Comparing Recent Health Care Proposals: From building on the ACA to Medicare for All

Democratic lawmakers in Congress have made a variety of proposals to strengthen or reform the United States health care system. These proposals range from building upon the Affordable Care Act (ACA) to fully transitioning the U.S. to a single-payer system.

This fact sheet categorizes and compares the major provisions of these proposals, including possible implications for consumers, health care providers, and federal and state governments.

Read Comparing recent health care proposals: From building on the ACA to Medicare for All.

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.




Michigan at a crossroads: CHRT highlights key health policy issues for the incoming gubernatorial administration

The Michigan government has jurisdiction over a wide array of health policy issues. From the regulation of insurance products, to oversight of the state’s Medicaid program, to investing in local public health efforts, Michigan policymakers craft policies and budgets that impact the health of millions of Michiganders.

This brief provides an overview of four key and timely health policy topics:

  • Medicaid and the Healthy Michigan Plan;
  • the individual health insurance market and the federal Health Insurance Marketplace;
  • the opioid epidemic; and
  • the integration of services to address the social determinants of health.

It also explores some of the forces influencing our state’s health and discusses policy approaches to today’s health and health care issues.

Read the full brief.


Learning health for Michigan: The path forward

In the United States, health care purchasers, consumers, and policymakers are demanding improvements in the quality and efficiency of medical care. A promising approach to meet this demand is the development of what is known as a learning health system (LHS). A learning health system has the capability to continuously study and improve itself. Among many types of benefits it can bring about, the learning health system makes it possible for providers to make faster and better decisions about which treatment options would produce the best outcomes for patients. Today, the Michigan-based stakeholder initiative, Learning Health for Michigan (LH4M), is proposing the use of a learning health system approach to address persistent health care problems in Michigan. Unwarranted and costly hospital readmissions—which are discussed in this paper—are one example of a problem that could benefit from a learning health system approach.

In 2013, the Center for Healthcare Research and Transformation (CHRT) convened a group of patients, clinicians, researchers, public health professionals, and payers to discuss ways to apply the idea of the learning health system at a state level: to turn Michigan into what might be called a “learning health state.” The initiative was named “Learning Health for Michigan,” or LH4M. Later convenings of the LH4M stakeholder group were organized by the Michigan Health Information Network (MiHIN) Shared Services and the Department of Learning Health Sciences at the University of Michigan Medical School.

Michigan has many resources that are key ingredients for a state-wide learning health system.

Read the full brief, Learning Health for Michigan: The Path Forward.


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 (CHRT) 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.

Read Full Brief Here

Uncoordinated prescription opioid use in Michigan

Prescription opioids such as morphine, oxycodone, and hydrocodone provide pain relief to patients with chronic pain. However, these drugs also pose safety risks to patients. Opioid use can cause respiratory depression, resulting in overdose or death.

As prescription opioids have been used more extensively for pain control in the past two decades due to changing practice guidelines, overdose deaths surged in both Michigan and the United States. Notably, the majority of opioid-related disabilities and deaths result from patients taking opioids as prescribed, rather than from deliberate abuse or misuse. Furthermore, opioid-related deaths are frequently associated with concurrent use of prescribed antidepressants or benzodiazepines like Valium and Zanax.

Pain control is an essential part of patient care, and opioids are one of the primary pain treatments available. While most opioids are used and prescribed appropriately, a small number of patients receive numerous prescriptions from separate prescribers within a short period of time. This lack of coordination increases patients’ risk of accidental overdose and death. This issue brief analyzes accidental deaths from opioid overdoses in Michigan, uncoordinated opioid prescribing among privately insured Michigan patients in 2013, and policy options to improve safe prescribing in the state.

Key Findings

  • Uncoordinated opioid prescribing is a critical patient safety issue in Michigan, particularly for patients who receive a large volume of opioids from multiple prescribers. It is essential that patients receive appropriate pain control, which may include the use of opioids, but pain treatment should not jeopardize patient safety.
  • Accidental overdose deaths involving opioids (including prescription drugs and heroin) increased sixfold in Michigan between 1999 and 2013 (from 81 to 519 deaths). These opioid-related deaths represented 38 percent of all accidental drug deaths in 2013, up from 23 percent in 1999.
  • Accidental overdose deaths involving prescription opioids represented 43 percent of total opioid deaths in 2013. The remaining 57 percent of deaths were from heroin, which is noteworthy since some patients first become addicted to prescription drugs and then turn to heroin, the strongest form of opioid.
  • In 2013, over 600 privately insured Michigan patients in the study group were defined as having uncoordinated opioid prescriptions (0.3 percent of all patients using prescription opioids). These patients filled at least ten opioid prescriptions from four or more providers within three months. As a result, they ran a higher risk of accidental overdose and death because their providers may not have been aware of all their opioid prescriptions.
  • In October 2015, the Michigan Prescription Drug and Opioid Abuse Task Force released its findings and recommendations.

Key recommendations to address these issues include:

  • Expanding provider education on safe opioid prescribing;
  • Requiring providers to have a bona-fide relationship with patients before prescribing controlled substances;
  • Launching a public awareness campaign;
  • Increasing access to the lifesaving overdose reversal drug naloxone;
  • Exploring the possibility of limiting criminal penalties for people who report or seek medical attention for overdoses; and
  • Improving the state’s database of controlled substance prescriptions and increasing its use by providers and pharmacists.

Read Full Brief Here

Health care spending for chronic conditions in Michigan

Chronic conditions affect millions of Americans and have a major impact on U.S. health care spending each year, accounting for seven out of every ten deaths in the United States annually. It is estimated that more than 75 percent of all health care costs are associated with chronic diseases. Approximately 45 percent of Americans nationwide are affected by at least one chronic condition, and 60 percent of adults in Michigan suffer from a chronic condition.

In 2010, roughly 30 percent of total national health care spending—$347 billion—was associated with the following chronic conditions: heart conditions, cancer, chronic obstructive pulmonary disease, asthma, diabetes, and hypertension. The largest contributing factors to the increase in the prevalence of such conditions include physical inactivity, tobacco use, and poor diet. Currently, over 95 percent of Michigan adults report at least one behavior that may increase their risk for chronic conditions.

This issue brief summarizes health care spending in Michigan for five common chronic conditions for Blue Cross and Blue Shield of Michigan members:

  • Coronary artery disease
  • Congestive heart failure
  • Chronic obstructive pulmonary disease
  • Depression
  • Diabetes

Read Full Brief Here

Suggested citation: A. Hammoud and M. Udow-Phillips. 2014. Healthcare Spending for Chronic Conditions in Michigan. Center for Healthcare Research & Transformation, Ann Arbor, MI.

Special thanks to Robyn Rontal and team.

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. 

Autism spectrum disorder in Michigan

Autism spectrum disorder (ASD) comprises a group of developmental disabilities that cause impairment in social interactions, communication skills, and behaviors that can have long-term health and social functioning costs for individuals with ASD and their families. In 2014, the Centers for Disease Control and Prevention (CDC) reported that approximately one in 68 children in the United States were diagnosed with autism spectrum disorder.

Researchers estimate that it costs between $1.4 and $2.4 million to support an individual with ASD over a lifetime for direct costs such as medical care or special education, and indirect costs such as lost employment. Federal agencies, advocacy groups, and states are paying more attention to the prevalence, diagnosis, and treatment costs for ASD, demonstrated by an influx in research and an increasing number of states that have mandated certain insurers to provide coverage for ASD diagnosis and treatment.

Read or download the full brief

Suggested Citation: Peters, Claire; Lausch, Kersten; and Udow-Phillips, Marianne. Autism Spectrum Disorder in Michigan. October 2014. Center for Healthcare Research & Transformation, Ann Arbor, MI.

Special thanks to Lisa Grost.

Best Practices in Care Management for Senior Populations

Care Management is a service designed to help patients and their caregivers manage medical conditions more effectively, in order to improve health and reduce the need for hospitalizations and emergency department visits. The concept arose in the past decade from disease management programs of the 1990s, which focused on individual diseases rather than more comprehensive consideration of patients’ needs. Care managers are generally nurses or social workers who work closely with patients and caregivers to assess health risks and needs, collaboratively develop care plans, and coach patients in self-care.[footnote list=”1″ style=”lower-alpha”]All references in this paper correspond to item numbers in the Annotated Bibliography, which details the research on care management.

This seminal report offers a wealth of information about the evidence base for care management, detailing what works in research and practice. The authors considered evidence from randomized controlled trials (RCTs), Medicare demonstration projects, and programs initiated by health systems and private insurers. They concluded that while most care management programs successfully improved quality of care, few achieved cost savings. The authors identified four key elements needed to both save money and improve quality: (1) targeting only high-risk patients, (2) incorporating in-person contact between patients and care managers (including home visits), (3) hiring highly-trained care managers to work with primary care physicians (PCPs) in multidisciplinary teams, and (4) coaching patients in self-care.

The authors concluded that hospital-to-home care transitions programs are most effective at reducing cost and improving quality. Two successful models—Eric Coleman’s Care Transitions Intervention and Mary Naylor’s Transitional Care Model (as described below in items 8 and 9)—demonstrated cost-savings in RCTs and have been adapted to real-world settings by health systems and plans.Care managers strive to ensure close communication between patients and physicians, and among all providers involved in patients’ care.

Health care providers increasingly offer care management, driven in part by reimbursement changes under the Affordable Care Act that sparked provider interest. Health plans are encouraging this trend through reimbursement policies and are moving away from offering care management directly or through vendor-supplied services. This analysis focuses on the question: do care management programs work for senior populations and, if so, what characteristics are shared by the most effective programs?

Key Research Findings

Research shows that care management programs generally improve quality of care, but cost reduction is hard to achieve, especially for patients age 85 and older.6 The research also identifies several key attributes that can increase the likelihood of a program to achieve improved quality and efficiency.

Randomized Controlled Trials

Hospital-to-home care transition programs delivered in health systems are most effective at reducing costs and improving quality.[footnote list=”1″]For additional detail on care transitions, see the CHRT report Care Transitions: Best Practices and Evidence-based Programs. Two proven models are Eric Coleman’s Care Transitions Intervention and Mary Naylor’s Transitional Care Model. In the Coleman program, advanced practice nurses contacted high-risk elderly patients as they were discharged from the hospital, then followed up with the patients by conducting one home visit and three phone calls over a four-week period. In a 2006 study, this program showed a 30 percent reduction in 30-day admissions and a 20 percent reduction in patient costs.

Naylor’s more intensive model provided high-risk, high-cost elderly patients with care management for three months after discharge from the hospital. Advanced practice nurses regularly visited patients’ homes and met with their primary care physicians, and patients could reach care managers by phone seven days a week. As reported in a 2004 study, readmissions dropped by 36 percent and patient costs by 39 percent (nearly $5,000 per patient) within one year.

Care management delivered in other provider settings, including primary care and multispecialty groups, has shown quality improvements but little evidence of cost reduction in RCTs. Evaluations of vendor-supported care management are inconclusive. The Congressional Budget Office determined that the methodologies that vendors used to evaluate their own products were too weak for cost or quality claims to be reliable,1 and the few independent studies of vendor-delivered programs showed limited quality impacts with no evidence of cost reduction.

Demonstration Projects

The Centers for Medicare and Medicaid Services (CMS) runs demonstration projects to test innovative health programs for seniors and measure their impact. Few CMS demonstration projects of care management programs have achieved sufficient cost-savings to offset implementation expenditures. Of the 34 CMS-funded care management demonstration projects since 1999, two raised costs and 31 had no statistically significant impact on reducing costs. There are, however, two programs that did improve quality and produce savings: the Program of All-Inclusive Care for the Elderly (PACE), which began as a CMS demonstration in the 1970s, and a recent demonstration project at Massachusetts General Hospital.

PACE programs generally save money over time but have substantial start-up costs. PACE provides integrated care to elderly, high-risk patients through multidisciplinary teams. Enrollees’ care is managed in adult day care centers, with home care offered as needed. The program dramatically improves patients’ functional status and quality of life, decreases mortality, and reduces hospital and nursing home use. PACE programs have grown slowly, however, largely due to strict program requirements. These requirements include leaving personal physicians in favor of PACE physicians and mandatory attendance at adult day care. Programs that modify the PACE model to increase patient flexibility have not produced the same magnitude of cost savings or quality improvements. For example, in a comparison of a Wisconsin PACE program to a more flexible local competitor based on the PACE model, PACE participants were 68 percent less likely to be hospitalized and 59 percent less likely to be admitted for preventable conditions.

Massachusetts General Hospital ran the only other CMS demonstration that achieved statistically significant cost savings within three years, reducing Medicare expenditures by an estimated 7 to 11 percent by decreasing hospital admissions and emergency department visits. The program enrolled high-risk patients receiving care from the health system and affiliated primary care clinics. Care managers were employed by primary care physicians and managed patients’ care both in person and by phone. The care managers also had access to the health system’s electronic medical records to facilitate communication between providers.

Patient-Centered Medical Homes

Patient-Centered Medical Homes (PCMHs) are the preferred care management delivery model for many health systems, insurers, and state Medicaid agencies. PCMHs are new ways of organizing primary care practices to promote quality of care, coordination between providers, and increased responsiveness to patients’ needs. Care management is a central component of most PCMH demonstration projects. As of 2010, 14 PCMH interventions had demonstrated at least a 10 percent improvement in quality and cost metrics, although some cost measures were not statistically significant. Most successful PCMH programs integrated care managers within practices as part of multidisciplinary teams, aligned financial incentives between providers and payers, and leveraged electronic medical records to increase communication between providers.

Best Practices

Care management programs that successfully reduced costs and improved quality did the following:

  • Provided face-to-face contact between patients and care managers. The frequency of in-person contact varied from an initial appointment in the PCP’s office to regular home visits.
  • Integrated care management within primary care practices. In the best programs, care managers were co-located with primary care physicians or, at minimum, regularly visited the physicians and managed the care of all eligible patients in the practice. In one model, care managers worked in up to three small practices with space set aside for them in each, in order to build strong communication with all physicians.
  • Targeted patient selection. High-risk patients with multiple chronic conditions—generally a subset of the elderly—benefit most and have the greatest potential for cost savings.
  • Stratified services based on patient needs. Stratifying high-risk patients allows more complex patients to receive more intensive services; care managers that manage the most high-risk patients require lower caseloads.
  • Focused on transitions of care from the hospital to other settings. Hospital-to-home transitions are one of the best cost-saving measures, and engage patients when they may be most receptive to behavior change.
  • Coached patients in self-management techniques. Coaching helps patients engage in self-care, manage their medications, and recognize and respond to “red flags” for their conditions.
  • Used electronic medical records. Electronic medical records can be leveraged to assess patients’ health risks, reduce duplication, facilitate communication between providers, and provide feedback to primary care physicians.

While including these elements does not guarantee programs’ success, the research is strong that these features do create the foundation for high-quality, cost-saving care management services.


Care management can help patients and caregivers mitigate the impact of chronic conditions, and reduce the need for expensive health care services such as hospitalizations and emergency department visits. However, while many care management programs have improved quality of care, relatively few have achieved cost savings. This paper outlines best practices that can help providers and health plans invest in care management programs that are designed to promote both quality and efficiency.