Since the Supreme Court ruling on the Affordable Care Act (ACA), the discussion about Medicaid has largely focused on a choice states now have: whether or not to expand coverage to those at or below 138 percent of poverty. This issue is extremely important because of the impact it could have on those who are uninsured today.

However, there is a lesser-known, more technical provision in the ACA that could also have an impact on the numbers of uninsured: eligibility and enrollment process changes. Specifically, in addition to expanding Medicaid, the ACA simplifies eligibility standards for the existing Medicaid program, which should make enrollment easier for clients.

Medicaid enrollment processes in many states are complex and have been a deterrent to enrollment for many. As part of the work CHRT is doing with the Washtenaw Health Initiative, we looked in-depth at the enrollment process in Michigan today to determine what could be done to simplify it, now and in preparation for 2014. As we dug into this issue, the full complexity of the eligibility process became clearer, surprising even those of us who have worked in the Medicaid enrollment world.

We found that in Michigan today there are 40 different ways to qualify for Medicaid—all with different eligibility nuances and administrative requirements. It was so hard for us to put the full picture together that we decided to document it and make it available for others to use.

It is an understatement to say that navigating Medicaid today is complex, both those for those who might be eligible and for those who have to administer the eligibility and enrollment process. There are no fewer than 23 programs in Michigan related to an individual’s eligibility for cash assistance, 16 programs related to eligibility for supplemental security income (SSI), and one emergency services program for certain immigrants. Today, these programs involve income tests, assets tests, special deductions, and income disregards.

In 2014, those eligibility categories collapse into just three: those at or below 138 percent of poverty (assuming the state decides to accept the Medicaid expansion), those eligible under parts of the existing program with higher income standards, and those who are medically needy and receiving SSI.

And regardless of whether a state decides to expand eligibility for Medicaid, the ACA will simplify and standardize eligibility. Income eligibility will be determined using a method based on an income tax definition known as “modified adjusted gross income” (MAGI), which means no more asset tests or special deductions. The ACA also requires the upfront use of electronic data matches to eliminate the need for applicants to provide documentation. All of these changes will make the enrollment process easier and reduce the time it takes to get health coverage.

To the best of our knowledge, these parts of the ACA were unaffected by the Supreme Court’s decision on the Medicaid expansion. Both the Congressional Research Service and Centers for Medicare and Medicaid Services have said they believe that the Supreme Court’s decision affected only the penalty that would be applied if a state chose not to expand Medicaid.

So, assuming this view holds, all states will need to convert their eligibility processes to these more simplified approaches, regardless of their expansion decision.

What does this mean in Michigan? Well, today, of the approximately 1.2 million people who are uninsured, about 11% are already eligible for Medicaid but not enrolled. The complexity of the enrollment process is clearly a deterrent for many of them (not to mention its impact on the extremely over-burdened case workers in the Department of Human Services). Eliminating these barriers to coverage could mean that more than 132,000 of them could become enrolled, even if nothing else happens to expand coverage in the state.

That’s a pretty remarkable impact for a “technical” change to Medicaid enrollment.

Debates about the Affordable Care Act continue—especially in this election year—but health reform is already happening all around us. All we need to do is look.

Case in point: Cheboygan, Michigan, where the local hospital was closed suddenly at the beginning of April, and then resurrected—in a different form—in mid-May.

Initial press reports about the closure left the impression that the federal government was unreasonably blocking the sale by requiring new certifications; later reports shed more light on the government’s position, which turned out to be more nuanced than originally reported (see my July 23 blog post for a discussion of the communication issues surrounding the closure).

By mid-May a deal went through to restore emergency room and outpatient services (and the rehiring of 150 staff)—but the inpatient beds were to remain closed.

Classic good news/bad news? Not so fast.

The compelling question that was lost in the story is this: Should we really mourn the closure of those inpatient beds? After all, Cheboygan Memorial was a small hospital, in bankruptcy, with fewer than 50 acute care beds.

People living in rural areas with small hospitals would say yes, citing the critical need for access to care, and reminding us that hospitals are often a community’s major employer. But while the strong community identity of these hospitals is completely understandable, the questions we need to ask and answer are: Do they deliver the best care? Is that care cost-effective? Would travelling further put people at risk?

In fact, research would lead us to question the assumption that keeping small hospitals open is always a good idea, especially running as they have historically: as independent, community-based organizations. Practice does matter: when it comes to certain health care services, doing more of something is associated with better, safer outcomes for patients. Small hospitals don’t have the volume necessary for staff to practice the full range of service needs that larger hospitals do.

And if we are ever going to get a handle on the cost of care, economies of scale and efficiencies will certainly be part of the solution.

In the end, it was not only inevitable, but probably a good thing that Cheboygan Memorial Hospital closed and reopened—with scaled back services—as part of the much larger McLaren Health System. Emergency and basic care will remain in the community; inpatient care will likely mostly be delivered at McLaren Northern Michigan Hospital, 30 miles away. Some are still unhappy: after all, Cheboygan Memorial was a major employer.

But this is health care reform on the ground, and it ain’t all bad.

A version of this post was originally published in the June 19, 2012 issue of Bridge, an online magazine published by The Center for Michigan.

Earlier this year, on April 3, the Cheboygan News reported that Cheboygan Memorial Hospital was closing unexpectedly. The hospital had been in a purchase agreement with McLaren Health Care, based in Flint; the closure came as an unwelcome surprise to many in the community.

Here’s what was in the press as it became clear the hospital would close in early April:

The Cheboygan Memorial Hospital (CMH) is closing today leaving 300 employees without a job. 9 & 10 News reports the hospital had filed for bankruptcy on March 1. (Michigan Radio)

Cheboygan nurses and community leaders are in shock today. The sale of Cheboygan Memorial Hospital to Flint-based McLaren Health Care has fallen through at the last minute. (Interlochen Public Radio)

“With this closure, we will have to close our emergency room,” said Shari Schult, Chief Executive Officer of CMH. “We will need to coordinate with area EMS services and local law enforcement to divert all ambulances to the most appropriate hospital. This closure …also means all of our employees are without a job,” she added. (Cheboygan News)

The long-awaited proposed sale of CMH to McLaren Health Care was set to be finalized today. But now, federal regulations are causing it to come to a halt. CMH officials say the problem is with recertification and licensure under Medicare. And now, the organization is running out of money. (Cheboygan Memorial Hospital press release)

The impression left by these reports was that the federal government was unreasonably blocking the sale by requiring new certifications. But thanks to the digging of Linda Stephan of Interlochen Public Radio, a more nuanced view of the situation unfolded over time. Linda spent considerable time on April 3 and 4 trying to get to the full facts of the situation.

Linda’s initial knowledge came from a press release issued by the hospital. Inexplicably, the Centers for Medicare and Medicaid Services released nothing but a rather bureaucratic statement indicating the sale could have gone through if McLaren had agreed to take over the existing Cheboygan Medicare contract. Linda probed further and it became clearer that the hospital owed the federal government more than $8 million in loans, and McLaren did not want to assume that liability.

Linda’s probing put the real issues into perspective. The first news reports left the impression that an unreasonable government bureaucracy was putting licensure reviews in the way of access to care. The community was outraged; care was being cut off and people were suddenly unemployed. The deeper analysis, however, led to a better understanding of the government’s position: they had never before allowed a transfer of a Medicare contract that transferred only assets, not liabilities. And this was likely something that was known by all parties before the 11th hour failure to close the deal, which raised more questions about the structure of the deal in contrast to the hospital’s initial press releases.

The Cheboygan situation is a microcosm of a much bigger issue; I raise it not to debate the merits of this particular situation, but rather to point out a core failure in Washington: the failure to communicate. Why does it take a reporter’s probing and prodding to surface facts that put the government’s position in a more reasonable light?

Because of a good reporter, the public got more information about the Cheboygan situation, which enabled a more thoughtful assessment. But Cheboygan is just one example of Washington’s broader failures to communicate around health reform generally, and the Affordable Care Act specifically. And unlike Cheboygan, which was pretty quickly sorted out, the myths and misconceptions around health care reform abound. Those misconceptions could have devastating consequences well beyond those in one community – something we should all be concerned about.

It is hard for me to understand why opponents of the Affordable Care Act (ACA) react so negatively to the law and use such vitriolic language in describing their views. There is a legitimate public policy debate about this law, but the policy debates have not been much in evidence in the aftermath of the June 28 Supreme Court ruling. More typical is this from House Speaker John Boehner, who said his caucus would “rip [the healthcare law] out by its roots.” What does that even mean?

Another example: the very well-off woman who preceded me at the beauty salon the day the decision came out, who said it was one of the darkest days of her life. She didn’t understand why the law was even needed, because “anyone can buy health insurance when they want it, even on the way to the emergency room.”

How is it possible to be that disconnected from the one million people in Michigan—more than 10% of our population—who cannot afford health insurance without help?

Why is there so much emotion around this law? The ACA is significant, but it is fundamentally a compromise—it doesn’t change the underlying structure of health care coverage in this country. Indeed, my personal critique of the law is it doesn’t go far enough to address the major flaws in Medicaid or our employment-based coverage system.

But isn’t that the kind of compromise our democracy is designed to produce—something not too far toward one political ideology or another?

The Affordable Care Act is not the law I would have written if I had a magic wand, but it is far better than what we have in place today. And for those who think this law wasn’t needed, I would point to an important example in the press, published just before the Supreme Court ruling, that we shouldn’t forget as the political process takes over.

In late June, the New York Times described the situation of a father, who after donating a kidney to his daughter, was denied health insurance:

“Like most other kidney donors, Mr. Royer, a retired teacher in Eveleth, Minn., was carefully screened and is in good health. But Blue Cross and Blue Shield of Minnesota rejected his application for coverage last year, as well as his appeals, on the grounds that he has chronic kidney disease, even though many people live with one kidney and his nephrologist testified that his kidney is healthy.”

While Blue Cross and Blue Shield of Minnesota would not say precisely why he was refused coverage it appears the father was considered to have a pre-existing condition.

When I read the article, I could not have been more surprised—not because this is unheard of in today’s market place, but because of what I know about the Minnesota Blue Cross and Blue Shield plan. Minnesota’s Blue Cross and Blue Shield is a non-profit plan that has long been known as one of the more consumer-oriented plans. I had always viewed Minnesota Blue Cross and Blue Shield as one of the “good guys” in the health insurance world.

If Minnesota’s plan is applying pre-existing condition clauses as restrictively as this story suggests, it can only mean one thing: the individual and small group insurance markets have become so unstable that more and more limits are being imposed to stave off the adverse selection spiral. If this is true, then there are few protections anywhere any more for those who are sick. And while many health insurers committed to continue some of the ACA’s reforms before the Supreme Court ruling, they made no commitments to address the kinds of issues this father faced.

The Supreme Court’s ruling means that people like the father in this story will have a shot at the equality of opportunity we so prize in this country. Perhaps now, a father like this one won’t face bankruptcy because he couldn’t afford health insurance. Perhaps now, this father’s own health won’t be compromised by delaying care for lack of health insurance.

So, I am OK with this compromise less-than-perfect law. Now let’s hope that the political process comes to its senses and doesn’t undo what the Supreme Court affirmed.

It is a remarkable day in healthcare in America. The Affordable Care Act is largely upheld and millions of people can stop holding their breath. Whether you were in support of the law or opposed to it, you now know where things stand in the legal system. And, it is good.

Millions of people who have not been able to get health coverage will now be able to get it; health innovations will continue with secure funding; health insurance exchanges will move forward in many states; providers and health plans can plan for reforms and implement new approaches. In short, change will now accelerate toward more coverage, higher quality care, and new delivery systems.

Yes, the political process continues and things could still change. But in the meantime even more will be accomplished, making it harder to undo what has been done.

The Affordable Care Act is not a perfect law. But it is so much better than what we have without it. The court’s decision and careful deliberation affirms that our form of government works, balancing competing views in a fair and thoughtful manner. It is, indeed, a remarkable day in health care.

Recent Supreme Court oral arguments have left many wondering about the fate of the Affordable Care Act (ACA). If the ACA does not remain in effect—the result of Supreme Court decisions or the political process—employers need to understand what might happen next. (Hint: it won’t be pretty.)

The problems the ACA was designed to address—coverage, quality, cost, and individual/small group market instability—will not go away even if the Act does. Indeed, without systemic solutions, they will only get worse.

Business leaders—even those who already offer health benefits—should care just as much about coverage and insurance market stability as they do about cost and quality. Why? Because lack of coverage comes at a cost to everyone.

Hospitals are required by law to provide emergency care to any patient, with or without insurance, and that cost has to be covered somehow. Often, it is built into the way health plans pay hospitals. Blue Cross Blue Shield of Michigan includes some compensation for bad debt and charity care in their payments to hospitals, and most other health plans also consider uncompensated care in their payments to hospitals.

Many economists believe uncompensated care costs are shifted to those with health insurance in other ways as well. For example, physicians cross-subsidize services to those who can’t pay through those covered by health insurance.

Bottom line: people (and employers) with insurance are bearing the cost of those without.

These problems are only getting worse. In just one year (2008 to 2009) the percentage of Michigan’s population that was uninsured jumped from 10.8 percent to 12.8 percent. And fewer employers—especially small ones—offered coverage. In 2004, 60 percent of Michigan employers offered health insurance; by 2009, that number had dropped to 54 percent. Not surprisingly, hospital uncompensated care costs increased accordingly—from about $1.1 billion in 2004 to $2.34 billion in 2009.

Ideas about what could realistically “replace” the ACA are limited and do nothing to address market problems and the increasing instability of the risk pool: i.e., the less affordable insurance is, the more healthy people gamble and don’t buy it; without healthy people in the risk pool, health care costs go up, making coverage even less affordable…and so on. We also risk losing popular features of the ACA that eliminate pre-existing condition exclusions and caps, cover evidence-based preventive services, and allow children to ride on parents’ policies to age 26—not to mention the chaos that would ensue if things already in effect had to be reversed.

The best hope for business is that the Affordable Care Act stays in place. While it may not be perfect, it addresses critical issues systemically and can be improved in the future. If it is struck down or repealed, it will be a long time before we have the public will again—especially the political will— to deal with systemic healthcare reform. In that event, all stakeholders in healthcare—and that’s all of us—will be worse off as a result.

(Originally published in Crain’s Detroit Business, April 29, 2012)

While many have criticized the Obama administration’s communication about the benefits of the ACA (and justifiably so), few have focused on the role of the press.

The press has an obligation to inform, educate and elucidate. While they have thoroughly covered the politics of the ACA, they haven’t done nearly enough to cover the content of the law. I’ll grant you it isn’t easy—the ACA is a complex and sweeping law—but there have been many missed opportunities in this regard.

Case in point: At the end of April, the New York Times published a story about an aggressive collection agency that located staff hospitals and pursued patients for payment of hospital debts—in some cases, while patients waited in the emergency room or obtained care elsewhere in the hospital.

The company, Accretive Health, has contracts with many hospitals to improve their “revenue cycle management.” As noted in the article, hospitals have employed collection agencies for many years to help reduce their bad debt loads. But this degree of intrusiveness in the patient care setting is new. The aggressiveness of this approach to collections reflects the increasing pressure on hospital finances, as more and more people lose health coverage or have considerably higher copays and deductibles than in the past.

The Times’ article was a good investigative piece on this new practice, highlighting the issue and raising questions about whether the practice violates the Emergency Medical Treatment and Active Labor Act (EMTLA), which requires hospitals to provide emergency care regardless of insurance status, or the Health Insurance Portability and Accountability Law (HIPAA), which requires personal health information to be kept confidential.

But the article had one major flaw: it says nothing about underlying causes, nor does it discuss any possible solutions.

And the underlying causes are truly clear: as fewer people have comprehensive health benefits, hospitals have a growing bad debt burden. The solution is also pretty clear: providing more coverage to more people to assure the financial viability of our health care system, which affects all of us, insured and uninsured alike. The fact that the article makes absolutely no mention of this (or the ACA as part of the solution) is hard to understand and, I believe, a major press failure.

Myths about the ACA abound—most notably that it is a “far left law” that will result in “federal takeover” of health care. This inaccurate view of the ACA persists in part because the press has not helped the citizens connect the dots. It is no wonder more than half of the U.S. population is still confused about what the law does or doesn’t do.

The hospital collection agency issue was a perfect opportunity for the press to help Americans make the link between harsh financial realities and a law that will allow millions to focus more on the care they need and less on the bills they have to pay. Assuming the ACA stays in effect, let’s hope that after the Supreme Court ruling and the election, the press will write more about what the law will do, and less about the political football it has become.

In a New York Times op-ed last December, Elizabeth Bradley and Lauren Taylor wrote about the study of global health spending published they published in the journal BMJ Quality and Safety. Their analysis broadened the concept of international health care spending to include spending on social services.

Their findings were significant and ought to help us all think about health care in a different way.

When we look at health care spending in isolation, as we often do in the U.S., we conclude—completely accurately—that the U.S. spends far more per capita on health care than any other country in the world (40+ percent more than our nearest neighbors).

But Bradley and Taylor looked at combined spending on health and social services. By this measure, the U.S. was no longer at the top. The U.S. spent 29 percent of GDP on combined health and social services, while many Organisation for Economic Co-operation & Development (OECD) countries spent from 33 to 38 percent of GDP on the same set of services. In America, for every dollar spent on health care, we spend $.90 on social services; in the other OECD countries, the ratio is more like $1 on health care to $2 on social services.

Of course, these data don’t tell us anything absolute about cause and effect. We don’t know from the data if higher spending on social services resulted in lower health spending, or was caused by it. But it is telling that the countries used in this comparison all have better life expectancy and infant mortality statistics than the United States.

I was reminded about this while reading some recent articles, including Maurice Isserman’s op-ed in the New York Times, triggered by Charles Murray’s writings on the “culture of poverty” and critiques leveled at Michael Harrington (who was first to use that phrase in his book The Other America: Poverty in the United States, published 30 years ago this month).

The critiques have been compelling—and somewhat sad—about the use of the phrase “culture of poverty,” and how it has contributed to our disinvestment in poverty programs. As Maurice Isserman wrote in the Times, Harrington thought the term would spark investment in housing, medical care, education and jobs—and it did, to some degree, in Lyndon Johnson’s Great Society programs (though the programs were never as fully executed as Harrington had hoped). Harrington didn’t anticipate, however, that the behaviors he described as symptoms of poverty would come to be seen as causes.

As a result—and, perhaps because the description “war on poverty” implied the war would eventually end—we have disinvested in poverty programs over time. With under-investment come inevitable program failures, leading some to the conclusion the programs and ideas themselves don’t work. These conclusions are most unfortunate, because we know many of these programs do indeed work—when investments are appropriately targeted and focused (e.g., investments in high quality early childhood programs).

Perhaps the global data on combined health and social services spending can help policy makers rethink our investments in medical care. Wouldn’t it be exciting to discuss ways to reduce medical spending by reducing poverty, rather than chipping away at medical spending itself?

Maybe after the acrimonious debate and Supreme Court decision about the Affordable Care Act we can begin to have a broader discussion about health care in America. After all, the act is really mostly about our medical care system. And based on global data, when it comes to cost and health, medical care spending is clearly only part of the equation.

In 2010, when we published our study on healthcare variation in Michigan, we were able to show considerable geographic variation around the state of Michigan on a variety of procedures and services. We intentionally chose services where the research indicated either a tendency toward over-utilization (relative to evidence-based guidelines) or where the guidelines were unclear.

While we adjusted for age, gender, and severity (to the extent possible) in that report, we did not look at outcomes or risk factors that might be influencing variation. So, although we were able to demonstrate considerable variation that seemed unrelated to any particular patient attribute, some wondered whether or not higher rates of utilization could be explained by other population-specific risk factors, and whether or not they might be producing better outcomes of care.

Our latest study, Variation in Interventional Cardiac Care, was designed to look more closely at variation and possible associated circumstances. And while we still cannot definitively answer questions about cause and effect, we do have more information about associations between various factors that have been attributed to practice variation by researchers, policy makers, and clinicians.

We decided to look at several specific questions about cardiac care. In particular, our focus was on regional variation in Michigan for percutaneous coronary intervention (PCI) – surgical stenting. Meta analyses of the clinical research on indications and outcomes for PCI have showed that for many with stable coronary artery disease, surgical intervention may not be necessary. Many people do just as well with a non-invasive approach: medical intervention. Given that research, we wanted to look at both supply-related questions and clinical issues that might be associated with higher rates of PCI in the population.

One theory about practice variation is that use rates tend to be higher in areas with more facilities, services, and/or specialty practitioners. That conclusion has spawned an adage in health care: supply creates demand (or, as an economist, Milton Roemer, put it many years ago: “a built bed is a filled bed is a billed bed”). We looked at this question in terms of the number of catheterization labs in communities, as well as the number of cardiovascular surgeons, compared to the rate of combined cardiac interventions in those communities (much of which is driven by elective PCI). While we did not find any association between the ratio of cardiovascular surgeons and the rate of elective PCI, we did find an association between the ratio of cath labs and rates of elective PCI. That is, regions with higher ratios of cath labs to population also tended to have higher rates of elective PCIs.

Also of great interest was the lack of association we found between higher regional rates of elective PCI (among patients with stable coronary artery disease) and either cardiac risk factors or cardiac mortality rates. That is, communities with higher rates of elective PCI did not have worse population health status than those with lower rates of elective PCI, nor did they have lower mortality rates. Again, we cannot determine cause and effect from these data, but the lack of any association between variation and cardiac risk factors or mortality rates is quite telling.

So, what are we to make of this latest contribution to the variation research? Our work certainly directionally supports the idea that practice variation is largely reflective of community-wide practice patterns rather than evidence-based, clinical guidelines. And, based on other research, we think these community-wide practice patterns tend to be driven by informal medical cultures rather than by patient preferences. If we are correct, and we really want to reduce unwarranted variation and have an impact on health care spending, then informing those practice communities and changing incentives to better align with the evidence will be fundamental to changing the picture we see today.

Everyone should read this article in Health Affairs. It is the moving story of a woman diagnosed with terminal breast cancer who chose palliative treatment over interventionist strategies.

Amy Berman is one knowledgeable and connected patient. She is a nurse, works for a health foundation in New York, and is a long time policy leader in health care. She received a terrible diagnosis: stage IV inflammatory breast cancer that had already spread—incurable, even with aggressive treatment. And though she was only 51 years old when she received this diagnosis, she chose a path of palliative rather than aggressive care.

The April issue of Health Affairs is all about cancer: research on cancer; quality improvement in cancer, and the cost of cancer care. It is a rich issue and includes great examples of new and improving strategies for dealing with cancer, including an article about the Cancer Care Continuous Quality Improvement Initiative led by the University of Michigan and Blue Cross Blue Shield of Michigan.

But Amy’s story is the most powerful. It is powerful because it is personal and beautifully told. It is also powerful because in it, Amy reflects on what is important in life and counters the pressures so pervasive in medical care today—pressures that often cause patients to seek more care even when it seriously interferes with quality of life.

When she was diagnosed with inflammatory breast cancer, she went to see a specialist who told her what kind of treatment she should get without ever asking about her wishes. The specialist made it clear that he expected she would do everything possible—at whatever personal cost—to prolong her life, even if it meant just a few more months for her.

Those of us who have had friends who have died of cancer even after trying aggressive treatment approaches know what a cost those treatments exact on quality of life: nausea, pain, fatigue, disfigurement, and a pervasive feeling of always, always being sick. Amy chose another path: one of symptom management, to feel as good as possible for as long as possible, even if that might mean less time than possible with aggressive treatment.

In medical care today, we are bombarded with constant messages that more is better—more tests, more surgery, more visits to the doctor. But that isn’t really true. Indeed, nine leading physician groups have now come out with a list of procedures that should not be done on a routine basis—saving dollars, yes, but more importantly, saving people from diagnostic and other interventions they may not need. Physicians in this Choosing Wisely effort were goaded into action by Howard Brody, a physician and medical ethicist. Dr. Brody challenged the profession to lead an effort to recommend a more sensible use of medical resources. It is refreshing to see physician organizations begin to educate the public that more might not be better.

Similarly, the use of palliative care needs a different framework in our thinking about health care. Choosing palliative care is not “giving up,” as too many think it is. It is choosing to live life—and handle death—with dignity and quality.

Amy Berman, a knowledgeable and strong woman, chose her own path. Wouldn’t it be wonderful if millions more had the information and support to make a choice that reflected their personal values, as Amy did?