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What COVID-19 teaches us about health and human services integration by Melissa Riba

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What COVID-19 teaches us about health and human services integration by Melissa Riba

June 4, 2020
Melissa Riba, Director of Research and Evaluation

For much of the last year, CHRT has been working with The Kresge Foundation and other national partners to better understand and advance the concept of health and human services integration.

At CHRT, we are focusing our health and research transformation lens and our expertise in systems change to learn about the challenges and opportunities that occur as organizations work to connect historically separated systems to improve the health and socio-economic opportunities of communities. Throughout this work, we are mindful of the critical importance that racial inequities play in individual and community health and well-being.

Working on health and human services integration during and through the COVID-19 crisis, our team is learning at an accelerated pace. Our awareness of barriers and policy issues are heightened as we see the real-world impact of this pandemic.

Here’s what we’re learning:  

Our most vulnerable citizens are at greatest risk: The negative effects of this pandemic are falling disproportionately on our most vulnerable citizens—people who struggle to earn enough to live on; to maintain a roof over their heads; to stay clean and sober; to maintain their mental health; to feed themselves and their families; to be safe from violence—all while trying to keep safe from a deadly virus for which there is no vaccine or cure.

The pandemic is exposing and exacerbating racial inequality: In Michigan, 40 percent of COVID-19 deaths are among our African American residents, yet they are only about 12 percent of the population. Why is that? Health, and alternatively, vulnerability to a devastating virus, is not something that happens in isolation. It is impacted by historical and structural inequalities that have been shaped by racist policies and practices and the lack of economic and social mobility that came along with them.

The ability to share data safely, securely, and meaningfully is key: In order for health and human services systems to effectively address the complex, multi-faceted needs of individuals, information needs to flow across systems, programs, and agencies. Such information can help to identify which individuals and families need extra support and can support ‘no-wrong door’ approaches for them by using universal enrollments, assessments, and protocols.

Tele-health has expanded, but it is re-exposing our digital divide: Until recently, expanding tele-health existed mostly on health care wish-lists. Now it has been thrust to the forefront of health interventions. As CHRT senior analyst Karen Teske points out in a timely April, 2020 publication, since the beginning of the year 80 additional services are now billable through Medicare for telehealth with a certified clinician. But even as we see tremendous progress, we ae mindful that disparities in access to high-speed internet determine how effective tele-health is as a means to deliver care and services—rural communities, lower income households, and older individuals are far less likely to have the high-speed internet that makes effective use of this innovation possible.

Right now, and far into the future, we need our health and human services systems to:

  • Share information, reduce duplication, and create and maintain an organizational culture that puts people at the center.
  • Address health while at the same time addressing the social determinants of health, racial inequalities, and barriers to social and economic mobility.
  • Implement more culturally competent, trauma-informed practices and ‘no wrong door’ approaches to ensure people can get the services and resources they need, when they need them, delivered in ways that elevate, rather than marginalize.

Across the country, more and more organizations are examining and talking about their integration work, but we are coming to recognize that true integration is often difficult to achieve.

While consolidating offices or administrative tasks and collaborating on individual programs may be part of an integration framework, achieving real health and human services integration means unwinding entrenched systems, reintegrating the cultures of organizations, the data systems they use, the funding streams they require, and the governance structures they depend upon—all while recognizing that social determinants are inseparable from the health and wellbeing of people and communities.

Another existential threat to the Affordable Care Act in the midst of the COVID-19 pandemic

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Marianne Udow-Phillips

Another existential threat to the Affordable Care Act in the midst of the COVID-19 pandemic

April 16, 2020

Having health insurance is essential to getting early diagnosis and treatment.  And if we’ve learned one thing during this coronavirus crisis, it’s that early diagnosis and treatment isn’t just important for the individual affected, it’s important for all of us. That’s why I was so troubled this week when, during a press conference, President Trump reaffirmed his support for a Texas lawsuit—set to be reviewed by the U.S. Supreme Court this year–that threatens to eliminate the entire Affordable Care Act.

The Affordable Care Act just turned 10 years old.  The Act’s successes are well documented – the steep reduction in the numbers of uninsured Americans from 15.4% in 2009 to 9.5% in 2018; the fact that coverage is now available to those with pre-existing conditions who were unable to get it before; the fact that preventive services are now covered in full with no cost-sharing for consumers; and the fact that fewer people report not getting needed medical care because of cost than they did before the ACA.  That last fact could not be more important as we face the most critical public health issue of our lifetimes – the coronavirus.

The Texas lawsuit I’m referring to—the one that President Trump supports—was filed in February 2018 by 18 Republican Attorneys General and 2 Republican Governors who challenged the constitutionality of the Affordable Care Act in light of the 2017 tax bill that eliminated the tax penalty for individuals who did not enroll for minimum health coverage under the ACA.  The plaintiffs argued that without the penalty, the mandate was unenforceable as a tax, and that since the entire ACA relied on the mandate, the law itself should be struck down. In December of 2018, a federal judge in Texas agreed with the plaintiffs and determined the entire ACA to be invalid. 

Many of the judge’s legal rulings were criticized by both conservative and liberal legal scholars. And the case was immediately appealed. But the Trump administration sided with the plaintiffs and supported the ACA being struck down in its entirety.  In December 2019, the appeals court determined that the individual mandate was unconstitutional but made an inconclusive ruling on the constitutionality of the rest of the ACA. And earlier this month, the Supreme Court agreed to take up the case in its next term.

There is no question that the Texas lawsuit poses an existential threat to the ACA. And, there is also no question that that threat could not come at a worse time. The full story of the coronavirus is yet to unfold.  But, one thing that the coronavirus makes clear: health care coverage is a public health measure.

With a disease as infectious as the coronavirus, we need public health measures to protect us all.  The coronavirus doesn’t skip infecting people just because they are uninsured. And uninsured people are just as likely to infect others as are people with insurance. It is essential to all of us that people who are sick get tested early to both save their lives and protect others from being infected.

Unfortunately, financial barriers keep people from seeking need medical care. The first phase emergency measures that Congress put in place to address the coronavirus acknowledged how much cost can be a deterrent to care by making sure that there would be no copays for people getting tested. 

One issue the Congressional measures did not address is the fact the thousands of Americans who get the coronavirus will now be considered to have a “pre-existing” condition. The emergency measures don’t need to address that issue because the ACA is in place today and Americans with pre-existing conditions are protected from losing health coverage because of the ACA. But, if the Trump administration has their way, the ACA will go away; the health care system will face further chaos and there is no certainty that a replacement will be put in place to protect the millions likely to be infected with this virus over time. There is simply no doubt that the ACA is essential to our fight against the coronavirus. Now is the time to be expanding the ACA, not throwing it away.

Related content:

Lost insurance in COVID-19 crisis? Act quickly to get ACA coverage. Already uninsured? In 38 states, including ours, it’s complicated.
Health Insurance Marketplace: Michigan 2020 rate analysis finds increased choice, decreased rates, federal policy impact

Backbone organizations: What they do, and why they matter

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Nancy Baum in a black jacket, smiling

Backbone organizations: What they do, and why they matter

March 30, 2020
Backbone organizations and why they matter

At CHRT, we devote much of our time to policy analysis, research and evaluation, and project management.  More recently, as our emphasis on collective impact has grown, CHRT is expanding our role as a backbone organization. So what does it mean to be a backbone organization, and why does it matter?

One way to conceptualize a backbone organization is that its goal is not to work one-on-one with individuals or organizations, but to create a broader understanding of what a community needs and provide capacity to address those needs in the community. Backbone work is accomplished working among multiple organizations in a community, rather than between two entities, as might occur in project management or traditional consulting work.

Until very recently, foundations and other organizations historically hadn’t funded the infrastructure necessary for this type of coalition work. Now, as government agencies and NGOs increasingly recognize the interconnectedness of multiple factors affecting the health of people and communities, support for the work of backbone organizations is growing. Backbone work provides both infrastructure and context for mission-based organizations, and can help focus efforts taking place across entire communities and among those community organizations.

CHRT’s work with the State Innovation Model (SIM) is one example of the role a backbone organization can play in facilitating collaborative efforts to reach shared goals across regions and organizations. CHRT’s job with the SIM is, in part, to help develop key strategies and provide capacity to align resources so that regional partners – social service and health organizations in two counties – can achieve their specific missions as service providers while working together to focus on the needs of their shared clients. In the case of the SIM, care management services are provided to individuals who have high health and social needs to help them achieve their health goals and to reduce reliance on emergency departments.

As we collect and aggregate partner data locally we can start to see what the need is at a community level and measure collective impact of our joint work. We can also disaggregate the data in nuanced ways to pinpoint specific challenges key populations face and identify best practices that help our partners better address those specific needs. Similarly, in the process of facilitating the collaborative approach, we learn how to help the organizations we work with more effectively carry out their complementary work. The vantage point and capacity of a backbone organization helps local organizations that individually deal with housing, or food insecurity, or complex health care to talk to each other, collaborate, and work more efficiently together for the good of the individual.

The perspective and expertise of a backbone organization also extends beyond the ability to connect and synergize mission-driven organizations with differing core competencies. As collective work becomes more effective through better insight into process and practice, backbone organizations like CHRT also help ensure that funders understand what the partners are addressing in their community, what’s working, and where further efforts should be focused. Backbone organizations can provide expertise in budgets, offer administrative capacity and resources, create summary documents or presentations, and implement convenings to make it easier for foundations and legislative allies to support regional collaborations and tout the results of ongoing public, private or non-profit investments.This level of backbone work provides the partners with crucial resources to make the case for longer-term sustainability. 

To learn more about CHRT’s backbone work, policy analysis, research and evaluation click here.

The gift of simplicity means a lot. It means even more in the midst of coronavirus.

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Erin Spanier

The gift of simplicity means a lot. It means even more in the midst of coronavirus.

March 19, 2020

When it comes to business, simplicity is the rule. 

Amazon lets you buy with a single click. The App Store lets you do it with a print. And you can sign up for discounts at your favorite stores with an email address–no name, no phone number, no hassle.

But when it comes to government–particularly when it comes to government aid for people and families in poverty–simplicity is too often the exception. 

I recently learned that Michigan is trying to buck that trend. And as a professional communicator watching from the sidelines as coronavirus threatens the livelihood of hourly workers and business owners across the state, that makes me proud to be a Michigander.

Last summer, the Michigan Department of Health and Human Services launched a “Simple Gifts’ contest for its staff. The department-wide competition encouraged staff members to submit ideas that would make it less challenging for Michiganders to apply for government aid. 

Some 331 entries were submitted to streamline and improve the application process for healthcare coverage, emergency housing, food assistance, cash assistance, and other basic aids for those who are struggling financially.

Jennifer Bellini, an eligibility specialist from Ingham County, suggested updating verification checklists with plain language to make it easier for clients to understand requirements.

Stacy Kiger, an eligibility specialist from Genesee County, suggested making a computer and printer available at each county office so clients could print off the documents and forms they needed to complete their applications. 

Angela LaLonde, a registration support staff member from Iosco County, suggested implementing live chat on the MiBridges website for quicker responses to client questions. 

Emily Luther, a family independence manager from Macomb County, suggested adding an option to pay by phone to the toll-free line for MiChild, a health insurance program for Michigan’s working families. 

The suggestions to increase simplicity went on and on. And they were good ones. Really good.

In January, more than 30 Michigan Department of Health and Human Services employees were honored for their winning ideas at a celebratory lunch at the George W. Romney Building near the State Capitol. 

“We aim to simplify everything we do and the winning Simple Gift ideas advance that goal,” said MDHHS Director Robert Gordon at the luncheon. “We will implement as many as we can as quickly as we can.” 

Already, the state has simplified asset tests for several assistance programs, and I hope to see more of these ideas implemented in the weeks ahead.

Luke Shaefer, director of Poverty Solutions at the University of Michigan, warns that with virus-related social distancing policies “many low-earning hourly workers don’t have the option to work remotely, and this unexpected change in income will exacerbate challenges for families working hard to make ends meet.”

Small food and financial supports could go a long way toward helping those families weather this time. But to apply, families will need to navigate paperwork, procedures, and protocols that have been tooled, retooled, and complexified by generations of administrations. 

Streamlining these applications, and making sure they can be completed quickly and easily online or over the phone, would be a win for everyone–government and workers alike.

Building a business case for sustainability–why you need one, and why this is the time to get started

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Marianne Udow-Phillips

Building a business case for sustainability–why you need one, and why this is the time to get started

March 19, 2020
Marianne Udow-Phillips
Marianne Udow-Phillips, Founding Executive Director, Center for Health and Research Transformation (CHRT)

Community based organizations providing important social services–supportive housing, food security, mental health, substance use services and the like–are often challenged to maintain programs over time. Without an ongoing revenue stream, many human service oriented organizations struggle to keep important services available in the community. In this context, when we talk about sustainability, we’re talking about ensuring that organizations that provide effective human services can keep those services going and scale them to magnify their impact.

It’s common for foundations and government entities to fund pilots. But foundations rarely fund programs for more than a few years. How then do community based organizations that have implemented programs–programs with demonstrated results–continue those programs on an ongoing basis? 

America spends a great deal on health care–more than any other country in the world–and in an ideal world, those dollars would support the programs that improve health, regardless of whether those are flu shots, nutritional supplements, counseling sessions, supportive housing, or financial coaching. Unfortunately, that’s not the case. The health financing system we have in this country generally focuses on funding the medical delivery system and not broader services that might actually make a bigger impact on health. 

However, there are signs that the historical approach to funding health care in the U.S. is beginning to change. In 2019, Medicare added a new opportunity for Medicare Advantage plans to pay for services related to the social determinants of health. Medicare’s decision opens the door for new and sustainable funding for organizations providing these needed and evidence-based services. Many private payers follow Medicare’s example, as does Medicaid. So, new opportunities for sustainable funding are definitely on the horizon.

At CHRT, we help clients navigate these realities to achieve sustainability. We help them develop robust evaluation protocols; analyze the data they’ve collected to ascertain the impact in terms of quality, customer experience, and cost; then build a compelling business case for payers. Ultimately, we help clients think about projects objectively, analyze their impact, and demonstrate the value to the payers and providers that have the power to keep them going. 

Ten years in, Riba shares the legacy and future of CHRT’s Cover Michigan Survey

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Melissa Riba

Ten years in, Riba shares the legacy and future of CHRT’s Cover Michigan Survey

December 19, 2019
Melissa Riba, Research and Evaluation Director, Center for Health and Research Transformation (CHRT)

Recently, our research and evaluation team sat down for a 2020 work-planning meeting, and we asked ourselves, “what did we want to accomplish in 2020?” As our conversation focused on the year ahead, it also led me to think about the last ten years of Cover Michigan – the issues and subjects we explored, and the impact that the survey has had.

The initial concept for Cover Michigan was to conduct a consumer survey that regularly explored health, health insurance, and health care access trends across Michigan.

We developed the concept in 2009 to better understand the likely impact of the Affordable Care Act on the state of Michigan and the people who live here. Over the last decade the survey has revealed important trends about health status, health care coverage, and access to health care across populations.

Survey findings

Some of the topics we asked people about included insurance churning and access, satisfaction with health coverage, and wellness and prevention programs – and we learned a lot.

  • In 2013, we found that Michigan’s mental health care system faced significant capacity challenges.
  • In 2015 we learned that cost, not physician choice, was the most important factor for consumers selecting a health plan. And we also learned that race and economic status were strong predictors of whether people had a flu vaccination, and that Michigan had opportunities to improve vaccination rates.
  • In 2016 we found that a substantial share of Michiganders reported having participated in wellness programs – though they perceived limited benefit from those programs – and that those who participated in mental health and stress relief programs reported the greatest perceived benefits.

And of course, it’s always gratifying when a Cover Michigan Survey brief is part of a story in the media, whether it’s regional coverage of our mental health care access survey brief in Crains Detroit or national print stories mentioning our Insurance churning survey findings in The Week or The New Republic.

This partial list of the useful information that has developed from the Cover Michigan survey really just scratches the surface of what we’ve learned and shared at CHRT over the last decade.

Going forward

So the Cover Michigan Survey will continue, and expand.

In the next decade, we will maintain our emphasis on learning about the health of people and communities, and we will continue tracking trends in coverage and access to care.

But we will also increase our focus on the social determinants of health; use new platforms to disseminate what we learn through the survey; and work to expand statewide partnerships that help us provide local and regional health data to inform policy decisions that positively impact the health of people in communities all across Michigan.

CHRT is growing: Join us in welcoming new staff

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CHRT is growing: Join us in welcoming new staff

November 8, 2019

Several new staff members have joined the Center for Health and Research Transformation. They bring expertise in pay for success financing, evaluating case management interventions for superutilizers, recovery-oriented communities, integrative approaches to health disparities, program evaluation and improvements, and more. Please join us in welcoming them to the team.

Ryan Bartholomew is an analyst at CHRT. He manages CHRT’s Health Policy Fellowship and provides analysis of issues and trends in health policy. Prior to joining CHRT, Ryan worked as a research intern for Michigan’s Children, an independent organization that works to promote public policies in the best interest of the children and families of Michigan. He has also worked as an AmeriCorps VISTA member at the United Way of Southeastern Michigan, an Office of Presidential Correspondence intern in the White House, and as a political department intern at the Democratic National Committee. Ryan holds both bachelor’s and master’s degrees in public policy from the Gerald R. Ford School of Public Policy at the University of Michigan.

Matthew Hill is a program manager for the Center for Health and Research Transformation. He manages all Substance Use Disorder (SUD) and Mental Health related programs that fall under the Washtenaw Health Initiative (WHI). In doing so, Matthew supports the WHI Opioid Project, a community based coalition that aims to help address the opioid epidemic locally, as well as the Washtenaw County SUD System Transformation Initiative. Prior to joining CHRT, Matthew managed the Washtenaw Recovery Advocacy Project, a recovery community organization that worked to eliminate the stigma surrounding SUD, provide community education, and create a recovery oriented community in Washtenaw County. Matthew holds a bachelor’s degree in biopsychology, cognition, and neuroscience from the University of Michigan.

Samantha Iovan is a senior analyst at CHRT and will be supporting the Washtenaw Health Initiative UNITE Group and Medicaid and Marketplace Outreach and Enrollment (MMOE) Group. Prior to joining CHRT, Samantha worked as a project manager in the Department of Emergency Medicine at the University of Michigan. There, she oversaw health services research projects focused on addressing cardiac arrest outcomes in the state of Michigan and improving care coordination and patient-centered care. Before joining Michigan Medicine, Samantha managed multiple population health policy projects at the University of Michigan Ford School of Public Policy. She led data collection and analysis efforts to understand Pay for Success (PFS) financing models and interventions to address superutilizers of acute care. Samantha holds a master’s degree in public health from Wayne State University and a bachelor’s degree in philosophy from the University of Michigan.

Myra M. Tetteh is a senior analyst at CHRT. She provides project management to the Vital Seniors Initiative, a convening of multiple organizations in Washtenaw County creating actionable solutions to problems faced by seniors and their caregivers. Prior to joining CHRT, Myra worked with the Blue Cross Blue Shield of Michigan Foundation where she developed program evaluation measures for grantees, wrote and reviewed requests for proposals, and revamped multiple award programs. She also worked as a program coordinator on the translation of physical science to urban community audiences at two federally-funded research centers, Michigan Center on Lifestage Environmental Exposures and Disease (M-LEEaD) and the Michigan Center for Integrative Approaches to Health Disparities (CIAHD). In addition, Myra formerly served as the public health policy analyst at the Detroit Health Department where she coordinated multiple projects, including work on food systems and the built environment. Myra holds a doctorate in public health from the University of Michigan School of Public Health, a master’s degree in public policy from the University of Michigan-Dearborn, and a bachelor’s degree in political science and sociology from the University of Michigan-Ann Arbor.

John Tsirigotis is a healthcare analyst at CHRT.  He performs data analysis and conducts research regarding health care trends in Michigan and across the nation. Prior to joining CHRT, John worked as a survey specialist with Wolverine Pathways, a University of Michigan outreach program that serves middle school and high school students throughout Michigan that hope to attend the University. In this role, he created surveys that were used for data collection and analysis in evaluating the efficacy of the program. Before moving to Michigan to attend graduate school, John served as a middle school math teacher in New Orleans, Louisiana for three years. John holds a master’s degree in program evaluation and improvement research from the University of Michigan’s School of Education and a bachelor’s degree in philosophy, with a minor in mathematics, from Lafayette College in Easton, PA.

Cover Michigan 2018: Health Care Benefit Use Variation by Demographics

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Cover Michigan 2018: Health Care Benefit Use Variation by Demographics

November 1, 2018

Data from the Center for Health and Research Transformation’s (CHRT) 2018 Cover Michigan Survey Report, “Use of Health Care Benefits in Michigan,” show which health benefits Michiganders with health insurance coverage have used in the past year and how benefit use varies by age, race, gender, and economic status.

For more detail on the 2018 health care use analysis, review “Health Care Benefit Use Variation by Demographics.” For Cover Michigan Survey methodology, review “Cover Michigan Survey Methods.“

Nine lessons for the leaders of health and human services integration initiatives (and for the grantmakers that want them to succeed)

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Diagram of a straight line vs a diagram of a tangled ball of a line

Nine lessons for the leaders of health and human services integration initiatives (and for the grantmakers that want them to succeed)

July 10, 2018

In Health Affairs’ GrantWatch column, Marianne Udow-Phillips, Kathryne O’Grady, and Phyllis Meadows share Nine lessons for the leaders of health and human services integration initiatives (and for the grantmakers that want them to succeed).

“Collectively addressing the environmental and social factors that influence health, a process known as health and human services integration, is not a new concept in the United States, but our understanding of the value of integration is far ahead of our implementation of integration,” they write. “Visionary leaders have shown that real integration is possible, that integration can effectively diminish health disparities, and that community life—and human lives—are better off when it can be achieved. Yet, significant barriers continue to stand in the way of integration, including isolated government departments, data systems that rarely “speak” to each other, and siloed funding sources—all of which have emerged organically over many years.”

To better understand the current state of health and human services integration across the United States, the Kresge Foundation and the Center for Healthcare Research and Transformation (CHRT) at the University of Michigan embarked on an exploration of integration initiatives across the country. They tracked the goals of these initiatives; the groups, systems, and programs that had been integrated; the factors that proved critical to success; the outcomes for those who are the most vulnerable (populations such as youth at risk, seniors, and those living in poverty); and, importantly, they recorded the challenges and lessons learned along the way.

Read more at Health Affairs.

Rising Deductibles and the Underinsured

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Rising Deductibles and the Underinsured

December 4, 2015

Co-authors

  • Leah Corneail, Health Policy Analyst and CHRT Policy Fellowship Program Manager
  • Josh Fangmeier, Senior Health Policy Analyst

November 1st of this year marked the beginning of the Affordable Care Act’s third marketplace open enrollment period. As consumers, health plans, and exchanges prepared for open enrollment, much of the current health policy debate shifted from reducing the number of uninsured Americans to how best to manage the growth in out-of-pocket expenses. In September, the Kaiser Family Foundation/Health Research & Education Trust 2015 Employer Health Benefits Survey found that the average deductible for covered workers increased 67 percent since 2010, significantly more than the increase in both premiums and wages. According to the Health Care Cost Institute, average out-of-pocket spending was $810 per person with employer-sponsored insurance in 2014.

These trends have prompted presidential candidates Hillary Clinton and Bernie Sanders to make cost-sharing controls a priority. Clinton recently proposed required coverage for three physician office visits per year without cost-sharing, a new limit on out-of-pocket spending on certain drugs, and tax credits for consumers with high out-of-pocket spending relative to income.

Consumers who experience large out-of-pocket costs are often considered to be “underinsured,” since their insurance coverage may not provide adequate protection from large medical expenses. The Commonwealth Fund defines the underinsured through two income thresholds: residents with health insurance in families below 200 percent of the federal poverty level (FPL) with out-of-pocket medical spending (excluding premiums) that exceed 5 percent of family income; or, 10 percent if family income is above 200 percent of FPL.

In August 2015, at the Center for Healthcare Research and Transformation (CHRT), we published an issue brief that provided baseline characteristics of Michigan’s underinsured population in 2013, just prior to the ACA’s coverage expansion. To measure underinsurance, we used the Commonwealth Fund definition and found that more Michiganders were underinsured (1.2 million) than uninsured (1 million) in 2013, and underinsurance was concentrated in certain populations, particularly low-income residents and those with certain forms of health insurance. Among those with private insurance, the underinsurance rate was nearly four times greater for those who directly purchased coverage on the individual (private, non-group) market as those enrolled in group coverage through an employer.

Challenges of Measuring Underinsurance

Compared to tracking the number of uninsured Americans, underinsurance is a difficult concept to define and measure. High levels of predictable out-of-pocket spending may be a financial burden for insured individuals, but it may not be a sign of too little insurance, since the purpose of insurance is to reduce the economic risk of catastrophic health shocks. Focusing on financial burden, people with health insurance could be considered underinsured if they require services not covered by their plan; forgo necessary care due to the co-pays and deductibles they would face; or if they experience high out-of-pocket costs for the care they do receive. The definition used by the Commonwealth Fund and CHRT only takes the last of these situations into account when measuring underinsurance. The Commonwealth Fund’s two-tiered threshold to determine underinsurance does take into account the consideration that a higher percentage of income going towards medical bills may be less burdensome for higher income individuals. However, it does not adjust for the economic risk insured individuals may face or account for individuals who forgo necessary care due to high cost-sharing.

Surveys indicate that nearly 20 million insured individuals in 2012 did not receive or delayed seeking medical care within the year due to costs. While some of this population may have also experienced large out-of-pocket spending, only measuring out-of-pocket costs relative to income leads to conservative underinsurance estimates. In addition, some insured individuals experience the combination of high out-of-pocket costs and delayed necessary care. In a 2014 survey, the Commonwealth Fund found that about one-quarter of underinsured adults reported having to change their way of life to pay medical bills, and underinsured adults were twice as likely to report not getting needed care because of cost in the past year, compared to adequately insured adults. While high medical spending can cause financial difficulties for consumers, forgone care is also an important issue to understand and measure.

Among the underinsured identified in our study, half were enrolled in employer-based coverage, but a substantial share had public insurance and were not subject to the rising deductibles of private coverage. For example, we found that almost 25 percent of Michigan residents enrolled in either Medicaid or the Children’s Health Insurance Program (CHIP) were in underinsured families in 2013. On its face, this is a surprising result, since federal Medicaid law limits beneficiary premiums and out-of-pocket spending to 5 percent of family income (effectively below the underinsured definition). While the complete explanation for this finding is not clear, there are multiple factors that likely contributed, including Medicaid benefit caps or other coverage limitations and mixed sources of coverage in low-income families.

For example, half of the Medicaid/CHIP beneficiaries who were underinsured in 2013 had at least one family member not covered by Medicaid/CHIP. This means that while one person in a family may be enrolled in Medicaid/CHIP, other family members were either uninsured or had another form of health insurance. Thus, while the Medicaid beneficiary in the family had financial protection in the form of the 5 percent cap on out-of-pocket spending, other family members may have had deductibles and other medical costs that were high enough compared to total family income that the whole family was considered underinsured. Notably, the Medicaid underinsured population we observed was before implementation of ACA’s Medicaid expansion in Michigan with its own explicit cost-sharing requirements approved through a federal waiver. Due to these circumstances, it is not clear how comparable underinsurance is for the publicly and privately insured.

Opportunities for Further Research

More than 17 million people have gained insurance since the ACA’s coverage expansions took effect in 2014. The ACA includes several provisions designed to help reduce consumer out-of-pocket spending, including cost-sharing reductions for low-income marketplace enrollees, maximum out-of-pocket spending caps on most private insurance plans, and first-dollar coverage for certain preventive services. It is too soon to understand how the ACA will affect underinsurance among both newly and previously insured individuals, but the continued growth in employer-sponsored deductibles likely means that the issue of underinsurance will not go away anytime soon.

As out-of-pocket spending continues to grow, there are certainly opportunities for researchers to develop more comprehensive and nuanced definitions of underinsurance to better examine the challenges and characteristics of this population. Not all underinsured residents are the same or experience the same degree of hardship, so it would be helpful to identify various degrees of underinsurance. This distinction could recognize how the underinsured experience can vary by source of insurance coverage and other characteristics, similar to how researchers on uninsurance developed distinctions between the short-term and long-term uninsured.