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Editor’s Note: This column was published in Bridge Magazine.

It is hard to believe that as the Affordable Care Act turns five on March 23, it continues to be as controversial as it was on day one. The U.S. House of Representatives has taken 56 votes to repeal all or some of the landmark health care reform law, most recently in February. Earlier this month, the U.S. Supreme Court heard another ACA case with significant and far-reaching implications for the law’s future. Governors and legislatures across the country are continuing to debate whether or not to expand Medicaid. And legal and policy debates about contraceptive coverage and other components of the law are ongoing with no end in sight.

Yet against great odds, the ACA is having a profound effect on coverage and care across the country and in Michigan.

The second year of the ACA’s individual health insurance market coverage expansions came to a formal close on February 15. The first year of the Medicaid expansion in Michigan ends on March 31.

What has been the ACA’s actual impact in Michigan?

The answer is in the numbers. While there have certainly been negative effects for some individuals and businesses, it is hard to argue that the ACA’s coverage expansions, health system reforms and economic impacts at large have not positively affected hundreds of thousands in our state (and will be a topic of discussion at our Center’s March 26 symposium).

One has only to add up the numbers:

In Michigan, about 272,000 people received individual coverage through the Health Insurance Marketplace in 2014, blowing through all predictions made at the federal level. In 2015, Michigan exceeded 341,000 covered through the Marketplace. In 2014, 87 percent of these individuals have received a subsidy (making the upcoming U.S. Supreme Court case on this issue profoundly important). Many now covered on the Marketplace were able to get health insurance for the first time.

By early March, more than 579,000 people received coverage under the Healthy Michigan Plan, the state’s expanded Medicaid program, exceeding the state’s first-year enrollment predictions in just 10 months. The vast majority of these individuals were also uninsured before the expansion.

Data shows that despite some predictions otherwise, employers have not dropped coverage as a result of the ACA. In fact, employer-sponsored coverage continues to be the way most U.S. employees get their health insurance coverage. In 2014, 71.4 percent of non-elderly employees had employer-sponsored insurance nationally, up slightly from the 71.2 percent who had it in 2013.

As a result of these coverage changes, Michigan’s uninsured rate dropped by half between 2012 and 2014, based on CHRT’s most recent survey of Michigan adults. It does not appear that patients are experiencing access problems as nearly 9 out of 10 survey respondents (87 percent) reported that it was not difficult getting a primary care appointment.

Michigan has received almost half a billion dollars in federal funding for grants and demonstration projects since the ACA’s inception. These funds have gone to efforts such as increasing access to care at federally qualified health centers, expanding early childhood home visitation programs, and implementing new models of innovation like the grant recently awarded to the state for $70 million to test a variety of approaches to improving coordination of care and innovations in reimbursement.

Hundreds of providers across the state are testing new models of reimbursement and care integration under the ACA through initiatives like Accountable Care Organizations and bundled payment demonstration projects. The federal government extended one of these initiatives, the Michigan Primary Care Transformation Project, for another two years because it demonstrated first-year savings of $148 per beneficiary for Medicare alone.

In light of these real, tangible and measurable accomplishments, it is hard to understand why the focus by some in Washington continues to be on getting rid of the law rather than strengthening it.

There is no question that the ACA is complicated and needs changes to fully achieve the goals it set out to accomplish. But in just five years, the law has given hundreds of thousands in our state a chance they never had before: access to health care.

Let’s not lose that focus as we go forward in 2015 and beyond.

Co-authors

• Marianne Udow-Phillips, director of the Center for Healthcare Research & Transformation
• Dr. John F. Greden, founding chair of the National Network of Depression Centers and executive director of the University of Michigan Comprehensive Depression Center

It will take leaders like Lt. Gov. Brian Calley, who are willing to speak up about their personal journey, to move public policy in a way that will make the difference for the more than 1 million people in Michigan who suffer from other depression, bipolar illnesses and other mental disorders.

In 2012, Michigan passed significant legislation to expand insurance coverage for children with autism spectrum disorder, a group of developmental disabilities that can impair a person’s behavior and social and communication skills. A little more than two years later, it appears that implementation of the legislation has challenges—but also considerable promise—for achieving its goals.

While it is too early to see the legislation’s full impact, there are important lessons in the law’s passage for mental health advocates who want public policy to go beyond autism according to a recent report from the Center for Healthcare Research & Transformation, “Autism Spectrum Disorder in Michigan.”

The debate on autism coverage had been an active and contentious one when Gov. Rick Snyder was first elected governor in the fall of 2010. Bills to expand coverage for autism spectrum disorder were considered and defeated in 2010 because of cost concerns expressed by health plans and groups representing employers.

The legislative climate changed, however, when Snyder assumed office in January of 2011 because a father with a young daughter with autism also assumed an accompanying legislative leadership position that year.

Lt. Gov. Calley, who had long advocated for expanding autism services, served as a powerful advocate for finally moving this legislation forward—a key missing piece in advocates’ efforts to broaden the legislation past autism.

Those willing to speak about their own or their family member’s illness have always moved public policy—whether it is securing disease-specific research funding in the budgets of the Centers for Disease Control or the National Institutes of Health, or expanding coverage of certain types of services included in the Affordable Care Act. Calley’s voice for advocating for autism coverage in Michigan follows this tradition.

At the time of the autism coverage debate, mental health advocates argued that the legislation should have been expanded to cover all mental disorders. Relative to other mental health disorders, autism spectrum disorder is relatively rare and advocates argued that the legislation should benefit all of those suffering from mental health disorders.

Autism spectrum disorder is estimated to affect a little more than 1 percent of children compared to an estimated lifetime prevalence for mood disorders among adults approximating 20 percent.

Despite the overall greater magnitude in prevalence, disability, and financial costs for depression, bipolar illnesses and other mental disorders, advocates for broadening the legislation beyond autism failed. While several factors contributed to this failure, notable was the lack of a leader with as powerful a voice and as personal a story as Calley in the autism debate.

Mood disorders or other mental health diagnoses like schizophrenia continue to carry with them a stigma that autism simply does not. Parents and public figures are not afraid to speak out and organize for better services for individuals with autism. Autism is not seen as a failure of the child’s will or failure of the parent. Rather, it is generally seen as a developmental brain disease that requires coverage and research to improve treatment.

In contrast, while mood and other mental health disorders are also brain illnesses influenced by environmental events, they too often are erroneously seen as a failure of the individual or family. Stigma persists. That stigma results in a reticence by leaders in sharing their personal stories and engaging in advocacy that can move public policy.

The implementation of the autism legislation in Michigan has not been entirely smooth.

Wait times range between one month and two years because there are still too few providers or approved specialized centers that can diagnose and develop treatment plans.

But there is no question that the legislation is changing how care is delivered and financed for many Michigan children, and new approaches to training practitioners and providing treatment are being established. Importantly, the autism legislation provides a platform to strengthen the delivery system and build additional approaches to help these children and their families.

Mental health disorders continue to take an incredible toll on individuals, families and society at large. More funding for research and dissemination of best practices is desperately needed. The payoff would be profound.

Co-authors

• Marianne Udow-Phillips, director of the Center for Healthcare Research & Transformation
• Theodore J. Iwashyna, M.D., Ph.D., Research Scientist, Center for Clinical Management Research, Ann Arbor Veterans Affairs Health System; Associate Professor of Internal Medicine, University of Michigan

Today in the United States, more than half of all hospital deaths are from something that most people have never heard of: severe sepsis. That is the medical term for an overwhelming infection. Many more people die of sepsis than die of prostate cancer and breast cancer combined. From 2000 through 2010, deaths from sepsis increased by 17% while deaths from other causes, such as heart disease and cancer, actually declined. Indeed, the rise in hospital deaths from sepsis is in part because of a decline in the death rate from these other diseases: people are surviving other serious diseases, but in a weakened condition that makes them more vulnerable to sepsis. Today’s challenge is to do more to recognize and treat sepsis earlier—when it is most treatable.

The rise in the proportion of deaths in hospitals from sepsis calls for public health and public policy action. Michigan can become a leader in sepsis diagnosis and treatment, including setting statewide standards of care.

Sepsis is caused by an overwhelming immune response to infection. Immune chemicals released into the blood in response to infection trigger widespread inflammation that leads to blood clots, leaky blood vessels and damage to vital organs. In the worst cases, the heart and lungs can weaken, organs can fail and patients can go into septic shock and die.

Sepsis is most commonly caused by bacteria that have infected the lungs, abdomen or urinary tract. Prompt diagnosis and treatment (usually with antibiotics and large amounts of intravenous fluids) is essential to survival. Once shock has set in, even a single hour delay in appropriate treatment can mean a 7% rise in mortality.

Policy leadership is essential to both increasing research and disseminating best practices in diagnosis and treatment. We need to fund pilot projects and evaluate innovative models of sepsis care in Michigan hospitals. These models need to integrate the emergency department, intensive care unit and other inpatient units to ensure patients get the right care wherever they are. Policymakers can convene hospitals, insurers, EMS and consumer groups to develop systematic, coordinated responses to severe infections.

Policy leadership has always been important in advancing public health and treatment of disease. As an example, our state’s policy leadership built the statewide trauma system we have today. In 2001, the Statewide Trauma Care Commission was created and concluded that Michigan’s trauma system was sorely lacking. By 2004, the Michigan Trauma System Plan was created.Patients across our state are benefitting every day from this coordinated approach to reducing deaths from trauma—the Centers for Disease Control and Prevention has held up Michigan as a model of success.

What the state did for trauma systems, it can do for sepsis. The development of the comprehensive trauma system in Michigan was a 20-year journey. We cannot wait that long to improve the care of patients with sepsis. It is time to start now.

Editor’s Note: This column appeared in Bridge Magazine.

In 1990, 14.1 percent of Michigan’s population was considered obese. Twenty years later, that rate was at 30.3 percent and has stayed fairly constant for the last few years. Michigan is one of the 10 “fattest” states in the country – one of the few northern states in the top 10. This is one measure where it is not good to be in the top 10.

Obesity contributes significantly to many health issues, especially cardiovascular disease, cancer and diabetes. It is not surprising, then, that Gov. Snyder has chosen obesity as a major area of focus and a key health indicator on the Michigan Dashboard. It is essential that we understand this issue and do something about it in our state.

The issue of obesity has long been of concern to public health professionals and while there is uniform agreement that this is a national (indeed, a global) problem, what to do about it has been an issue of much greater debate. Michael Bloomberg is famous for his attempts to tax sugary beverages and ban supersized drinks while serving as New York City mayor. Snyder has promoted his “4 by 4” plan, which calls for maintaining a healthy diet, exercising, obtaining an annual physical and avoiding tobacco use and exposure. While these ideas may have merit at addressing obesity (though evidence does not generally support an annual physical exam), the causes of obesity are complex and the solutions less clear than they are for other health behavior related issues such as smoking.

The importance of this issue, combined with the lack of clarity on what to do about it, led us at Center for Healthcare Research & Transformation (CHRT) to take a look at detailed health risk assessment and claims data available to us from Blue Cross Blue Shield of Michigan to see what we could discern.

Our findings show that those who are severely obese (those with a BMI of 35 or higher) have considerably more health problems than the moderately obese (those with a BMI between 30 and 35). Severely obese individuals had many more health issues, and had average annual health care costs of $7,117 per year – 50 percent higher than costs for the moderately obese and 90 percent higher than those with a healthy weight. Those who were moderately obese were two to three times more likely to have multiple chronic conditions or serious health conditions, along with higher health care costs, compared to those with a healthy weight.

What do these findings tell us?

Well, first of all: It may be important to distinguish between levels of obesity rather than trying to develop a one size fits all approach. For those who are severely obese, it is essential that health professionals and community leaders do what we can to help them lose weight. And, for those who are moderately obese, it is essential that we do what we can to help them from progressing to become severely obese along with trying to help them to lose weight.

There is good news in our findings as well. Fifty percent of both the severely and moderately obese reported that they were actively trying to manage their weight. And, more than one-third of both the moderately and severely obese were “confident” that they could be successful.

Motivation and confidence are tremendous assets to build on. And, fortunately, we do know that there are strategies that work. Two strategies have evidence-based support: bariatric surgery and intensive behavior therapy.

Bariatric surgery is one of the only treatments that has shown the ability to reduce body weight by 20 to 60 percent. But today, in Michigan and nationally, many fewer people get bariatric surgery than are clinically eligible.

Intensive behavioral therapy (IBT) for obesity is one of the few primary care-based approaches to obesity shown to work. Indeed, the U.S. Preventive Services Task Force found that 12 to 26 sessions could produce significant reductions in weight. The evidence was strong enough for this service to be included as one of the required preventive care services (with no patient cost-sharing) in benefit plans under the Affordable Care Act. Unfortunately, there is currently no agreed upon definition or criteria for what constitutes IBT in Michigan and many people may not have access to high-quality services in this regard.

While there are many interventions related to obesity that have popular support, if we are truly going to tackle this issue and reduce both the related human suffering and health care costs, shouldn’t we focus on the things we do know work and make sure they are widely available in Michigan at high quality and reaching the population they are intended to serve? With a population that appears as motivated as those in our study, shouldn’t we all work together to give them the kind of help that has been shown to make a difference?

Editor’s Note: This column appeared in Bridge Magazine.

Soon, many hundreds of thousands of Michigan citizens will be obtaining mental health coverage through the Affordable Care Act—coverage that many have never had before. Our Center wanted to understand what Michiganders might be facing in terms of the need for these services and access to care. To find out, we surveyed primary care physicians in Michigan as well as consumers, and we found that we have a big problem in our state today—a problem that could get much worse in the future.

Specifically, 68 percent of Michigan primary care physicians say that there is inadequate access to mental health care for children; 57 percent say that there is inadequate access to mental health care for adults; and, 64 percent say that there is inadequate access to substance use services. And, in some parts of the state, the numbers are even higher: At least three out of four providers in the Muskegon, Petoskey, and St. Joseph regions consistently reported that mental health services were inadequate in all three categories.

This lack of access to mental health care is particularly troubling in light of the magnitude of the need for mental health care: 1 in 4 Michigan residents report ever having been diagnosed with depression and/or an anxiety disorder—a quarter of the state’s population! And, the numbers are even higher for those who are low income or uninsured with more than one-third reporting these conditions.

Lack of access to mental health care is a serious issue in our state. Michigan ranks 42 out of the 50 states in our ratio of inpatient hospital beds to population. In some areas of the state, there are no child psychiatrists at all. And, as our survey data shows, even in the areas of the state with the best access to care (mostly Southeast Michigan), more than one-third of primary care physicians say that they have a hard time finding places to refer patients.

By some estimates, there is more mental health care being provided in prisons than in the community at large. Indeed, more than 50 percent of those in prisons nationally have been identified as having been diagnosed with a mental illness. And as Michigan closed 12 of its 16 state mental hospitals between 1987 and 2003, rates of incarceration for the mentally ill are reported to have increased significantly and in some reports, quadrupled.

This is an enormous public health and public policy issue.

Depression, anxiety and other mental illnesses take a tremendous toll on individuals, families and society. In our Center’s survey, respondents with these diagnoses reported difficulty in carrying out activities of daily living, including work, five days a month—two times greater than those with other chronic diseases.

In February 2013, Governor Snyder supported the need to improve mental health in Michigan by charging a bipartisan Mental Health and Wellness Commission with looking at ways to strengthen Michigan’s mental health system. The commission will report at the end of this year.

But, in order to make substantial progress in mental health care in our state, there will need to be an enormous commitment at every level of government as well as a partnership with the private sector. Our current mental health system is fragmented in its funding, governance and delivery systems. Funding comes from the state, the counties and private health plans. Governance is at the state level and at the county levels in the public mental health system. And, the courts and our state laws have a critical role to play. All these entities will need to work together in ways they have not before if we are going to address the depths of the problem we face.

Unless we fundamentally change the current fragmented and under resourced mental health system, the insurance coverage that so many will soon have will mean very little to those who need it the most.

On November 4, our Center—along with the Knight-Wallace Fellows at Michigan, Institute for Healthcare Policy and Innovation, and Michigan Radio—held a symposium at the University of Michigan on communication of the Affordable Care Act. The symposium was energetic and the panelists thoughtful. But, what has been most striking to me has been the reaction we have received from those who attended (almost 400 were there). For the most part, people loved the different opinions expressed and were thrilled to hear viewpoints different from their own. The reaction of our audience shows that actual dialogue is possible when we create the right opportunities.

We were fortunate to have as panelists many of those who have given this issue a tremendous amount of thought. Our policy panel included:

• John Ayanian, MD, MPP, director of the Institute for Healthcare Policy and Innovation at the University of Michigan
• Tom Buchmueller, professor at the Stephen M. Ross School of Business at the University of Michigan
• Michael Cannon, director of Health Policy Studies at the Cato Institute
• Heather Howard, JD, director of the Robert Wood Johnson Foundation’s State Health Reform Assistance Network

Our journalism panel included:

• Reed Abelson, health care business reporter at The New York Times
• Steven Brill, author of “Bitter Pill: Why Medical Bills are Killing Us” featured in TIME Magazine
• Jonathan Cohn, senior editor at The New Republic
• Holman Jenkins, Jr., member of the editorial board and columnist at The Wall Street Journal
• Sarah Kliff, health policy reporter at The Washington Post
• Julie Rovner, health policy correspondent at NPR

The journalists were thoughtful and reflective about how they cover the Affordable Care Act. They clearly have given much thought to even what they call it—Obamacare or the ACA. And, they were impressive in how much research they have done on the facts and how much they try to represent those facts. Even those who editorialize rather than simply report about the ACA (Holman Jenkins, Jr., and Jonathan Cohn) expressed their thoughts as questions or frameworks for really probing the law and its impact rather than polemicizing.

On the policy side, Heather Howard focused on how implementation was going and the role of the states. John Ayanian and Tom Buchmueller framed the law in terms of its impact on patient care and economic impacts. All three were expressed support for the law. Michael Cannon, on the other hand, forcefully articulated a negative view of the law along with how it has been described. He laid out how the law does not reflect the kinds of market principles that Michael thinks are necessary to truly reform health care along with his concerns that the law moves health care reform in the wrong direction.

Most of those in the audience were generally supportive of the ACA and Michael’s views were often at odds with theirs. But, even though his views were strongly different from the audience at large, it was his comments that generated the most positive reaction from the attendees. Indeed, they were grateful to hear a viewpoint that was clearly and cogently articulated and that was so different from their own. They gave us comments like, “This is what should happen at a university” and “I’m very glad that Michael Cannon was included—he was sharp and engaged and pushed the conversation into fascinating territory.”

We all spend a lot of time with people who think like we do. We tend to work in environments where there are shared world views shaped by common experiences. We tend to socialize with those who have similar beliefs to ours. But, as a result, we miss the opportunity to learn about different world views and different ways of thinking. Creating more opportunities for that kind of understanding seems to be a hunger we share. We can, indeed, learn from each other—if only we have those chances. We are grateful to all of our panelists for giving us that chance at the University of Michigan.