When Michigan elected to expand its Medicaid coverage, the state customized its program to emphasize primary care and preventive health services. Studies are showing the approach is paying off for patients.

Fostering healthier communities

This episode of AMA Doc Talk explores how physicians can better serve their patients by thinking beyond the walls of the exam room.  

The Healthy Michigan Plan, which now covers residents in households with incomes up to 138% of the federal poverty line, has helped enrollees find a regular source of care other than a hospital emergency department, improved access to and use of preventive services such as cancer screenings, and reduced forgoing needed care because of cost.

“This adds to the evidence that Medicaid expansion improves access to care and the impact of Medicaid expansion on access to preventive and primary care services is something we should take note of,” said Susan Goold, MD, adding that patients get more “health for the buck” when they get primary care.

“I’m biased because I’m a primary care doctor, but the research shows this over and over,” said Dr. Goold, a professor of internal medicine and health management and policy at the University of Michigan, Ann Arbor. She also previously served as chair of the AMA Council on Ethical and Judicial Affairs.

Dr. Goold and her colleagues surveyed 4,090 Healthy Michigan enrollees and examined preventive services claims data to produce three studies published in the Journal of General Internal Medicine (JGIM).

The JGIM studies stem from independent evaluations of the Healthy Michigan Program that were required under the section 1115 waiver the state received from the Centers for Medicare & Medicaid Services.

The University of Michigan Institute for Healthcare Policy and Innovation was awarded a contract in 2014 to conduct the evaluations, which have resulted in several related reports that have been published in JGIM, JAMA Internal Medicine (April 2018) and other medical journals.

The general finding is that patients report improved health “after being enrolled in Healthy Michigan,” said Dr. Goold, the lead author of one JGIM study and a co-author on the other two.

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Affordable care’s value

Opponents of Medicaid expansion have argued that increasing eligibility would not necessarily improve patient access to care, Dr. Goold said, but these studies have refuted that argument.

“There is now growing recognition across the political spectrum of the value of being able to afford care,” she said. “You can’t grow your economy unless people are healthy. Good health helps people gain employment or stay employed.”

Key findings of the reports include:

  • Of enrollees with chronic conditions, 42% reported having it first identified after their enrollment.
  • 52% of those with chronic conditions reported that their physical health improved and 43% said their mental health improved.
  • Nearly 90% said they had seen a primary care provider since enrolling.
  • 92% said they had a regular source of care since enrolling.
  • The percentage of survey respondents who said an emergency department or urgent care center was their regular source of care dropped from 25.3% to 7% after enrollment.
  • Nearly 58% said they had not had health insurance in the 12 months before they enrolled in Healthy Michigan.
  • One third said they had forgone needed care due to cost or lack of insurance in the 12 months before enrollment.
  • More than 70% of women over 50 received a breast cancer screening after enrollment.
  • More than half of enrollees over 50 had received a colon cancer screening.
  • Nearly 90% said obtaining coverage resulted in lower stress and worry.

“That’s pretty remarkable,” said Dr. Goold regarding the patient-reported improvements that were seen in only one year.

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The expansion does come with strings attached. Similar to Indiana and Iowa Medicaid programs, enrollees are encouraged to complete a health risk assessment (HRA) and commit to healthy behavior, according to one of the JGIM reports. And, like the Indiana and Iowa plans, cost sharing is involved.

Except for preventive services, all enrollees are subject to co-pays and individuals at 100% of the federal poverty line and above pay a monthly “contribution” of around $25. Dr. Goold said that, in reality, it could be considered a “premium.”

Almost half of enrollees (49.3%) reported completing the HRA and were then eligible for a financial reward—usually a gift card or reduced co-pay—but most were unaware of an incentive being offered. The most common reason given for completing the HRA (46%) was that their primary care physician suggested it. Of those that completed the HRA, almost 84% said they considered it a valuable tool to improve their health.

Dr. Goold and colleagues reported three important findings in this study:

  • Self-reported HRA completion was substantial.
  • Physicians and other primary care providers were influential in getting enrollees to complete the HRA and to commit to at least one “healthy behavior” such as improving their diet.
  • The financial incentives being offered had little influence.
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