Coverage Archives

ACA Health Insurance Marketplace: Michigan overview and operations

On March 31, 2014, the Affordable Care Act’s (ACA) Health Insurance Marketplace officially closed for most people until open enrollment begins for 2015 health plans on November 15, 2014. By the end of the first open enrollment period, 272,539 Michigan residents had signed up for a plan through the ACA marketplace. Assuming that many of these residents complete the enrollment process, Michigan marketplace enrollment exceeded 2014 projections from CHRT, the Department of Health and Human Services (HHS), and the Urban Institute.

This issue brief summarizes the plans that have been offered on the ACA individual marketplace, explains the financial assistance available through the marketplace, describes the operational challenges faced by the marketplace, and recaps Michigan’s enrollment during the 2014 open enrollment period.

The first marketplace open enrollment period began on October 1, 2013, and ended on March 31, 2014. The marketplace offered consumers the opportunity to compare qualified health plans (QHPs) from multiple insurers. QHPs were required to comply with several newly effective ACA provisions which created minimum standards for coverage, regulated the design of plans, and allowed premiums to vary based on a limited set of factors unrelated to health status. To make QHPs more affordable to consumers, the ACA provides tax credits and cost-sharing reductions to qualifying individuals to lower the premium and out-of-pocket costs.

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Suggested citation: Fangmeier, Josh; Hatch-Vallier, Leah; and Udow-Phillips, Marianne. Michigan Health Insurance Marketplace: Overview and Operations Issue Brief. August 2014. Center for Healthcare Research & Transformation, Ann Arbor, MI.

Special thanks to Jon Linder.

Pain-Related Care and the Affordable Care Act: Summary of Common Practices

This paper provides a brief overview of key findings in the Institute of Medicine (IOM) 2011 report on pain, how public and commercial insurers approach pain management, and the pain-related provisions in the 2010 Patient Protection and Affordable Care Act (ACA).

The IOM released a report, Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research, summarizing findings and recommendations on how to address the gaps in pain prevention, care, education and research. The report identified the following recommendations related to service delivery and reimbursement:

Develop strategies for reducing barriers to pain care
Promote and enable self-management of pain
Support collaboration between pain specialists and primary care clinicians, including referral to pain centers when appropriate
Improve the collection and reporting of data on pain
Expand patient and public education, including prevention
Revise reimbursement policies to foster coordinated and evidence-based pain care

The IOM report also identified six treatment areas associated with pain care and where lack of coverage can be a barrier to effective pain care:

Medication
Regional anesthetic interventions
Surgery
Psychological therapies
Rehabilitative/physical therapy
Complementary and alternative medicines (CAM)

The ACA contains three key provisions to increase understanding and improve the delivery of evidence based care for pain management:

ACA Section 4305 – Requires the U.S. Department of Health & Human Services (HHS) to partner with the IOM to convene the Conference on Pain. The Conference is charged with:

Evaluating the adequacy of pain-related care and treatments in the general population and among identified groups;
Identifying barriers to pain care; and
Establishing an agenda for both the public and private sectors that will reduce barriers and improve pain research, education and care.

ACA Section 409J – Establishes the Interagency Pain Research Coordinating Committee (IPRCC) to coordinate all pain-related research within HHS and other federal agencies. IPRCC’s duties include:

Developing a summary of advances in pain care research relevant to the diagnosis, prevention, and treatment of pain and diseases and disorders associated with pain;
Identifying research gaps on the symptoms and causes of pain; and
Providing suggestions on how best to disseminate information on pain care.

ACA Section 759 – Encourages HHS to award grants, cooperative agreements, and contracts to health profession schools, hospices, and other public and private entities for the development and implementation of programs that provide pain care education and training to healthcare professionals.

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Premium cost changes attributable to the Affordable Care Act

The Affordable Care Act (ACA) expands health insurance coverage to millions of uninsured Americans and introduces several reforms to the health insurance market, particularly for people who purchase coverage on their own or receive it through employment at a small business. These reforms standardize benefits, limit insurance rating practices, prohibit coverage denials, limit out-of-pocket costs, and levy new taxes on health plans. These reforms primarily apply to non-grandfathered qualified health plans, sold on and off the marketplace, beginning in 2014. Combined with other ACA provisions already in effect, these reforms mean that some people in the individual and small group insurance markets looking for coverage on the new health insurance marketplaces will experience significant increases in premium costs for coverage and others will experience significant reductions.

Prior to the ACA’s passage in 2010, the Congressional Budget Office estimated that the ACA’s effects on average premiums—before subsidies are considered—would be an increase of 10 to 13 percent in the individual market and a range between a 2 percent decrease and a 1 percent increase in the small group market. In practical terms, however, the ACA’s impact on premium rates varies so widely from individual to individual and from small group to small group that the average impact is largely irrelevant to case-by-case experiences and perceptions. Compared to the pre-ACA environment, older people and small firms with disproportionately older, unhealthy workers will generally see lower premiums under the ACA, while young people and firms with predominantly younger workers will experience higher premiums (before considering the subsidies that apply to many in the individual market).

This expectation led to concerns that the young and healthy will experience “rate shock” and financial strain from premium increases. This issue brief describes the ACA provisions most likely to affect premium costs in the individual and small group markets (summarized in Figure 2). In addition to premium cost changes, this brief comments on out-of-pocket health care spending because personal health care spending includes both premiums and out-of-pocket costs.

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Suggested citation: Fangmeier, Joshua; Udow-Phillips, Marianne. Premium Cost Changes Attributable to the Affordable Care Act. February 2014. Center for Healthcare Research & Transformation. Ann Arbor, MI.

Special thanks to Jon Linder and Yan Yang.

For more information please contact us at: chrt-info@umich.edu

Access to mental health care in Michigan

One in five Michigan residents report having been diagnosed with depression at some point in their lives. Mental health disorders cause more disability among Americans than any other illness group.

Using data from the Cover Michigan Survey and the Michigan Primary Care Physician Survey, both fielded in calendar year 2012, this brief explores issues related to the prevalence of mental health disease, specifically depression and anxiety, and the capacity of the Michigan health care system to serve people with these conditions.

Overall, it is clear that there is high need for mental health services in Michigan and the capacity to serve those in need is not adequate to the task. Without addressing increased capacity for care, the increased mental health coverage provided to many under the Affordable Care Act will do little to help those most in need.

Key findings include:

Depression and anxiety are prevalent in Michigan and higher than the U.S. average. Twenty percent of Michiganders reported ever being diagnosed with depression, compared to 18 percent of Americans. Prevalence is greater when diagnoses of depression and/or anxiety are combined
- Depression and/or anxiety were reported in Michigan at particularly high rates among those with Medicaid (59 percent) and the uninsured (33 percent).
People with depression and/or anxiety had greater difficulty completing everyday activities, including work, than did Michiganders with other or no chronic conditions.
- Respondents with depression and/or anxiety reported twice as many limited activity days compared to those who reported having other chronic conditions. Respondents with depression and/or anxiety reported an average of five days in which poor health limited their activity.
The health care system in Michigan is inadequate to serve adults and children with mental health needs.
- Fifty-seven percent of primary care physicians reported that availability of mental health services in their community was inadequate for adults and 68 percent reported it was inadequate for children.
  - Adult mental health services in the St. Joseph, Muskegon, and Petoskey regions had the highest inadequacy ratings (89, 82 and 77 percent, respectively).
  - Child mental health services received the poorest ratings in the Muskegon and Petoskey regions (100 and 94 percent respectively).
  - Even in regions where primary care physicians reported the best access (Pontiac and Royal Oak), more than a third noted that access was inadequate.
- The availability of psychiatric beds in Michigan is extremely low compared to other states—Michigan was ranked 42nd among the 50 states and the District of Columbia in availability of inpatient psychiatric beds.

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Suggested Citation: Smiley, Mary; Young, Danielle; Udow- Phillips, Marianne; Riba, Melissa; Traylor, Joshua. Access to Mental Health Care in Michigan. Cover Michigan Survey 2013. December 2013. Center for Healthcare Research & Transformation. Ann Arbor, MI.

Employee cost-sharing for health insurance in Michigan and the United States

This brief reports on trends in health insurance premiums and cost-sharing among private-sector employers in Michigan and the United States from 2002 to 2012, and provides a focused look at high-deductible health plans by employer size.

From 2002 through 2012, average total premiums in the United States increased by approximately 80 percent. While employer cost-control efforts in the 1990s could be characterized as a shift toward managed care, the first decade of the 2000s may be better characterized as a shift of costs to employees.

The strategies that employers have used to shift costs to employees differed by employer size. Small employers (those with fewer than 50 employees) widely adopted high-deductible health plans between 2009 and 2012, whereas larger employers (50 or more employees) relied more on increasing the employees’ share of premiums as the primary form of cost containment. Recent trends indicate, however, that large firms may also be moving toward high-deductible plans.

The total cost of insurance premiums rose dramatically from 2002 to 2012 in Michigan and throughout the United States. At the same time, employee cost-sharing grew at an even faster rate, largely as a result of small employers offering HDHPs. The lower premiums associated with HDHPs may make insurance more affordable for employers, but requires employees to shoulder a large proportion of total health care costs. Trends suggest that enrollment in HDHPs will continue to grow, underscoring the importance of understanding whether HDHPs increase the affordability of health care or simply shift more costs to consumers.

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Suggested Citation: Hemmings, Brandon and Udow-Phillips, Marianne. Employee Cost-Sharing for Health Insurance in Michigan. Cover Michigan 2013. September 2013. Center for Healthcare Research & Transformation. Ann Arbor, MI.

Private health insurance in Michigan and the U.S.: Declines in employer-sponsored insurance

More than 500,000 people in Michigan lost their private health insurance from 2008 to 2011. The primary reason for the decline in private insurance in Michigan and in the nation was the erosion of employer-sponsored insurance (ESI), the most common way that Americans get private coverage.

From 1999 to 2011, the proportion of individuals covered by ESI decreased by approximately 15 percent nationwide. In Michigan during that time, the percentage of people with ESI fell by 20 percent, the second greatest reduction among all states, exceeded only by South Carolina.

In spite of these declines, in 2011 the proportion of people covered by employer-sponsored plans in Michigan remained 4.5 percentage points higher than the national average, in part because a larger percentage of employers in Michigan have historically offered health insurance.

This issue brief describes trends in private health insurance coverage in Michigan and the U.S., and focuses on coverage both by industry type and by income level. Key findings include:

The percentage of people with private coverage declined by more than 4 percentage points in both Michigan and the nation from 2008 to 2011. Reductions in the proportion of people with employer-based plans drove the overall decline in private coverage nationally and in Michigan, while the proportion of people with individually purchased coverage fell more slowly.
The percentage of employers offering health benefits fell by approximately 5 percentage points from 2008 to 2011 in Michigan and the U.S. However, a larger proportion of employers in several industries in Michigan offered benefits in 2011, compared to the national average, including manufacturing, agriculture, and construction.
In Michigan from 2010 to 2011, approximately 55,000 low-income people aged 18 to 25 years gained or retained private insurance as a result of the Affordable Care Act (ACA).

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Suggested Citation: Hammoud, Abdullah; Dreyer, Theresa; Baum, Nancy; and Udow-Phillips, Marianne. Private Health Insurance in Michigan, 2008 to 2011. Cover Michigan 2013. September 2013. Center for Healthcare Research & Transformation. Ann Arbor, MI.

Access to health care in Michigan

Understanding the impact of health care coverage (or the lack of it) on health care access is crucial to improving health care in Michigan.

The Center for Healthcare Research & Transformation (CHRT), in partnership with the Institute for Public Policy and Social Research (IPPSR) at Michigan State University, surveyed Michigan residents three times (in 2009, 2010, and 2012) on key issues relating to health care coverage, access to care, and health status. The latest survey, Cover Michigan Survey 2013, was fielded in the third quarter of 2012.

This report compares data from 2010 and 2012 and focuses on one aspect of that survey: The relationship between coverage status and access to care. Future reports will cover other aspects of health care in Michigan.

Key findings include:

More respondents said they had an identified primary care provider than in 2010; the greatest increase was found among those with Medicaid coverage.
Those with Medicaid coverage reported a significantly easier time in scheduling appointments for primary and specialty care than in 2010—now on par with those with employer-sponsored coverage.
Those with individually-purchased coverage reported greater difficulty scheduling appointments for primary care than in 2010.
Respondents reported using public or community health clinics as their usual sources of care at significantly higher rates than in 2010.
Respondents who lacked coverage reported using emergency rooms and urgent care centers as their usual sources of care at considerably higher rates than those who had coverage.

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Suggested Citation: Young, Danielle; Stadler, Phillip; Udow-Phillips, Marianne; Riba, Melissa. Access to Health Care in Michigan. Cover Michigan Survey 2013. March 2013. Center for Healthcare Research & Transformation. Ann Arbor, MI.

Acknowledgements: The staff at the Center for Healthcare Research & Transformation would like to thank Matthew M. Davis, MD, MAPP, and Helen Levy, PhD, at the University of Michigan; Robert Goodman, DO, at Blue Care Network of Michigan; and the staff of the Institute for Public Policy and Social Research (IPPSR) at Michigan State University for their assistance with the design of the survey and data collection.

Primary care capacity and the Affordable Care Act: Is Michigan ready to expand Medicaid coverage?

Since one of the most immediate questions facing the State of Michigan is whether to expand Medicaid coverage, this issue brief focuses specifically on one area of inquiry—Michigan primary care physicians’ capacity to serve new patients in both Medicaid and the private insurance market.

In the fall of 2012, the Center for Healthcare Research & Transformation (CHRT), in partnership with the Child Health Evaluation & Research Unit (CHEAR) at the University of Michigan, conducted a statewide survey of primary care physicians. The purpose of the survey was to understand the challenges and opportunities primary care physicians are facing in their practices in this era of health care reform.

Our goal was to inform policymakers about a number of key issues ranging from meaningful use of electronic health records to the capacity to care for Michigan residents, especially in light of the expected significant growth in insurance coverage beginning in 2014.

The bottom line of the survey is that primary care physicians in Michigan overwhelmingly anticipate having the capacity to serve more patients with all forms of health coverage, including Medicaid.

Overall, 81 percent of primary care physicians anticipate expanding their practices to include newly insured patients. Of those physicians, 90 percent of pediatricians; 78 percent of internal medicine practitioners; and 76 percent of family physicians reported that they will have capacity to accept additional patients if the number of Michigan patients with insurance coverage increases in the future.

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Suggested citation: Davis, Matthew M.; Udow-Phillips, Marianne; Riba, Melissa; Young, Danielle; Royan, Regina. Primary Care Capacity and Health Reform: Is Michigan Ready? January 2013. Center for Healthcare Research & Transformation. Ann Arbor, MI.

Special thanks to the Michigan State Medical Society and the Michigan Osteopathic Association in survey development, and to Krishna Davis, Seetha Davis, Lakshmi Halasyamani, Brandon List and Rose Kenitz for data entry.

The path to health care coverage under the Affordable Care Act: A flow chart

Following the U.S. Supreme Court’s decision to uphold the constitutionality of the Patient Protection and Affordable Care Act (ACA), efforts continue at the state and federal levels to prepare for implementation of key provisions of the ACA scheduled to take effect in 2014. These provisions, such as the (now optional) Medicaid expansion, the individual mandate to purchase insurance, state insurance exchanges, and employer “play or pay” rules will create new or different pathways to health coverage for many after the ACA comes into effect.

This flow chart provides a high-level picture of the ways that people will obtain health coverage in 2014, assuming the ACA is implemented as it exists today. The flow chart clearly reflects the complexity of the existing system for health coverage in the U.S., a public/private hybrid the ACA builds upon, but does not fundamentally change.

This diagram is intended as an overview of the pathways to coverage: while individuals may follow the flow chart to determine possible options, it is not intended to be comprehensive for that purpose. Rather, it is offered as a way to look ahead and better understand the many pathways to coverage that will exist in 2014, specifically in states that accept the option to expand Medicaid eligibility to individuals and families with incomes up to 138 percent of the federal poverty level (FPL).

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Updated February 12, 2013.

Cover Michigan Survey 2011

In 2009, the Center for Healthcare Research & Transformation (CHRT) commissioned the first Cover Michigan Survey, to gain insight into the issue of health care access in Michigan. The report was released in March 2010. Now, this 2011 report presents the findings of the Cover Michigan Survey conducted in 2010, which was designed to delve deeper into key questions raised by the previous report.

One of the most important conclusions of the Cover Michigan Survey was this: Having health coverage is not synonymous with having access to health care. Many respondents—even those with health coverage—reported significant barriers to obtaining affordable care.

The specific goals of the 2011 Cover Michigan Survey were:

To describe and better understand the connection between health coverage and access to care, with an in-depth look at the current Medicaid population.
To explore issues people face when seeking and receiving medical care.
To develop an in-depth profile of health status and its connection to health coverage.

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Suggested citation: Riba, Melissa, Nathaniel Ehrlich, Marianne Udow-Phillips, and Karen Clark. Cover Michigan Survey 2011. Ann Arbor, MI; Center for Healthcare Research & Transformation, 2011.

The staff of the Center for Healthcare Research & Transformation (CHRT) would like to thank 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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