even if the Affordable Care Act were never to go into effect, our 2011 survey tells us that there are already significant access issues today for those who are on Medicaid.

We sincerely hope the data in our Cover Michigan Survey can help policy makers with the tough decisions and challenges that lie ahead.

Michigan Governor Rick Snyder deserves special notice and acknowledgement for the courage and focus he displayed in his decision not to sign on to the letter signed by all other Republican governors, asking for changes to the Medicaid program and advocating for the repeal of the Affordable Care Act.

I am sure Governor Snyder disagrees with some provisions of the Affordable Care Act—and it may not reflect his preferred approach to dealing with health care reform in this country.

But his rationale for not signing the letter is admirable. He sees the debate as a distraction from the very real importance of focusing on how to improve health care for Michigan citizens.

His focus is rightly where it should be: on how to make things work. He wants Michigan to be seen as a role model for effective implementation, and for doing what needs to be done to reduce the number of uninsured and improve the operation of Medicaid.

Next week, our Center will be releasing a report on the state of health care access in our state. The survey underlines the importance of Governor Snyder’s focus: the need to improve access to care for the uninsured and strengthen the Medicaid program. Those without health coverage are suffering, and the data show that.

Governor Snyder’s courage—in moving forward to help expand coverage, and in taking this position against considerable pressure—is a great thing for our state, and as citizens, we should all be grateful.