Coverage Archives

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

This brief looks at trends between 2008 and 2014 with regard to Michigan federally qualified health centers (FQHCs) and free clinics. We find that more Michigan patients are receiving care at FQHCs and some free clinics are converting to FQHCs.

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.

Key findings include:

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.

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.

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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 acute care 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.

The HRRP has spurred a significant amount of activity to curb acute care hospital readmissions. In 2013, CHRT identified 10 readmissions initiatives used by hospitals and health plans nationally. Six of these initiatives have been implemented in Michigan (Appendix A provides an update on the other four programs). Those programs implemented in Michigan included:

Care Transitions Intervention® (CTI): Transitions Coaches® (e.g. advance practice nurses, registered nurses, and social workers), trained through the CTI program, review a patient’s discharge plans at the hospital, visit the patient at home within 48 to 72 hours of discharge, and call the patient three times within the first 28 days after discharge.
Project Re-Engineered Discharge (RED): Nurses coordinate patients’ transitions home, while pharmacists call patients after discharge to review medications and communicate any problems to the primary care provider.
Transitional Care Model (TCM): Advanced practice nurses provide home visits to high-risk elderly patients for three months, and are available by phone seven days a week.
Hospital to Home (H2H): A central clearinghouse provides hospitals and cardiovascular care providers with information and tools for improving care transitions and reducing readmission rates among patients who experienced heart failure or a heart attack.
Project BOOST (Better Outcomes for Older adults through Safe Transitions): A toolkit that offers hospitals and primary care providers evidence-based clinical intervention tools for improving care transitions.
State Action on Avoidable Readmissions (STAAR): A pilot program that focuses on building community-based and state-based partnerships to improve care transitions.

Each of the six initiatives target one of three levels for intervention—patient, system, and community levels—and are supported by varying degrees of evidence. The following is a summary of their implementation in Michigan, and an introduction to BCBSM’s new initiative to help reduce hospital readmissions in the state.

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

This brief provides an overview of price transparency initiatives in health care 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.

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.”

The opportunities we discuss include providing price information to consumers, providing price information to providers, and federal and state databases.

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

This brief examines the factors that most influenced consumer health plan selection among those with different types of coverage during the first enrollment period in the Affordable Care Act Health Insurance Marketplace. 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.

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.

Key findings include:

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.

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.

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

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.

The Michigan health insurance landscape 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.

Key findings include:

More Michigan residents gained health care coverage—the proportion of adult Michiganders who reported being uninsured was cut in half, from 14 percent in 2012 to 7 percent in 2014 after the ACA.
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.

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).

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The Affordable Care Act and its effect on employers

The Patient Protection and Affordable Care Act of 2010 (ACA) is designed to expand coverage to millions of Americans, yet the ACA largely preserves the system of health insurance sponsored by employers 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.

Although the prevalence of employer coverage has declined over the last decade, the majority of Michigan residents still rely on their employer for health insurance. As of 2013, 60 percent of residents received ESI coverage, down from 65 percent in 2008. Small firms still comprise the vast majority of private-sector employers in Michigan, as almost three out of every four employers have fewer than 50 employees. While large firms with 1,000 or more employees only represent 13 percent of total firms, they employ nearly 45 percent of Michigan workers.

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

Rate analysis: Michigan’s 2015 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 data.healthcare.gov. 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 Affordable Care Act in Michigan, focusing on Michigan’s route to expanded Medicaid coverage and decision to default to a federally-facilitated Health Insurance Marketplace.

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 Affordable Care Act implementation in Michigan and other state reports published to date are available on the Rockefeller Institute of Government’s ACA Implementation Research Network: http://www.rockinst.org/ACA/.

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Community mental health services: Coverage and delivery in Michigan

Since 1965, the number of Community Mental Health centers (CMHs) has increased from 12 covering 16 counties to 46 covering all 83 counties in Michigan.

Today, Medicaid is the major source of most funding for the publicly funded mental health system in Michigan, and care at CMHs is an entitled benefit under Medicaid. As such, individuals with Medicaid coverage are more likely to receive care through CMHs than uninsured and underinsured individuals.

Furthermore, CMHs providing care for non-Medicaid covered individuals in Michigan must use limited state general fund dollars to cover their care. State general fund dollars are allocated to each CMH based on historical funding formulas that are modified at the state’s discretion. Changes to the allocations have related to administrative expenses, previous general fund transfers between CMHs (under Public Act 236), and an effort to bring all CMHs to the same level of funds based on county populations.

Beginning in 2014, general fund dollars to CMHs were reduced substantially as a result of the state’s decision to expand Medicaid under the Patient Protection and Affordable Care Act. Medicaid funds are allocated monthly to each CMH through PIHPs according to the number of Medicaid beneficiaries in the PIHP’s service area. Decreases in general funds in recent years have threatened the ability of CMHs to deliver care to many of those in need. (See Appendix B for details about the flow of funding streams.) That is, only non-Medicaid patients with the most severe mental illness or developmental disabilities (“priority populations” under the Michigan Mental Health Code) receive care through CMHs.

Non-Medicaid eligibles may also be subject to waiting lists at CMHs, while individuals covered by Medicaid are not. Emergency cases are an exception, and are treated immediately regardless of a person’s ability to pay. Of the 227,020 people served at CMHs in Michigan in 2010, 69 percent were covered by Medicaid.

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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.

From 2009 to 2011, Michigan had an average of nearly 1.2 million non-elderly residents without health insurance coverage. Assuming the size and composition of the uninsured population has remained fairly constant, the vast majority would be eligible for some form of ACA affordability assistance. As shown in Figure 1, 61 percent of the uninsured are eligible for Medicaid or the Children’s Health Insurance Program (CHIP), including both those eligible under pre-ACA rules and adults who are are newly eligible under Medicaid expansion (also known as the Healthy Michigan Plan).

Nearly 28 percent of the uninsured have an income level and other characteristics that allow them to be eligible for subsidies (premium tax credits and/or cost-sharing reductions) if they purchase coverage through the ACA’s health insurance marketplace. On the other hand, 11 percent are ineligible for assistance due to their income level or because they have access to affordable employer-sponsored insurance (ESI). Individuals and families are not eligible for subsidies if their income level is greater than 400 percent of the federal poverty level (FPL), which is defined as $45,960 for an individual and $94,200 for a family of four in 2014.

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