Publications

Access to Health Care in Michigan: Cover Michigan Survey

The Center for Health and Research Transformation’s (CHRT) 2018 Cover Michigan Survey asked Michigan residents about their experiences in accessing health care, specifically how easy or difficult it was to get appointments with different providers.

The survey found that two factors—the presence of primary care providers (PCP), and whether or not people had a medical home—figured prominently in reported ease of access to care.

Read the full report: Access to Health Care in Michigan.

Cover Michigan Survey: Use of Health Care Benefits in Michigan

Data from the Center for Health and Research Transformation’s (CHRT) 2018 Cover Michigan Survey show health benefits that Michiganders with health insurance coverage have used in the past year (1)Survey participants were asked whether or not they or other family members covered by their plans used each health care benefit in the past 12 months.. Detail on the Cover Michigan Survey and analysis methodology can be found on CHRT’s website. In addition to findings on overall use of health care benefits, this brief focuses on three key areas: dental and vision, reproductive health, and mental health care.

Nearly all Michiganders used some kind of health benefit over the last year. To understand differences in the use of health care benefits, several variables were examined including gender, age, race, insurance type, income, and employment status.

  • Preventive care: The highest utilized benefit was routine, preventive primary care This was consistent across all groups.
  • Dental and vision care: There is high use of these benefits even though they are not generally core offerings of most insurance
  • Reproductive health care: Women, especially younger women, use these benefits at a significantly higher rate than men and older Reproductive health care represents 11 percent of younger women’s health care utilization.
  • Mental health care: Younger women and people who are unemployed reported significantly higher use of their mental health care or substance use treatment coverage.

Other findings include:

  • Aside from dental and inpatient care, women consistently utilized more health care benefits than men.
  • African Americans were the least likely to visit a doctor and use vision care benefits compared to other races, while white Michiganders were the most likely to use inpatient services.
  • Regardless of insurance type, respondents use doctor visits at similar rates, however those with employer-provided insurance were the most likely to use dental care benefits.
  • Medicaid beneficiaries had the highest utilization of pediatric care, contraceptive/family planning, mental health/substance use, and maternity/newborn care benefits; and Medicare beneficiaries made the most use of the prescription drug benefit. These differences are likely due to the unique populations that make up membership in these plans.
  • Compared to those with lower household income, Michiganders with incomes of $50,000 or more per year were far more likely to use dental care, doctor visits, and vision benefits.
  • The unemployed population was more likely to use inpatient care, mental health/substance abuse services, and maternity/newborn care than those who are working/in school.

Read the full report, Use of Health Care Benefits in Michigan, and download a full analysis.

References   [ + ]

1. Survey participants were asked whether or not they or other family members covered by their plans used each health care benefit in the past 12 months.

Quick Facts: Chronic Pain in Michigan

Not everyone suffers from chronic pain in Michigan, but many people do. Our Cover Michigan Survey found that more than 35 percent of the state’s residents say they experienced chronic pain which limits their lives or work within the last year.
These infographics from the Center for Health and Research Transformation are based on consumer response, and show how many people report suffering from chronic pain, along with who is most affected.

 

 

 

Michigander’s satisfaction with health care coverage has increased since ACA implementation

Data from the Center for Healthcare Research and Transformation’s (CHRT) Cover Michigan Survey describes the rate of satisfaction with health coverage before and after implementation of the Patient Protection and Affordable Care Act (ACA).

Satisfaction with health care coverage in the state of Michigan has increased since the implementation of the ACA. In 2015, 57 percent of Michiganders reported that they were satisfied with their health coverage, which is in alignment with national rates of satisfaction with health care. This represents a significant increase from the 51 percent of respondents who reported they were satisfied with their health care coverage in 2012 before the ACA took effect.

The Cover Michigan Survey data presented in this brief were produced from a series of survey questions added to the Michigan State University Institute for Public Policy and Social Research quarterly State of the State Survey. Further methodology detail can be found on CHRT’s website.

 

Insurance Churning

The uninsured rate has declined substantially since provisions of the Patient Protection and Affordable Care Act (ACA) came into effect. Nevertheless, many individuals continue to experience instability in insurance coverage. Transitions between different insurance plans, as well as between insured and uninsured status, are often referred to as “insurance churning.”

The causes of insurance churning vary. Changes in job status may result in loss of coverage or transition to a new insurance plan. Eligibility for Medicaid or plans with Marketplace subsidies may change based on changes in family composition or fluctuations in income. Nationally, three to five percent of members are dropped each month by health plans offered on the Health Insurance Exchange due to non-payment of premiums.

Insurance churning can affect quality, cost, and continuity of care. Individuals may avoid seeking health care when they need it during gaps in insurance coverage. Even if consumers maintain continuous coverage while transitioning between different insurance plans, they may find that their regular health care providers do not accept their new insurance plan. In addition, when they change health plans, research shows that medication compliance is often disrupted. These and other churning-related problems tend to be exacerbated by uncertainty about what new co-pays or deductibles might be as well as by known increased costs associated with new insurance plans.

A recent study found no evidence of significant increases or decreases in broader indicators of insurance churning since the introduction of the ACA in three states (Texas, Kentucky, and Arkansas). Under the new administration, depending on which provisions of the ACA are repealed, replaced, defunded, or retained in the coming years and how these changes are implemented, rates of insurance churning could change dramatically.

Between 2013 and 2015, data from the Census Bureau show that the proportion of Michiganders who reported no source of health insurance declined by five percentage points—from 11 percent to 6 percent. Using data from the Center for Health and Research Transformation’s Cover Michigan Survey, this brief explores consumer experiences with insurance churning and access to care within the state of Michigan for approximately a one-year period in 2014–2015.

Key Findings

  • Medicaid recipients had the most instability in their coverage status of all respondents to the survey. Medicaid recipients were also seven times more likely to have experienced a temporary uninsured period in the past year compared to respondents with employer-sponsored or individual coverage.
  • Those with individually purchased coverage in 2014 were the most likely to switch to a different type of coverage in 2015. Among respondents with an individually purchased plan in 2014, less than half reenrolled in the same plan in 2015, and nearly a third transitioned to Medicare or to an employer-sponsored plan in 2015.
  • Those with employer-sponsored coverage experienced the least amount of churning compared to respondents with other coverage. Ninety-four percent of respondents with employer-sponsored coverage remained continuously insured from 2014 to 2015.

Wellness Program Participation

Wellness programs have grown increasingly common in recent years. A Kaiser Family Foundation study found that 63 percent of organizations that employed and provided insurance for at least three employees offered some form of wellness program. Larger employers were more likely to offer their own wellness program and smaller employers were more likely to offer a program through their employees’ insurer.

Despite their increasing prevalence, evidence on the effectiveness of wellness programs is mixed, and the Rand Corporation has estimated that only 20–40 percent of eligible employees participate in wellness programs.

This brief examines the characteristics of those who reported being invited to participate in wellness programs and their perceptions of these programs. The brief is based on data from the Center for Healthcare Research & Transformation’s 2015 Cover Michigan Survey of Michigan adults, fielded between October and December 2015.

Key Findings

A substantial share of Michiganders reported having participated in wellness programs, but they perceived limited benefits from these programs. Respondents reported participating in programs focused on mental health or stress management relatively infrequently, but those who participated in such programs reported the greatest perceived benefits.

  • One in five respondents (20 percent) reported having participated in a wellness program sponsored by their employer, insurer, or another organization within the year prior to the survey.
  • Wellness programs were most likely to focus on increased exercise, healthy eating, or preventive care. Eighty-two percent of those who participated in a wellness program reported that it emphasized exercise, 76 percent reported that it emphasized healthy eating, and 76 percent reported that it emphasized preventive care.
  • Only 27 percent of respondents who participated in a wellness program found the program to be “very helpful.”
  • Respondents who participated in a wellness program focused on mental health or stress management were most likely to report that they had found the wellness program “very helpful.” Forty percent of those who participated in programs focused on mental health or stress management reported that the program had been “very helpful” compared to only 23 percent of those who participated in programs focused on other topics.

The Uninsured in Michigan

Cover Page_CMS-Uninsured-v102

 

 

 

 

 

 

 

Introduction

A major goal of the Affordable Care Act was to reduce the number of Americans who are uninsured. The main provisions of the law intended to help achieve that reduction include the individual mandate, expansion of Medicaid, creation of the health insurance marketplaces and introduction of subsidies for individuals purchasing coverage, extension of coverage to adult children up to age 26, and requirements that certain employers offer affordable health insurance coverage or pay a penalty. Requirements that insurers cover those with preexisting conditions and prohibitions on rescission of coverage were also intended to further expand the number of Americans with access to affordable coverage. Because of these policies, estimates show that 16 million Americans gained insurance between 2010 and 2015.(1)The Affordable Care Act is Working (Washington, D.C.: U.S. Department of Health and Human Services, June 2015) http://www.hhs.gov/healthcare/facts-and-features/fact-sheets/aca-is-working/index.html (accessed 4/11/16). Nevertheless, an estimated 29 million Americans remained uninsured in 2015.(2)R. Cohen and M. Martinez, Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, January–March 2015 (Atlanta, G.A.: Centers for Disease Control and Prevention, Aug. 2015) http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201508.pdf (accessed 4/21/16).

This brief examines the characteristics of those in Michigan who reported being uninsured approximately two years after the ACA’s major coverage provisions went into effect beginning in 2014. The brief is based on data from the Center for Healthcare Research & Transformation’s 2015 Cover Michigan Survey of Michigan adults, fielded between October and December 2015. Comparison data is drawn from the 2009, 2011, 2012, and 2014 Cover Michigan Surveys.

Key Findings

Since 2009, Michigan’s uninsured rate has declined dramatically. Specifically:

  • Five percent of respondents reported being uninsured at the time of the survey. By comparison, in 2012, 14 percent of respondents reported being uninsured.
  • More than twice as many respondents reported having been uninsured at some point during the year before the survey than were uninsured at the time of the survey, indicating that many of the uninsured gained or regained coverage relatively quickly.
  • Forty-one percent of the uninsured reported annual household incomes below $30,000, and 54 percent reported incomes between $30,000 and $59,999.(3)The 2015 Federal Poverty Level for households of 3 people, the average household size of survey respondents, was $20,090. Those making up to 138% of the Federal Poverty Level, or $27,724 for a household of 3, are eligible for Medicaid. Those making up to $80,360 are eligible for Marketplace subsidies (https://aspe.hhs.gov/2015-poverty-guidelines).
  • Half of uninsured respondents worked full time.
  • Sixty-four percent of the uninsured were male.
  • Thirty-nine percent of uninsured respondents were between the ages of 18 and 30.
  • Half of uninsured respondents lived in small cities or towns.

Overall, those who remain uninsured are not a static group, and most Michiganders who reported having been uninsured during the year prior to the survey were uninsured for only short periods.

Rate of Uninsurance in Michigan

Fewer Michiganders reported being uninsured in 2015 than in any year since this survey was first fielded in 2009. Only 5 percent of Michiganders(4)40 respondents reported being uninsured at the time of the survey. The margin of error for the entire sample was ±3.9 percent and the margin of error for subgroup analyses of the uninsured was ±15 percent. reported that they did not have insurance at the time of the 2015 survey, compared to 14 percent in 2012 and 7 percent in 2014. Figure 1(5)The Cover Michigan Survey was not fielded in 2010 or 2013.

CT125_CMS-Uninsured-Fig1

Duration of Uninsurance in Michigan

Although the number of Michiganders without insurance has declined significantly, achieving continuous coverage may still pose a challenge. Respondents were significantly more likely to report having been uninsured at some point during the year prior to the survey than they were to report being uninsured at the time of the survey. Thirteen percent of respondents reported that they were uninsured for at least part of the year leading up to the survey, compared to only 5 percent at the time of the survey.

Of those respondents who were insured at the time of the survey but who had lacked continuous coverage during the 12 months prior to the survey, two-thirds had been uninsured for 3 months or less and only 5 percent had been uninsured for 10 months or more. Figure 2

CT125_CMS-Uninsured-Fig2

Profile of Uninsured Michigan Adults

Forty-one percent of uninsured respondents reported annual household incomes below $30,000, and 54 percent reported incomes of $30,000-$59,999. Only 5 percent of uninsured respondents reported incomes over $60,000. Figure 3

CT125_CMS-Uninsured-Fig3

Thirty-six percent of the uninsured reported that they had a high school education or less, 33 percent reported that they had taken college courses but did not graduate, and 31 percent reported that they were college graduates. Half of uninsured respondents reported that they worked full time, 19 percent reported that they worked part time, and only 9 percent reported that they were unemployed. Figure 4

Sixty-four percent of uninsured respondents were male and 36 percent were female. Thirty-nine percent of uninsured respondents were between the ages of 18 and 30, 36 percent were between the ages of 30 and 49, 20 percent were between 50 and 64, and 5 percent were 65 or older. Figure 5

CT125_CMS-Uninsured-Fig5
Eighty percent of the uninsured were white and 20 percent were African American. No uninsured respondents reported being of Hispanic origin. Fifteen percent of those who reported being uninsured lived in rural areas, 50 percent lived in small cities or towns, 14 percent lived in suburban areas, and 20 percent lived in urban areas. Characteristics of the uninsured did not differ significantly between 2014 and 2015.

Conclusion

The uninsured in Michigan are not a static group; many of those who reported being uninsured at the time of this survey had insurance at some point in the previous year. High proportions of the uninsured were young, male, and/or employed full time. Many did not have a college education, and half lived in small cities or towns, suggesting that future enrollment efforts might be most effective if targeted at these groups. The majority of uninsured respondents reported annual household incomes likely to make them eligible for Marketplace premium subsidies. This suggests that further education initiatives focused on eligibility for these subsidies could help many uninsured Michiganders find affordable coverage.

Methodology

The survey data presented in this brief were produced from a series of survey questions added to the Michigan State University Institute for Public Policy and Social Research (IPPSR) quarterly State of the State Survey. The survey was fielded between October and December 2015, and included a sample of 972 Michigan adults, with a 17.0 percent response rate. The margin of error for the entire sample was ±3.9 percent. The sampling design, a random stratified sample based on regions within the state, was a telephone survey conducted via landline and cellular phones of Michigan residents.

For analytical purposes, survey data were weighted to adjust for the unequal probabilities of selection for each stratum of the survey sample (for example, region of the state, listed vs. unlisted telephones). Additionally, data were weighted to adjust for non-response based on age, gender, and race according to population distributions from 2009-2013 American Community Survey data. Before weighting, 40 respondents reported being uninsured. Respondents who reported both Medicare and Medicaid coverage were considered Medicaid recipients for the purpose of this analysis. Results were analyzed using SAS 9.4 software. Statistical significance of bivariate relationships was tested using z tests or chi-square tests for independence. All comparison tables are statistically significant at the p ≤ 0.05 level unless otherwise noted. A full report of the IPPSR State of the State Survey methodology can be found at: http://ippsr.msu.edu/soss/.

References   [ + ]

1. The Affordable Care Act is Working (Washington, D.C.: U.S. Department of Health and Human Services, June 2015) http://www.hhs.gov/healthcare/facts-and-features/fact-sheets/aca-is-working/index.html (accessed 4/11/16).
2. R. Cohen and M. Martinez, Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, January–March 2015 (Atlanta, G.A.: Centers for Disease Control and Prevention, Aug. 2015) http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201508.pdf (accessed 4/21/16).
3. The 2015 Federal Poverty Level for households of 3 people, the average household size of survey respondents, was $20,090. Those making up to 138% of the Federal Poverty Level, or $27,724 for a household of 3, are eligible for Medicaid. Those making up to $80,360 are eligible for Marketplace subsidies (https://aspe.hhs.gov/2015-poverty-guidelines).
4. 40 respondents reported being uninsured at the time of the survey. The margin of error for the entire sample was ±3.9 percent and the margin of error for subgroup analyses of the uninsured was ±15 percent.
5. The Cover Michigan Survey was not fielded in 2010 or 2013.

Cover Michigan 2014 Survey: Satisfaction with Health Coverage in Michigan

The third open enrollment period for individual coverage on Michigan’s health insurance marketplace began on November 1, 2015, and will continue until January 31, 2016.(1)U.S. Centers for Medicare & Medicaid Services. November 2015. 2016 health insurance dates and deadlines.https://www.healthcare.gov/quick-guide/dates-and-deadlines/ (accessed 11/4/15) The average Michigan consumer will have 64 plans to choose from during the 2015 open enrollment period.(2)J. Fangmeier, 2015 Marketplace Rate Analysis (Ann Arbor, MI: Center for Healthcare Research & Transformation, Nov. 2015). Nationwide, 31 percent of consumers with marketplace coverage in both 2014 and 2015 switched plans during last year’s open enrollment period(3) T. DeLeire and C. Marks. Department of Health & Human Services. October 2015. Consumer Decisions Regarding Health Plan Choices in the 2014 and 2015 Marketplaces. http://aspe.hhs.gov/sites/default/files/pdf/134556/Consumer_decisions_10282015.pdf (accessed 11/4/15).

This brief examines how factors influencing health plan selection, both on and off the marketplace, were related to consumer satisfaction with insurance coverage. Our analyses suggest that when selecting a health plan during open enrollment, consumers may be happier with their coverage if they ensure that their plan includes their current primary care provider rather than looking for the plan with the widest network. Comparison shopping among plans at similar price points and looking for value instead of price alone may also lead to increased health plan satisfaction.

The brief is based on data from the Center for Healthcare Research & Transformation’s 2014 Cover Michigan Survey of Michigan adults, fielded between September and November 2014. Detailed methodology is available at http://chrt.sites.uofmhosting.net/publication/health-plan-selection-factors-influencing-michiganders-choice-of-health-insurance/.

Key Findings

  • Consumers for whom price played a major role when selecting a health plan were less likely to be satisfied with their plans than those for whom price was a less important consideration.
  • Consumers whose insurance did not include their primary care provider were far less likely to be satisfied with their coverage than those whose providers were included in their plans.

    Findings

    Forty-nine percent of respondents who reported that premium costs were a very important consideration when selecting a health insurance plan were satisfied with their plan (defined as having rated it as ‘excellent’ or ‘very good’), compared to 61 percent of respondents for whom premium costs were not such an important consideration. Similar differences existed for those who reported that deductible, copay, and coinsurance costs had been very important considerations in their selection of a plan, but respondents for whom the number of physicians in the plan had been a very important consideration were equally likely to report being satisfied with their coverage as those for whom this had not been as important factor FIGURE 1.

Figure 1: Percent of respondents satisfied with coverage, by importance of cost and network size in plan selection

Figure1

Source: CHRT Cover Michigan Survey 2014.

Only 21 percent of respondents who reported having had to change health care providers in the previous year because their provider was not included in their plan were satisfied with their coverage, compared to 54 percent of respondents whose insurance did not cause them to switch providers FIGURE 2.

Figure 2: Satisfaction with coverage, by insurance inclusion of provider
Figure2

Source: CHRT Cover Michigan Survey 2014.


Acknowledgements: CHRT would like to thank Thomas Buchmueller, Matthew M. Davis, Robert Goodman, Helen Levy, Renuka Tipirneni, and the staff of the Institute for Public Policy and Social Research (IPPSR) at Michigan State University for their assistance with the design and analysis of the survey.

 

 

References   [ + ]

1. U.S. Centers for Medicare & Medicaid Services. November 2015. 2016 health insurance dates and deadlines.https://www.healthcare.gov/quick-guide/dates-and-deadlines/ (accessed 11/4/15)
2. J. Fangmeier, 2015 Marketplace Rate Analysis (Ann Arbor, MI: Center for Healthcare Research & Transformation, Nov. 2015).
3. T. DeLeire and C. Marks. Department of Health & Human Services. October 2015. Consumer Decisions Regarding Health Plan Choices in the 2014 and 2015 Marketplaces. http://aspe.hhs.gov/sites/default/files/pdf/134556/Consumer_decisions_10282015.pdf (accessed 11/4/15).

Flu Vaccination in Michigan: Opportunities for Improvement

 

Introduction

Approximately 6,000 Americans die of influenza every year,(1)Centers for Disease Control and Prevention, “Estimates of Deaths Associated with Seasonal Influenza — United States, 1976–2007,” Morbidity and Mortality Weekly Report (MMWR), Aug. 27, 2010, 59(33): 1057–62: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5933a1.htm (accessed 6/25/15) and almost 800 people were hospitalized during the 2014–2015 flu season in the four Michigan counties that report flu hospitalizations (Clinton, Eaton, Genesee, and Ingham counties).(2)Michigan Department of Health & Human Services, “Influenza Surveillance Report for the Week Ending June 13, 2015,” MI Flu Focus, Influenza Surveillance Updates, (Lansing, MI: Michigan Department of Health & Human Services, Bureaus of Epidemiology and Laboratories, June 24, 2015), 12(23): http://www.michigan.gov/documents/mdch/MIFF_6-24-15_492747_7.pdf (accessed 6/25/15). Although the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices recommends that all adults and children over the age of six months receive an annual flu vaccination,(3)Centers for Disease Control and Prevention, Advisory Committee on Immunization Practices (ACIP) Reaffirms Recommendation for Annual Influenza Vaccination (Atlanta, GA: CDC, Feb. 26, 2015): http://www.cdc.gov/media/releases/2015/s0226-acip.html (accessed 6/25/15). only 42 percent of American adults were vaccinated against the flu during the 2013–2014 flu season.(4)Centers for Disease Control and Prevention, Flu Vaccination Coverage, United States, 2013–14 Influenza Season (Atlanta, GA: CDC, September 14, 2014): http://www.cdc.gov/flu/fluvaxview/coverage-1314estimates.htm (accessed 9/1/15). Michigan’s vaccination rate during the 2013–2014 flu season was slightly lower than the national average at 40 percent.(5)Centers for Disease Control and Prevention, 2013–14 State, Regional, and National Vaccination Report II (Atlanta, GA: CDC, N.D.): http://www.cdc.gov/flu/fluvaxview/reportshtml/reporti1314/reportii/index.html (accessed 9/1/15). Effectiveness of the flu vaccine varies greatly from year to year based on the annual vaccine’s match with strains of flu virus circulating at the time as well as other factors. Nevertheless, even the 2014–2015 vaccine, which was not as well matched to the predominant strains during that season as some previous vaccines, was able to reduce the odds of influenza infection by almost one-fourth among those vaccinated in the United States.(6)Centers for Disease Control and Prevention, “Early Estimates of Seasonal Influenza Vaccination Effectiveness—United States, January 2015,” Morbidity and Mortality Weekly Report (MMWR), Jan. 16, 2015, 64(01): 10–15: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6401a4.htm (accessed 6/25/15).

Michiganders insured through Medicaid or the Healthy Michigan Plan (the state’s expanded Medicaid program) are able to receive annual flu vaccination without a copay.(7)Michigan Department of Community Health, MSA Bulletin 10-30 (Lansing, MI: Michigan Department of Community Health, Medical Services Administration, Aug. 10, 2010): https://michigan.fhsc.com/Downloads/ MSA_10-30_330003_7.pdf (accessed 8/20/15). The Healthy Michigan Plan encourages beneficiaries to choose vaccination by reducing annual out-of-pocket contributions by 50 percent for those with an annual household income above the federal poverty level who complete a Health Risk Assessment with their primary care office/clinic and identify a health behavior goal such as receiving a flu shot.(8)State of Michigan, Healthy Michigan Plan, MI Health Account (Lansing, MI: Healthy Michigan Plan, 2015): http://www.michigan.gov/healthymiplan/0,5668,7-326-67957_69564—,00.html (accessed 8/20/15). Because Healthy Michigan Plan beneficiaries whose income is below the federal poverty level are not required to make out-ofpocket contributions, many plans instead provide them with a $50 prepaid card or gift card for completing the Health Risk Assessment.(9)U nitedHealthcare, Healthy Michigan Plan – Health Risk Assessment
Provider FAQ’s (Southfield, MI: United Healthcare, April 2014): http://www.uhccommunityplan.com/content/dam/communityplan/healthcareprofessionals/providerinformation/MI-Provider-Information/MI_Healthy_Incentive_FAQ.pdf (accessed 8/20/15).
,(10)HealthPlus Partners Healthy Michigan, HealthPlus Partners will reward you for taking steps toward getting and staying healthy! (N.P.: HealthPlus, April 8, 2014): https://www.healthplus.org/uploadedFiles/PDFs/Healthy_Michigan/HMP%20HRA%20Member%20Incentives%20Letter%20050514.pdf (accessed 8/20/15). As one of the Affordable Care Act’s preventive health services, annual flu vaccinations are also available without a copay or deductible to many Michiganders with private insurance.(11)U .S. Centers for Medicare & Medicaid Services, Preventive Health Services for Adults (Baltimore, MD: U.S. Centers for Medicare and Medicaid Services, N.D.): https://www.healthcare.gov/preventive-care-benefits/ (accessed 6/25/15). This brief examines the factors affecting flu vaccination in Michigan and how current and future policy initiatives could improve vaccination rates.

The brief is based on data from the Center for Healthcare Research & Transformation’s 2014 Cover Michigan Survey of Michigan adults, fielded between September and November 2014. All reported differences are statistically significant at the p ≤ 0.05 level.

Key Findings

  • Less than half (45 percent) of Michigan adults surveyed reported having received a flu vaccination in the past 12 months, a proportion similar to the national average.
  • Only 37 percent of African-American respondents reported having been vaccinated against the flu in the 12 months prior to the survey, compared to 47 percent of white respondents.
  • Women were more likely than men to report having received the flu vaccine: 48 percent of women reported having been vaccinated as compared to only 42 percent of men.
  • About one in three respondents under the age of 40 (34 percent) reported having been vaccinated, compared to more than two-thirds (70 percent) of those over 65.
  • Only 22 percent of respondents with Medicaid and 19 percent of uninsured respondents reported having received the flu vaccine in the past 12 months, about half the rate of respondents with employer-sponsored or individually purchased insurance.
  • Forty-eight percent of respondents who usually sought care at a doctor’s office reported having been vaccinated, compared to only 35 percent of those whose usual source of care was an urgent care clinic and 30 percent of those whose usual source of care was an emergency department.

    Demographic Predictors of Vaccination

Forty-five percent of Michigan residents surveyed reported having received a flu vaccination in the 12 months before the survey. Forty-seven percent of white respondents reported having been vaccinated in the year leading up to the survey, compared to only 37 percent of African-American respondents.

Only one-third of those whose income was less than $30,000 had been vaccinated, compared to half of those with an income above $30,000. Figure 1

CT958-CMS-Influenza-FIG1

Perceived household financial status had an even stronger relationship with flu vaccination than did reported household income. Those who rated their household financial status as “excellent” were more than twice as likely to report having received a flu shot than were those who rated their household financial status as “poor.” Figure 2

CT958-CMS-Influenza-vFIG2

Michiganders over the age of 65 were twice as likely to report having received a flu vaccine as those under 40. Only 34 percent of those between the ages of 18 and 39 reported having been vaccinated in the past year. Figure 3

CT958-CMS-Influenza-vFIG3

 

Insurance Status and Vaccination

Survey respondents reported wide variations in vaccination rates varied based on insurance status. Only 19 percent of uninsured respondents reported that they had been vaccinated in the past year, compared to 48 percent of insured respondents. Michiganders with Medicare were most likely to report having received the flu vaccine, while those who were uninsured or had Medicaid were least likely to report having been vaccinated. Respondents with employer-sponsored or individually purchased insurance were almost twice as likely as those with Medicaid to report having received a flu vaccine. Less than one-quarter of respondents with Medicaid reported having been vaccinated in the 12 months prior to the survey. Figure 4

CT958-CMS-Influenza-FIG4

 

Source of Care and Vaccination

Half of Michiganders who reported that they had a primary care provider received a flu vaccine, compared to only 28 percent of respondents who did not have a primary care provider. Those who reported that they usually went to a doctor’s office when they were sick or needed medical advice were more likely to have been vaccinated than those who reported usually receiving care at an emergency department or urgent care clinic. Figure 5

CT958-CMS-Influenza-FIG5

 

Conclusion

Despite recommendations that all individuals six months and older be vaccinated against the flu each year, less than half of Michigan adults surveyed reported having been vaccinated in the year leading up to this survey. Michigan residents whose income was less than $30,000 per year, those without a primary care provider and/or who relied on urgent care facilities or emergency departments for care, and those who had Medicaid or were uninsured were least likely to have been vaccinated. The low vaccination rates among these groups suggest a need for targeted future interventions. These data were collected too early in 2014 to fully reflect vaccination rates during the 2014–2015 flu season and therefore do not assess effectiveness of the Healthy Michigan Plan’s potential to effect changes in vaccination rates. It is possible that Michigan vaccination rates may increase as more Michiganders gain insurance coverage through the Medicaid expansion and the insurance marketplace, and as participation in the Healthy Michigan Plan’s incentive program expands.

Methodology

The survey data presented in this brief were produced from a series of survey questions added to the Michigan State University Institute for Public Policy and Social Research (IPPSR) quarterly State of the State Survey. The survey was fielded between September and November 2014 and included a sample of 1,002 Michigan adults, with a 20.2 percent response rate. The margin of error for the entire sample was ±3.9 percent. The sampling design, a random stratified sample based on regions within the state, was a telephone survey of Michigan residents conducted via landline and cellular phones.

For analytical purposes, survey data were weighted to adjust for the unequal probabilities of selection for each stratum of the survey sample (for example, region of the state, listed vs. unlisted telephones). Additionally, data were weighted to adjust for non-response based on age, gender, and race according to population distributions from 2009–2013 American Community Survey data. Respondents who reported both Medicare and Medicaid coverage or who reported coverage through the Healthy Michigan Plan were considered Medicaid recipients for the purpose of this analysis. Due to the timing of the survey, reported vaccination may have occurred during either the 2013–2014 flu season or during the 2014–2015 flu season. Results were analyzed using SAS 9.3 software. Statistical significance of bivariate relationships was tested using z tests or chi-square tests for independence. All comparison tables are statistically significant at the p ≤ 0.05 level unless otherwise noted. A full report of the IPPSR State of the State Survey methodology can be found at: http://ippsr.msu.edu/soss/.


Suggested Citation: Mary L. Smiley, Melissa Riba, and Marianne Udow-Phillips, Flu Vaccination in Michigan:
Opportunities for Improvement. Cover Michigan Survey 2014 (Ann Arbor, MI: Center for Healthcare Research & Transformation, October 2015).

Acknowledgements: The staff at the Center for Healthcare Research & Transformation would like to thank Thomas Buchmueller, Matthew M. Davis, Robert Goodman, Helen Levy, Renuka Tipirneni, and the staff of the Institute for Public Policy and Social Research (IPPSR) at Michigan State University for their assistance with the design and analysis of the survey.

References   [ + ]

1. Centers for Disease Control and Prevention, “Estimates of Deaths Associated with Seasonal Influenza — United States, 1976–2007,” Morbidity and Mortality Weekly Report (MMWR), Aug. 27, 2010, 59(33): 1057–62: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5933a1.htm (accessed 6/25/15)
2. Michigan Department of Health & Human Services, “Influenza Surveillance Report for the Week Ending June 13, 2015,” MI Flu Focus, Influenza Surveillance Updates, (Lansing, MI: Michigan Department of Health & Human Services, Bureaus of Epidemiology and Laboratories, June 24, 2015), 12(23): http://www.michigan.gov/documents/mdch/MIFF_6-24-15_492747_7.pdf (accessed 6/25/15).
3. Centers for Disease Control and Prevention, Advisory Committee on Immunization Practices (ACIP) Reaffirms Recommendation for Annual Influenza Vaccination (Atlanta, GA: CDC, Feb. 26, 2015): http://www.cdc.gov/media/releases/2015/s0226-acip.html (accessed 6/25/15).
4. Centers for Disease Control and Prevention, Flu Vaccination Coverage, United States, 2013–14 Influenza Season (Atlanta, GA: CDC, September 14, 2014): http://www.cdc.gov/flu/fluvaxview/coverage-1314estimates.htm (accessed 9/1/15).
5. Centers for Disease Control and Prevention, 2013–14 State, Regional, and National Vaccination Report II (Atlanta, GA: CDC, N.D.): http://www.cdc.gov/flu/fluvaxview/reportshtml/reporti1314/reportii/index.html (accessed 9/1/15).
6. Centers for Disease Control and Prevention, “Early Estimates of Seasonal Influenza Vaccination Effectiveness—United States, January 2015,” Morbidity and Mortality Weekly Report (MMWR), Jan. 16, 2015, 64(01): 10–15: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6401a4.htm (accessed 6/25/15).
7. Michigan Department of Community Health, MSA Bulletin 10-30 (Lansing, MI: Michigan Department of Community Health, Medical Services Administration, Aug. 10, 2010): https://michigan.fhsc.com/Downloads/ MSA_10-30_330003_7.pdf (accessed 8/20/15).
8. State of Michigan, Healthy Michigan Plan, MI Health Account (Lansing, MI: Healthy Michigan Plan, 2015): http://www.michigan.gov/healthymiplan/0,5668,7-326-67957_69564—,00.html (accessed 8/20/15).
9. U nitedHealthcare, Healthy Michigan Plan – Health Risk Assessment
Provider FAQ’s (Southfield, MI: United Healthcare, April 2014): http://www.uhccommunityplan.com/content/dam/communityplan/healthcareprofessionals/providerinformation/MI-Provider-Information/MI_Healthy_Incentive_FAQ.pdf (accessed 8/20/15).
10. HealthPlus Partners Healthy Michigan, HealthPlus Partners will reward you for taking steps toward getting and staying healthy! (N.P.: HealthPlus, April 8, 2014): https://www.healthplus.org/uploadedFiles/PDFs/Healthy_Michigan/HMP%20HRA%20Member%20Incentives%20Letter%20050514.pdf (accessed 8/20/15).
11. U .S. Centers for Medicare & Medicaid Services, Preventive Health Services for Adults (Baltimore, MD: U.S. Centers for Medicare and Medicaid Services, N.D.): https://www.healthcare.gov/preventive-care-benefits/ (accessed 6/25/15).

Cover Michigan: The Underinsured in Michigan, 2013

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Introduction

Over the last decade, consumers’ share of health care spending has steadily increased in the form of higher premiums and cost-sharing for services. The average deductible for employer-sponsored family coverage in Michigan more than doubled from 2003 to 2013, rising from $744 to $2,064. Deductibles for employer-sponsored individual coverage in Michigan more than tripled over the same period, increasing from $365 to $1,123.(1)Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey– Insurance Component, 2003 and 2013: http://meps.ahrq.gov/mepsweb/data_stats/quick_tables.jsp#insurance (accessed 7/6/2015). At the same time, wage growth averaged only 15 percent over the same period.(2)Bureau of Labor Statistics, Occupational Employment Statistics, 2003 and 2013: http://www.bls.gov/oes/tables.htm (accessed 7/6/2015).,(3)Deductible and wage data reported as nominal, not adjusted for inflation. As a result, many Americans are considered “underinsured,” meaning medical costs not covered by insurance exceed 5 percent of income for those with household income less than 200 percent of the federal poverty level (FPL), or 10 percent of income for those above 200 percent.

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The increase in out-of-pocket costs has made it more difficult for many consumers in Michigan to afford needed care, even though they have insurance. The 2012 CHRT Cover Michigan Survey found that 42 percent of Michiganders cited cost as a reason for not seeking needed medical care in 2012 and 27 percent reported struggling to pay medical bills.(4)M. Smiley, M. Riba, E. Ndukwe, and M. Udow-Phillips, Cover Michigan Survey: Coverage and Health Care Access (Ann Arbor, MI: Center for Healthcare Research and Transformation, March 2015): http://chrt.sites.uofmhosting.net/publication/cover-michigan-survey-2014-coverage-and-health-care-access/. Some consumers with high co-pays or deductibles may also not be able to pay their portion of the cost of care that they do receive, resulting in uncompensated care for providers. From 2007 to 2013, uncompensated care costs for Michigan hospitals grew from $722 million to $982 million.(5)Uncompensated care includes both bad debt for uncollected bills and charity care write-offs for uninsured and low-income patients. CHRT calculation using Healthcare Cost Report Information System data from the Centers for Medicare and Medicaid Services at https://www.cms.gov/Research-Statistics-Dataand-Systems/Downloadable-Public-Use-Files/Cost-Reports/?redirect=/CostReports/ (accessed 1/23/15).

This issue brief estimates the size of the non-elderly underinsured population in Michigan and in the United States in 2013 and analyzes several social and economic characteristics associated with the underinsured in Michigan, prior to the implementation of the major coverage provisions of the Affordable Care Act (ACA) in 2014. The brief also discusses the challenges faced by the underinsured and the likely impacts of the ACA’s coverage provisions and other policy changes on this vulnerable population.

Key Findings

  • Nationally, average out-of-pocket medical spending per capita grew almost 6 percent in just one year, 2012 to 2013. Over this same period, average family deductibles for employer-based coverage grew over 7 percent, while wages grew less than 2 percent.
  • The share of Michigan residents with adequate insurance in 2013 (74 percent) slightly exceeded the share nationwide (72 percent).
  • In 2013, nearly 1.2 million Michigan residents were underinsured, exceeding the total of approximately 1 million residents without health insurance.
  • Nearly 1.3 million people whose income was less than 138 percent of FPL were either underinsured (721,000) or uninsured (568,000) in 2013. A large share of this population became eligible for the Healthy Michigan Plan (Medicaid expansion) in April 2014.
  • Children up to age 18 had the lowest uninsured rate but were the most likely to be in an underinsured family (17 percent underinsured).
  • Workers in the leisure, hospitality, and service industries were the least likely to be adequately insured (63.9 percent). Among workers with health insurance, workers in the mining and construction industries were the most likely to be underinsured (12.7 percent).

Definition of Underinsured

In this brief, we evaluated underinsurance by measuring the economic costs of high out-of-pocket medical spending for people covered by health insurance. While this approach provides a clear definition of underinsurance, it does not necessarily capture people with insufficient benefits, unmet healthcare needs, or dissatisfaction with their coverage who forgo needed healthcare for these reasons.(6)State Health Access Data Assistance Center (SHADAC), Measuring the Adequacy of Coverage or Underinsurance (Minneapolis, MN: SHADAC, Jan. 2004): http://www.shadac.org/publications/measuring-adequacy-coverage-or-underinsurance (accessed 7/6/2015). Therefore, this analysis likely provides a conservative estimate of the number of underinsured residents in Michigan.

We adopted a definition of underinsurance developed by the Commonwealth Fund, which used two thresholds to identify the underinsured: residents with health insurance in families below 200 percent of the FPL with out-of-pocket medical spending (excluding premiums) that exceeded 5 percent of family income; or 10 percent if family income was above 200 percent of FPL.(7)C. Schoen, S. Hayes, S. Collins et al., America’s Underinsured: A State-by-State Look at Health Insurance Affordability Prior to the New Coverage Expansions (New York and Washington, DC: The Commonwealth Fund, March 2014): http://www.commonwealthfund.org/publications/fund-reports/2014/mar/americas-underinsured (accessed 7/6/2015). Residents who were insured but did not fall under either of these thresholds were considered adequately insured. We analyzed the non-elderly population (aged 0-64) using data from the U.S. Census Bureau’s Current Population Survey (CPS). For a detailed explanation of how we measured underinsurance, see the methodology section.

Underinsured Definition:

  • Family income is below 200 percent FPL and out-of-pocket medical spending is greater than 5 percent of income; or
  • Family income is above 200 percent FPL and out-of-pocket medical spending is greater than 10 percent of income.

 

Issues for the Underinsured

A growing body of evidence has shown that a lack of adequate insurance can leave consumers exposed to high medical costs that they are unable to afford. In a recent survey of adults aged 19 to 64, half of those who were identified as underinsured reported problems paying medical bills or were currently paying off medical debt, which is equal to the rate of uninsured adults experiencing these issues. About one-quarter of underinsured adults reported having to change their way of life to pay medical bills, while only 7 percent of adequately insured adults had to make changes. About 7 percent of underinsured adults had to declare bankruptcy due to medical debt.(8)S. Collins, P. Rasmussen, S. Beutel, and M. Doty, The Problem of Underinsurance and How Rising Deductibles Will Make It Worse—Findings from the Commonwealth Fund Biennial Health Insurance Survey (New York and Washington, DC: The Commonwealth Fund, May 2015): http://www.commonwealthfund.org/publications/issue-briefs/2015/may/problem-of-underinsurance (accessed 7/6/2015).

Underinsured adults are more likely than those who are adequately insured to forgo needed health care due to costs. Almost half (44 percent) of underinsured adults reported not getting needed care because of cost in the past year, compared to 23 percent of adequately insured adults. The underinsured were about twice as likely as adequately insured adults to not fill prescriptions; skip medical tests, treatments, or follow-ups recommended by a doctor; and not see a specialist when a doctor recommended it.(9)Ibid. Further, studies have shown that families enrolled in consumer-directed health plans(10)Consumer-directed health plans are health insurance plans with high deductibles ($1,000 or more for an individual) as well as tax-exempt health reimbursement arrangements or health savings accounts. use less preventive care than families in traditional plans.(11)A. Haviland, M. Marquis, R. McDevitt, and N. Sood, “Growth of Consumer-Directed Health Plans to One-Half of All Employer-Sponsored Insurance Could Save $57 Billion Annually.” Health Affairs, May 2012, 31(5): 1009–15: http://content.healthaffairs.org/content/31/5/1009.abstract (accessed 7/6/2015). Forgoing needed medical care has a direct impact on health outcomes. Among adults with a health problem or condition, underinsured adults were almost twice as likely to stay overnight in a hospital or visit the ER because of their health condition as adequately insured adults.(12)S. Collins et al., May 2015.

Out-of-Pocket Medical Spending Trends

From 2010 to 2013, average national out-of-pocket per capita medical spending (excluding premiums) increased from $628 per person to $690 per person—an average annual increase of 3.2 percent. Figure 1 However, from 2012 to 2013, such spending increased 5.8 percent—likely due to growing copays and deductibles, higher rates of insurance coverage, economic growth leading to more disposable income, or some combination of these factors. Nationally, from 2012 to 2013, the average family deductible for employer-based coverage grew by over 7 percent to nearly $2,500 per year.(13)Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey – Insurance Component, 2013: http://meps.ahrq.gov/mepsweb/data_stats/quick_tables.jsp#insurance (accessed 7/6/2015). By comparison, average worker wages increased by only 1.9 percent over the same period.(14)Bureau of Labor Statistics, Employment Cost Index: Historical Listing, April 2015: http://www.bls.gov/web/eci/echistrynaics.pdf (accessed 7/6/2015).

CovMI-Underinsured2015-FIG1

 

Michigan’s Underinsured Population

In 2013, nearly 1.2 million Michigan residents were underinsured. Figure 2 By comparison, approximately 1 million residents lacked health insurance coverage during that time. While Michigan’s underinsured rate of 14 percent just exceeded the national rate of 13 percent, a slightly larger share of Michigan residents had adequate insurance coverage (74 percent) than the share nationwide (72 percent).

Underinsurance in Michigan is concentrated in certain subpopulations, such as those with low incomes or those with coverage purchased through the individual (private, non-group) market. The following sections describe the characteristics of the underinsured population and where underinsurance was most likely to occur in 2013. Detailed tables are available in the Appendix.

CovMI-Underinsured2015-FIG2

Underinsured by Income

In Michigan, underinsured rates varied considerably by income level in 2013. Figure 3 More than 32 percent of residents with incomes below 138 percent FPL were underinsured, and an additional 25 percent lacked insurance coverage entirely. Figure 3 A significant share of this population became eligible for the Healthy Michigan Plan (Medicaid expansion) in April 2014.(15)Populations not eligible for the Healthy Michigan Plan include those eligible for traditional Medicaid or Medicare, unauthorized immigrants, or authorized immigrants with less than five years of residency. More than 19 percent of residents with incomes between 138 and 250 percent FPL were underinsured in 2013. Residents in this income range who became eligible for premium tax credits on the health insurance marketplace in 2014 were also eligible for cost-sharing reductions to lower their deductibles, co-pays, and other out-of-pocket costs if they selected a silver plan. Michigan residents with incomes greater than 250 percent FPL were more likely to be uninsured than underinsured in 2013.

CovMI-Underinsured2015-FIG3

Underinsured by Primary Form of Heath Insurance

Form of Health Insurance Rates of underinsurance also varied considerably by the type of health insurance residents had in 2013. Figure 4 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 (39.6 percent) compared to those enrolled in group coverage through an employer (11.1 percent). Similarly, a CHRT survey fielded in 2012, before major ACA reforms took effect, found that consumers with individual market coverage were the least satisfied with their health insurance (45 percent rated their coverage as “fair” or “poor”).(16)D. Young, A. Hammoud, M. Udow-Phillips, et al., Satisfaction with Health Care Coverage. Cover Michigan Survey 2013 (Ann Arbor, MI: Center for Healthcare Research & Transformation, July 2013): http://chrt.sites.uofmhosting.net/publication/satisfaction-health-care-coverage/.

Nearly 25 percent of residents enrolled in either Medicaid or the Children’s Health Insurance Program (CHIP) were underinsured in 2013. This result is unexpected, since most Medicaid enrollees were protected by an aggregate cap on total premium and cost-sharing expenses at 5 percent of family income—effectively lower than the underinsured threshold for lowincome families.(17)R. Rudowitz and L. Snyder, Premiums and Cost-Sharing in Medicaid (N.p.: Kaiser Commission on Medicaid and the Uninsured, Feb. 2013): http://kff.org/medicaid/issue-brief/premiums-andcost-sharing-in-medicaid/ (accessed 7/6/2015). While the full causes of underinsurance among Medicaid/ CHIP enrollees are not clear, about half of the Medicaid/CHIP underinsured in Michigan had at least one family member not covered by Medicaid/CHIP. In other words, many Medicaid/CHIP enrollees have their own financial protection from high out-of-pocket costs but could still be underinsured due to the costs their family members incurred.

CovMI-Underinsured2015-FIG4

Underinsured by Age

Underinsurance rates also varied across the age spectrum for Michigan residents in 2013. Figure 5 Children up to age 18 had the lowest rates of uninsurance (3.9 percent) but were the most likely to be in an underinsured family (17.1 percent). In older population groups, underinsured rates reach their lowest point for adults between the ages of 35 and 44 years (9.6 percent). However, after this point, underinsured rates rise again, reaching 15.3 percent for those between the ages of 55 and 64 years, who are approaching Medicare eligibility.

CovMI-Underinsured2015-FIG5

Underinsured by Industry

Among employed workers in Michigan in 2013, more than 80 percent of workers in the manufacturing, public administration (government), and health and education service industries were adequately insured. Figure 6 On the other hand, less than two-thirds of workers in the leisure, hospitality, and other services industries had adequate coverage. Lack of any coverage was a particular concern in these industries, with over 27 percent of workers being uninsured.

Regardless of whether they received insurance coverage through an employer or another source, almost 10 percent of insured workers were underinsured in 2013. Among covered workers, underinsurance rates were highest for those in the mining and construction industries (12.7 percent) and lowest for workers in public administration (5.5 percent). This could reflect varying degrees of collective bargaining, health plan generosity, and wage levels across these industries.

CovMI-Underinsured2015-FIG6

 

Conclusion

Over the last decade, Michigan residents with private coverage have experienced large increases in their health insurance deductibles and out-of-pocket costs for medical care. These trends resulted in an underinsured population even larger than the number of those without insurance. Underinsurance is a particularly prevalent issue for low-income families, including individuals in those families who are covered by Medicaid or CHIP and had robust cost-sharing protections for their own medical expenses.

While the Affordable Care Act expanded health insurance coverage through the health insurance marketplace and Medicaid expansion in 2014, it is not yet clear whether the newly insured will all find adequate coverage or what effect the law will have on those who were previously insured. The ACA provides cost-sharing reductions to low-income enrollees on the health insurance marketplace, and nearly all Americans with private insurance now have standardized caps on out-ofpocket spending and coverage for certain preventive services without cost-sharing. However, the overall effect of these ACA provisions on reducing underinsurance is not yet known.

In addition, employers continue to adjust their health plans by increasing consumer cost-sharing and considering new benefit designs such as defined contribution plans. These trends are important to monitor as they have broad implications for consumers, employers who offer health insurance, and providers who treat patients with insurance that requires significant out-of-pocket liabilities.

Methodology

Underinsured Data

This issue brief uses data from the Census Bureau’s Current Population Survey (CPS), a monthly economic survey of households across the United States.(18)Data downloaded from the National Bureau of Economic Research at http://www.nber.org/data/current-population-survey-data.html (accessed 4/8/2015). Around March every year, the CPS conducts the Annual Social and Economic Supplement (ASEC), which includes additional questions about health insurance coverage and out-of-pocket spending on medical care and insurance premiums for the previous year.(19)The Census Bureau has redesigned the health insurance questions for the 2015 ASEC. For the 2014 ASEC, the Census Bureau tested the questions
with five-eighths of the sample receiving the original questions, while the remaining three-eighths received the redesigned questions. This brief analyzed the respondents of the original questions. Therefore, it is unclear whether future underinsured analyses of the 2015 ASEC data will be directly comparable to this issue brief.
For example, the 2014 ASEC asks respondents about the coverage they had over the course of 2013. This is considerably different from the American Community Survey data used in other CHRT briefs, which is limited to health insurance coverage at the point in time when respondents answer the survey.

To identify Michigan residents that were underinsured, we adopted the underinsured definition developed by the Commonwealth Fund in their March 2014 report.(20)C. Schoen, et al., March 2015. Special thanks to David Radley, PhD, of The Institute for Healthcare Improvement and The Commonwealth Fund and
Claudia Solis-Roman of New York University for explaining their underinsured methodology and addressing our technical questions.
Individuals were identified as underinsured if they had health insurance and their family’s out-of-pocket medical spending (including both medical and over-the-counter spending but not premiums) exceeded certain family income thresholds, specifically, out-of-pocket medical spending exceeding 5 percent of family income if family income was below 200 percent of the federal poverty level (FPL) and out-of-pocket spending exceeding 10 percent of family income if family income was greater than 200 percent FPL. We restricted our analysis to nonelderly Michigan residents (aged 0–64).

Families were identified within households if they shared the same health insurance unit (HIU). HIUs are designed to resemble tax filing units, which are the logical groupings used to calculate income levels and eligibility for many financial assistance programs, including Medicaid and ACA tax credits. The HIU definition in this issue brief was developed by the Commonwealth Fund and differs slightly from the HIU definition developed by the State Health Access Data Assistance Center (SHADAC)(21)State Health Access Data Assistance Center (SHADAC), Defining Family for Studies of Health Insurance Coverage (Minneapolis, MN: University of Minnesota, March 2012): http://www.shadac.org/publications/defining-family-studies-healthinsurance-coverage (accessed 7/6/2015). used in previous CHRT briefs. Demographic and economic variables collected in the ASEC were used to generate cross-tabulations. Also, replicate weights were merged with the ASEC data to calculate the confidence intervals found in the Appendix.

Appendix

CovMI-Underinsured2015-Appendix


Suggested Citation: Fangmeier, Joshua; Corneail, Leah; Udow-Phillips, Marianne. The Underinsured in Michigan, 2013. Cover Michigan 2015 (Ann Arbor, MI: Center for Healthcare Research and Transformation, 2015).

 

References   [ + ]

1. Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey– Insurance Component, 2003 and 2013: http://meps.ahrq.gov/mepsweb/data_stats/quick_tables.jsp#insurance (accessed 7/6/2015).
2. Bureau of Labor Statistics, Occupational Employment Statistics, 2003 and 2013: http://www.bls.gov/oes/tables.htm (accessed 7/6/2015).
3. Deductible and wage data reported as nominal, not adjusted for inflation.
4. M. Smiley, M. Riba, E. Ndukwe, and M. Udow-Phillips, Cover Michigan Survey: Coverage and Health Care Access (Ann Arbor, MI: Center for Healthcare Research and Transformation, March 2015): http://chrt.sites.uofmhosting.net/publication/cover-michigan-survey-2014-coverage-and-health-care-access/.
5. Uncompensated care includes both bad debt for uncollected bills and charity care write-offs for uninsured and low-income patients. CHRT calculation using Healthcare Cost Report Information System data from the Centers for Medicare and Medicaid Services at https://www.cms.gov/Research-Statistics-Dataand-Systems/Downloadable-Public-Use-Files/Cost-Reports/?redirect=/CostReports/ (accessed 1/23/15).
6. State Health Access Data Assistance Center (SHADAC), Measuring the Adequacy of Coverage or Underinsurance (Minneapolis, MN: SHADAC, Jan. 2004): http://www.shadac.org/publications/measuring-adequacy-coverage-or-underinsurance (accessed 7/6/2015).
7. C. Schoen, S. Hayes, S. Collins et al., America’s Underinsured: A State-by-State Look at Health Insurance Affordability Prior to the New Coverage Expansions (New York and Washington, DC: The Commonwealth Fund, March 2014): http://www.commonwealthfund.org/publications/fund-reports/2014/mar/americas-underinsured (accessed 7/6/2015).
8. S. Collins, P. Rasmussen, S. Beutel, and M. Doty, The Problem of Underinsurance and How Rising Deductibles Will Make It Worse—Findings from the Commonwealth Fund Biennial Health Insurance Survey (New York and Washington, DC: The Commonwealth Fund, May 2015): http://www.commonwealthfund.org/publications/issue-briefs/2015/may/problem-of-underinsurance (accessed 7/6/2015).
9. Ibid.
10. Consumer-directed health plans are health insurance plans with high deductibles ($1,000 or more for an individual) as well as tax-exempt health reimbursement arrangements or health savings accounts.
11. A. Haviland, M. Marquis, R. McDevitt, and N. Sood, “Growth of Consumer-Directed Health Plans to One-Half of All Employer-Sponsored Insurance Could Save $57 Billion Annually.” Health Affairs, May 2012, 31(5): 1009–15: http://content.healthaffairs.org/content/31/5/1009.abstract (accessed 7/6/2015).
12. S. Collins et al., May 2015.
13. Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey – Insurance Component, 2013: http://meps.ahrq.gov/mepsweb/data_stats/quick_tables.jsp#insurance (accessed 7/6/2015).
14. Bureau of Labor Statistics, Employment Cost Index: Historical Listing, April 2015: http://www.bls.gov/web/eci/echistrynaics.pdf (accessed 7/6/2015).
15. Populations not eligible for the Healthy Michigan Plan include those eligible for traditional Medicaid or Medicare, unauthorized immigrants, or authorized immigrants with less than five years of residency.
16. D. Young, A. Hammoud, M. Udow-Phillips, et al., Satisfaction with Health Care Coverage. Cover Michigan Survey 2013 (Ann Arbor, MI: Center for Healthcare Research & Transformation, July 2013): http://chrt.sites.uofmhosting.net/publication/satisfaction-health-care-coverage/.
17. R. Rudowitz and L. Snyder, Premiums and Cost-Sharing in Medicaid (N.p.: Kaiser Commission on Medicaid and the Uninsured, Feb. 2013): http://kff.org/medicaid/issue-brief/premiums-andcost-sharing-in-medicaid/ (accessed 7/6/2015).
18. Data downloaded from the National Bureau of Economic Research at http://www.nber.org/data/current-population-survey-data.html (accessed 4/8/2015).
19. The Census Bureau has redesigned the health insurance questions for the 2015 ASEC. For the 2014 ASEC, the Census Bureau tested the questions
with five-eighths of the sample receiving the original questions, while the remaining three-eighths received the redesigned questions. This brief analyzed the respondents of the original questions. Therefore, it is unclear whether future underinsured analyses of the 2015 ASEC data will be directly comparable to this issue brief.
20. C. Schoen, et al., March 2015. Special thanks to David Radley, PhD, of The Institute for Healthcare Improvement and The Commonwealth Fund and
Claudia Solis-Roman of New York University for explaining their underinsured methodology and addressing our technical questions.
21. State Health Access Data Assistance Center (SHADAC), Defining Family for Studies of Health Insurance Coverage (Minneapolis, MN: University of Minnesota, March 2012): http://www.shadac.org/publications/defining-family-studies-healthinsurance-coverage (accessed 7/6/2015).