A new report on the impact of Medicaid expansion in Michigan shows positive effects and opportunities for improvement

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A new report on the impact of Medicaid expansion in Michigan shows positive effects and opportunities for improvement

At a pivotal moment for Medicaid health coverage for low-income Americans, a report on the impact of Medicaid expansion in Michigan shows many positive effects as well as opportunities for continued improvements.

The report was prepared by the University of Michigan’s Institute for Health Policy and Innovation as part of its evaluation of the Healthy Michigan Plan, Michigan’s Medicaid expansion program. The program currently has about 1 million enrollees and was signed off 10 years ago this September.

Overall, the report shows that the Healthy Michigan Plan is effective at:

  • reduction of uninsured,
  • supporting financial well-being,
  • promotion of primary care and responsible use of health services among people with low incomes and
  • maintaining the safety net and supporting coordinated strategies to address the social determinants of health.

The report also draws on data and interviews to show that two unique aspects of Michigan’s expansion—financial incentives for participants to focus on healthy behaviors and income-based cost-sharing to promote personal responsibility for health care decisions – have been only partially effective in achieving their goals.

The IHPI assessment is funded by the Michigan Department of Health and Human Services and required by the federal Centers for Medicare and Medicaid Services as part of Michigan’s Medicaid expansion waiver. This was the interim report published midway through the release period.

Data that could inform Michigan and other states

The findings have implications far beyond Michigan, the IHPI team notes.

All states are currently in the process of “rolling out” of the Medicaid Continuous Enrollment Special Provision, which was enacted during the height of the public health emergency during the COVID-19 pandemic.

Since April, more than 5.3 million people have lost Medicaid coverage nationally in the 45 states and the District of Columbia that reported data as of Aug. 24. The redetermination, as it’s called, of individual eligibility will run until 2024.

Michigan has launched an online dashboard to track redetermination data, including the number of individuals whose Medicaid is not renewed. MDHHS recently provided an update on the process and efforts to reach out to participants who must provide information to determine their eligibility.

Measuring the impact of the rollout on individuals, health systems and insurance network agencies will be important, especially in light of the positive impacts of coverage expansion, the authors of the IHPI report say.

At the same time, several states that did not pass the Medicaid expansion in the first six years of the program through 2019 have done so in the past few years; a full list of current state policies is available here. About 1.9 million potentially eligible low-income adults live in the 10 states that have not expanded Medicaid under the federal program.

Since 2014, the Healthy Michigan plan has increased access to care and has been linked to improved health and other outcomes reported by beneficiaries, many of whom were previously uninsured or unconnected to social support services that can impact health.

John Z. Ayanian, MD, MPP, IHPI Director and HMP Evaluation Project Leader

He continued, “During the COVID-19 pandemic, the Healthy Michigan plan maintained access to coverage and care for those already enrolled and offered coverage to new beneficiaries affected by unemployment and loss of health insurance. We hope our findings will inform other states as they go through the redistricting process, consider partial or full Medicaid expansion, or consider implementing specific features in their Medicaid programs, such as cost-sharing provisions or health behavior incentives.”

A recent Michigan law changes some of the Healthy Michigan plan’s income-based cost-sharing requirements, which the IHPI report found did not fully meet their goal and which the team recommended simplifying in its report. The new law also made other updates to the program.

Key facts about the Healthy Michigan Plan and the IHPI score:

  • The program is open to Michigan residents ages 19 to 64 who earn an income at or below 138 percent of the federal poverty level—as of 2022, $18,754 for an individual or $36,908 for a family of four.
  • The program began covering Michiganders in 2014 and now covers about 1 in 10 people living in the state. In total, about 1 in 4 Michiganders has some form of Medicaid coverage or the Children’s Health Insurance Program.
  • The program was implemented under a federal waiver that allowed Michigan to implement regulations aimed at increasing healthy behaviors and personal responsibility regarding health care use and basing cost sharing on a person’s income.
    • During the period covered by the report, people with incomes between 100 percent and 138 percent of the federal poverty level were required to pay monthly fees of $24 to $32 for HMP coverage and higher copayments for some services than people with income below the poverty level.
    • Some services are offered at no extra charge based on their role in preventing, detecting or managing serious health conditions.
    • HMP enrollees are incentivized through lower copayments and/or fees to complete a Health Risk Assessment, or HRA, and discuss it with a provider, and to engage in healthy behaviors such as stopping tobacco use or getting a flu shot vaccine.
  • The IHPI team has been evaluating the impact of the program since its inception.
    • For the current interim evaluation report, the team surveyed more than 4,000 HMP participants, including more than 1,400 who had completed previous surveys in earlier years.
    • The team interviewed dozens of participants who were subject to cost-sharing (copayments and/or monthly fees), as well as primary care providers and stakeholders from state government agencies and safety organizations.
    • The team also examined changes over time in administrative data from hundreds of thousands of HMP participants and data from national surveys and hospital financial reports.

Key findings from the report:

  • uninsured:
    • Uninsured rates in Michigan in 2020 were lower than in other states that expanded Medicaid, and much lower than in states that had not expanded Medicaid at the time.
    • All areas of the state saw a decrease in the uninsured rate among nonelderly adults, cutting the rate in half or more between 2013 and 2020, with the rate dropping to 6% in some areas.
  • Employment and Finance:
    • Despite the program’s income restrictions, 44% of HMP participants surveyed were employed and another 16% were self-employed at the time of the study. Of those with a job, 56% worked full-time.
    • Half of employed participants and 78% of unemployed participants said they had barriers that interfered with their ability to work, how much they could work, or the type of work they could do.
    • Participants say HMP coverage has helped them reduce their out-of-pocket health care costs, access medical treatment that in some cases has allowed them to start or continue working, and freed up financial resources for other needs such as food, transport and housing.
  • Primary care:
    • Almost all (91%) of the HMP participants surveyed reported having a primary care provider (physician, nurse practitioner, or assistant).
    • A total of 81% of those with a primary care provider reported having visited in the past year, and 77% reported no barriers to obtaining primary care.
    • Primary care providers report offering more same-day and after-hours appointments to encourage responsible use of health care services.
  • Using the emergency department:
    • The rate of ED visits and frequency of ED use (5 visits or more per year) were lowest for beneficiaries who had regular preventive visits compared to those with irregular or no preventive visits.
    • ED visits decreased over time among enrollees with four major chronic conditions (COPD, asthma, cardiovascular disease, and diabetes) who were enrolled over multiple years.
  • Hospital impact:
    • Michigan hospitals saw a 50% drop in the amount of care they did not receive payment for (also called uncompensated care) after the HMP began.
    • The percentage of hospitalized patients without insurance fell by 69%.
  • Cost sharing and health risk assessment/healthy behavior provisions:
    • A total of 75% of the surveyed HMP participants knew that some types of health visits and services do not have co-payments.
    • Only 29% knew that completing HRA or healthy behaviors can reduce the total amount they pay.
    • Provider interviews also revealed a lack of awareness of these incentives and a desire to have HRA information added to electronic health records.
    • People who were enrolled in HMP for a longer time were more likely to have had primary care and dental visits, had cancer screening and completed an HRA.
    • Interviews indicated that self-motivation and support from their health care providers, rather than financial incentives, led to HRA completion and healthy behaviors.
  • Security Network Services and Providers:
    • Primary care and safety net health care providers reported employing more care managers and community health workers to conduct regular outreach to people with high needs.
    • Safety net providers report more financial stability and an increased ability to expand services, collaborate with other agencies, and sustain efforts to address the social determinants of health.
    • HMP supports other programs such as the Michigan Behavioral Health Demonstration, Section 1115 for Substance Use Disorder, Health Homes programs for people who have both chronic medical and behavioral/mental illnesses, the Medicaid Health Equity Project to address racial disparities through evidence-based interventions and programs allowing inmates to apply for HMP before leaving prison.


Michigan Medicine – University of Michigan

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