Affordable Care Act trend analysis: Michigan’s safety net providers and clients

Editor’s Note: Counts for FQHC delivery sites in 2013 were updated to reflect the total number of permanent, seasonal, and administrative/service delivery sites in operation.

In 2014, the Affordable Care Act’s (ACA) major coverage expansions—the individual health insurance marketplace and Medicaid expansion—significantly altered the health care landscape.

In Michigan, more than 340,000 Michigan residents selected a marketplace plan by March 2015, and as of August 2015, approximately 606,000 Michigan residents had enrolled in the Healthy Michigan Plan, Michigan’s Medicaid expansion program. As a result of the ACA’s coverage expansions, Michigan’s uninsured rate decreased from 11 percent in 2013 to approximately 8 percent in 2014.

This brief looks at trends between 2008 and 2014 with regard to Michigan federally qualified health centers (FQHCs) and free clinics.

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Key Findings

  • Between 2013 and 2014, Michigan experienced significant growth in the number of FQHC delivery sites, from 164 to 220. During this time, the number of free clinics in Michigan decreased from 73 to 71.
  • Between 2013 and 2014, the number of total patients who received care at Michigan FQHCs increased by 7 percent to approximately 600,000 patients.
  • The number of patients seeking mental health services increased by 67 percent since 2008, stabilizing between 2013 and 2014. In 2014, nearly 26,000 patients were served.
  • Between 2013 and 2014, the number of Medicaid patients served by FQHCs increased by 24 percent, from 250,000 to more than 308,000 patients; and, the number of privately insured patients increased by 28 percent, from 78,000 to nearly 100,000 patients.
  • In 2014, approximately 125,000 FQHC patients in Michigan (21 percent) were uninsured, a 28 percent decline from 2013.
  • In response to the ACA’s coverage expansions, some free clinics are changing their structure or service scope, including converting to an FQHC or adopting new policies to serve underinsured or Medicaid patients while continuing to see uninsured patients.

Acute care readmission reduction initiatives: An update on major programs in Michigan

Inpatient hospitalizations account for 32 percent of the total $2.9 trillion spent on health care in the United States. In the majority of cases, it is necessary and appropriate to admit a patient to the hospital. However, patients returning to the hospital soon (e.g., within 30 days) after their previous stay account for a substantial percentage of admissions.

Research has shown that many factors—including a patient’s socioeconomic status, clinical conditions, and their communities’ characteristics—can influence hospital readmissions. In 2013, CHRT published an issue brief on the major programs aimed at reducing hospital readmissions, including the Hospital Readmissions Reduction Program (HRRP) established under the Affordable Care Act (ACA). This paper is an update on the HRRP and other programs previously highlighted. Read more.

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Learning health for Michigan: The path forward

A tale of three cities: Hospital and health system costs in the Midwest

Price transparency in health care: Federal and state initiatives, ongoing challenges, and opportunities for the future

In recent years, consumers have assumed an increasing share of health care spending through high deductible plans. For example, the average deductible for family coverage in Michigan more than doubled from 2002 to 2012, rising from $810 to $1,877, respectively. Deductibles for individual coverage in Michigan grew by 162 percent over the same period of time, increasing from $375 to $982, respectively.

In order to control rising health spending and provide more information on the cost of care to consumers, policymakers have increasingly focused on publishing data about payments to providers. As a result of these trends, the topic of “price transparency” has gained momentum in the United States.

For the purpose of this brief, price transparency in health care is defined as “the availability of provider-specific information on the price for a specific health care service or set of services to consumers and other interested parties.” This brief provides an overview of initiatives by federal and state governments and private entities; discusses the challenges associated with achieving the current goals of price transparency efforts; and highlights opportunities for moving forward to effectively achieve such goals.

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Health plan selection: Factors influencing Michiganders’ choice of health insurance

2014 marked the first open enrollment period for individual coverage on the Affordable Care Act Health Insurance Marketplace. In Michigan, over 272,000 people enrolled in health coverage during this time, choosing from 60 non-catastrophic plans. Plan choices ranged from five in Delta County to 52 in Macomb, Oakland, and Wayne Counties, and the average deductible for individual marketplace plans was approximately $2,900 in 2014. In most cases, consumers had a wide choice of plans representing different provider networks and levels of cost-sharing.

This brief examines the factors that most influenced consumer decision making among those with different types of coverage during the first enrollment period. 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. Those who purchased individual coverage on or off the marketplace are included in this analysis.

Key Findings

  • 92 percent of respondents with individually purchased insurance reported that at least one cost measure (premium, deductible, co-pay, or co-insurance) had been a very important factor in their selection of a health plan.
  • 41 percent of those with individually-purchased insurance noted that the physician network was a very important factor in their consideration of a health plan.
  • 18 percent of those with individual coverage indicated that they had to change their primary care physician as a result of their choice of health plans.

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Suggested Citation: Smiley, Mary L.; Riba, Melissa; Udow-Phillips, Marianne. Health Plan Selection: Factors Influencing Michiganders’ Choice of Health Insurance. Cover Michigan Survey 2014 (Ann Arbor, MI: Center for Healthcare Research and Transformation, 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.

Cover Michigan Survey: Coverage and health care access trends in the wake of the ACA

The Michigan health insurance landscape has changed substantially in the wake of the Affordable Care Act’s coverage expansion provisions. Starting in January 2014, many eligible individuals could enroll in private insurance coverage through the Health Insurance Marketplace and receive financial assistance to lower their cost of coverage.

On April 1, 2014, Michigan residents below 138 percent of the federal poverty level who were not previously eligible for Medicaid became eligible for the Healthy Michigan Plan, Michigan’s expanded Medicaid program.

Using data from two of the Center for Healthcare Research & Transformation’s Cover Michigan Surveys, this brief explores consumer experiences with insurance coverage and access to care within the state of Michigan between mid-2012 and late 2014. The 2014 survey was fielded beginning in September 2014, five months after the first Marketplace enrollment period ended and Healthy Michigan Plan enrollment had begun. By the end of the Marketplace’s first open enrollment period in March 2014, 272,000 Michigan residents had selected coverage through the Marketplace. By September 2014, 410,000 people were enrolled in the Healthy Michigan Plan, bringing the state’s total Medicaid enrollment to 2.2 million by that time.

This brief provides evidence of a dramatic change in Michigan’s health care landscape as a result of the first year of the ACA’s coverage expansions. Overall, the number of residents reporting they were uninsured, struggled to pay medical bills and/or delayed seeking needed medical care has dropped significantly compared to CHRT survey findings before the launch of the ACA coverage expansions. While most insured Michiganders reported easy access to primary care, they did, however, report a greater challenge in obtaining access to specialty care in 2014 than they reported before the ACA coverage expansions.

Key Findings

  • More people gained coverage—the proportion of adult Michiganders who reported being uninsured was cut in half, from 14 percent in 2012 to 7 percent in 2014.
  • Overall, from 2012 to 2014, those with insurance coverage reported access to primary care remained easy. Nearly 90 percent of insured adults reported having very or somewhat easy access to routine primary care appointments in 2012 and 2014.
  • Fewer people reported that they had delayed seeking medical care—22 percent of all respondents reported that they had not sought medical care they believed to be necessary in the previous six months in 2014, compared to 29 percent in 2012.
  • Between 2012 and 2014, Michiganders also reported fewer financial concerns associated with their health care:
    • In 2014, half as many respondents cited cost as a reason for not seeking needed medical care (21 percent, compared to 42 percent in 2012).
    • In 2014, 20 percent of respondents reported struggling to pay medical bills, compared to 27 percent in 2012.
  • Uninsured adults reported that it was more difficult to obtain primary care between 2012 and 2014. Those who reported very or somewhat easy access to primary care appointments declined from 67 percent in 2012 to 48 percent in 2014.
  • More people reported difficulty obtaining access to specialty care in 2014 compared to 2012. Specifically, 34 percent of adult Michiganders reported it was “very easy” to get an appointment with a specialist in 2012, compared to 24 percent in 2014.

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Suggested Citation: Smiley, Mary L.; Riba, Melissa; Ndukwe, Ezinne G.; Udow-Phillips, Marianne. Cover Michigan Survey: Coverage and Health Care Access. (Ann Arbor, MI: Center for Healthcare Research and Transformation, March 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.

The Affordable Care Act and its effect on employers

[Editor’s note: This brief was updated to clarify the differences between business establishments and firms.]

The Patient Protection and Affordable Care Act of 2010 (ACA) is designed to expand coverage to millions of Americans, yet it largely preserves the system of employer-sponsored health insurance that covers a majority of Americans.

Nevertheless, the ACA includes several provisions that directly affect employers and can influence their decisions about whether to offer coverage. Before many of the ACA’s provisions began in 2014, CHRT published separate issue briefs examining the key provisions for small employers, along with those affecting midsize and large employers. In addition, CHRT has published briefs on ACA taxes, premiums, and cost-sharing for employers and their workers.

This brief will summarize recent trends in employer-sponsored coverage and provide an update on certain key provisions that have faced implementation challenges. Several provisions of relevance to employers have faced significant delays or changes as the ACA has been implemented.

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Rate analysis: Michigan’s 2015 Health Insurance Marketplace

health insurance marketplace

On November 15, 2014, Michigan’s ACA Health Insurance Marketplace launched its second annual open enrollment period. During this period, which runs until February 15, 2015, Michigan residents can shop for health plans and determine if they are eligible for financial assistance to decrease the cost of coverage for the coming year.

Compared to the first open enrollment period, the Michigan marketplace saw large increases in the number of available health plans and, in certain areas, considerable changes in premium costs. These changes are especially important for residents who enrolled in 2014 marketplace coverage and plan to enroll again before the end of the 2015 open enrollment period.

All marketplace analysis was completed using 2014 and 2015 qualified health plan individual market medical plan data available at Notably, there are new benchmark plans (second-lowest cost silver plans) in nearly all (81 out of 83) Michigan counties. Changes in benchmark plans are an important factor in calculating the amount of premium tax credits marketplace applicants may be eligible for. Applicants in counties where the local benchmark premium decreased may be eligible for smaller tax credits, all other factors being equal.

The changing dynamics of the health insurance marketplace are particularly important for 2014 enrollees. Under current federal policy, enrollees who did not actively apply for and enroll in 2015 coverage by December 15 were auto-renewed into their 2014 plan, if it continued to be offered. Due to increases in new plan options and changes to benchmark plans that affect tax credits, many enrollees may have been better off actively selecting a 2015 plan that met their coverage needs.

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Michigan: Baseline report—state-level field network study of the implementation of the Affordable Care Act

The Affordable Care Act (ACA) expanded health insurance coverage in 2014 through two key provisions: premium tax credits offered through the health insurance marketplace and the state-option Medicaid expansion.

Michigan has taken a mixed approach to implementing the ACA. It very nearly became the first state-led entirely by Republicans to create a health insurance exchange as part of the ACA. Instead, Michigan was one of the more than thirty states to default to a federally run exchange. The state decided to adopt the Medicaid expansion, but with a delayed start date of April 2014.

The Center for Healthcare Research and Transformation examines the implementation of the ACA in Michigan, focusing on Michigan’s route to expanded Medicaid coverage and decision to default to a federally-facilitated Health Insurance Marketplace.

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The report is the most recent in a series of state and regional studies examining the rollout of the ACA. The national network, with 36 states and 61 researchers, is an effort of the Rockefeller Institute of Government at the State University of New York, the Brookings Institution, and the Fels Institute of Government at the University of Pennsylvania. The Michigan report was prepared by the Center for Healthcare Research and Transformation and David K. Jones, assistant professor of Health Policy & Management at Boston University and a graduate of the University of Michigan School of Public Health.

CHRT’s report on ACA implementation in Michigan and other state reports published to date are available on the Rockefeller Institute of Government’s ACA Implementation Research Network:

Community mental health services: Coverage and delivery in Michigan

Michigan’s publicly funded mental health system has its origins in Public Act 54, signed in April 1963. This state law permitted counties to form Community Mental Health (CMH) boards to support and treat people with severe mental illness, developmental disabilities, and substance abuse disorders outside of psychiatric hospitals and institutions.

The Act was intended to help states “provide for adequate community mental health centers to furnish needed services for persons unable to pay therefor.”

In 1974, Michigan’s PA 54 was repealed and replaced with Michigan PA 258, the Mental Health Code. The Michigan Mental Health Code is the basis for Michigan’s publicly funded mental health system today, allowing the creation of CMH agencies in single counties and CMH organizations in two or more counties.

Read about the evolution of federal and state community mental health policy. 

Effects of the ACA on insurance affordability for the uninsured in Michigan

January 1, 2014, marked the beginning of new health insurance affordability programs made available through the Patient Protection and Affordable Care Act (ACA). These programs include tax credits to lower premium costs, assistance to reduce out-of-pocket expenses, and an optional state expansion of Medicaid eligibility.

This analysis examines the effects of the ACA’s premium tax credits and cost-sharing reductions on Michigan’s uninsured population. While these two programs do provide financial benefits to many of Michigan’s uninsured, the extent of these benefits will vary due to the socioeconomic diversity of the uninsured population.

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