Medicaid Expansion in Michigan Reflects Catholic Social Principles

March-April 2020

BY: ALISHA COTTRELL, SEAN D. GEHLE and LINDA ROOT, RN, MAHCM

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Illustration by Roy Scott

Catholic health care is called to assure and promote the common good and Catholic social tradition, thought and practice. We answer the Gospel call to affirm that each person's life is a treasure and everyone should have the opportunity to flourish. Access to quality health care is a right and is necessary for everyone to achieve that vision.

We need to understand the impact of the call of Catholic health care on assuring that our words, deeds and actions inform the care we provide, especially to people who are poor and vulnerable. The preferential option to provide particular attention to those who are poor must be more than the words we profess in Catholic health care. If we commit to the transformation of health care, we are promising to support social structures that embrace health care for the least among us. As part of this transformation, we know that Catholic health care is best suited to undertake and support a cultural change that acknowledges and addresses health care benefits for everyone.

Promotion of the common good distinguishes the well-being of each person in relation to the broader community. When we speak of care for those who are poor and vulnerable, we must be aware of the social conditions that perpetuate their inability to escape poverty and live healthy lives. Jesus calls us to justice throughout his Gospel message. Our goal of the right relationship between our ministry and those we serve must support structures that address basic human needs, especially access to affordable health care. Such a hallmark of our very existence as Catholic health care providers flows from our foundational belief that every person is sacred and possesses inalienable worth.

Access to health care is necessary for an individual to flourish. Catholic health care ministries provide services that are accessible to all despite social or economic status. In a ruling on the Affordable Care Act, the U.S. Supreme Court decided each state could determine whether or not to expand Medicaid. Michigan responded to those most in need by creating the Healthy Michigan Plan, the state's unique response to Medicaid expansion.

Healthy Michigan aims to ensure that every low-income Michigan resident who was uninsured or underinsured has access to medical care and services. The plan primarily focuses on prevention and primary care access through a number of key elements including: an increase in healthy behaviors that would manifest as healthy behavior change; management of chronic conditions; provision of preventative care; and a reduction in emergency room utilization and inpatient hospitalization. Though this plan has its limitations, it is an example of how we can influence and support our vocational call to provide health care for those most in need.

The Healthy Michigan Plan was launched in the spring of 2014. The program opened enrollment for beneficiaries up to 133% of the federal poverty level. Early enrollment projections of 300,000-400,000 were quickly exceeded, and the enrollment over the last several years has averaged over 600,000. In early February 2020, more than 650,000 Michigan residents were enrolled in the plan.

A key component of the plan, the Healthy Behaviors Incentives Program, encourages Healthy Michigan Plan managed care members to maintain and implement healthy behaviors in collaboration with their health care provider, to complete a standardized Healthy Michigan Plan health risk assessment and to identify healthy behavior goals. Beneficiaries are expected to remain actively engaged in their health by seeing a primary care provider within the first three months of enrollment and by establishing at least one healthy behavior goal each year they are in the plan. Healthy behaviors could include, but are not limited to, attending preventive care visits, receiving vaccinations, having regular screenings, assistance with smoking and tobacco cessation and preventive dental care. There is a healthy behavior incentive for beneficiaries who agree to address or maintain healthy behaviors on the Healthy Michigan Plan health risk assessment. The incentive can be a reduction in required cost-sharing, as enrollees are required to contribute modest premiums and co-pays (based on income) to health savings accounts.

The Healthy Michigan Plan is achieving results. A recent paper in the Journal of General Internal Medicine, based upon a survey conducted by members of the Healthy Michigan Plan evaluation team at the University of Michigan, concluded that after enrolling in Michigan's Medicaid expansion program beneficiaries reported less foregone care and improved access to primary care and preventive services. The report also cited survey results indicating that prior to Healthy Michigan Plan enrollment, three quarters of enrollees reported having a regular source of care compared to 92% reporting such a regular source of care following enrollment. Additionally, the percentage of enrollees identifying the emergency room or urgent care center as their regular source of care fell dramatically from pre-enrollment to post enrollment.1

The study also found that Healthy Michigan Plan enrollees received significant preventative screening. The study indicated that more than 70% of the women over 50 had received breast cancer screening in the past 12 months under the Healthy Michigan Plan, and more than half of adults over 50 had received colon cancer screening. Cancer screenings, and other proven preventative screenings and vaccinations, are covered by the Healthy Michigan Plan with no co-pay. Additionally, 60% of enrollees had seen a dentist in the past year through their Healthy Michigan Plan coverage, and more than 10% of enrollees who reported using tobacco had gotten a prescription for an FDA approved product to help them break their nicotine habit.

The utilization of non-emergent emergency room visits has decreased due to those utilizing primary care and those who are being seen for chronic conditions and learning proper care and management techniques for their conditions. Those with chronic conditions also saw a decrease in inpatient stays after seeking primary care, filling out a Health Risk Assessment and identifying one healthy behavior they could work on.

One example of the impact that the plan is having in the lives of its beneficiaries can be seen in an example from Muskegon. A 49-year-old single male covered by the Healthy Michigan Plan has been working with a community health worker from Mercy Health's Health Project Hub in Muskegon since July 2019. Coverage through the Healthy Michigan Plan has been critical to him being able to see a primary care provider for his general health and a neurologist for seizures. He has obtained medication to manage his diabetes and counseling services for behavioral health. Working with his community health worker, he has begun a smoking cessation program and learned how to access his health plan's transportation assistance benefit to get rides to medical appointments. Without the Healthy Michigan Plan, he could not afford to pay for his medical care out of pocket. Because of his fragile health, he is not able to work at this time and will be applying for an exemption to the work requirements.

As a result of Michigan's decision to expand its Medicaid program as provided for under the ACA and the corresponding establishment of Michigan's health care exchange, Michigan's uninsured rate has been cut by an average of 40%, according to a study provided by the Center on Budget and Policy Priorities.2 Hundreds of thousands of Michigan residents who did not have health insurance before the plan was passed have it now.

Unfortunately, there may be some unintended consequences. Increased co-insurance will be implemented in July of 2020 as part of the original requirements of the Healthy Michigan Plan. The Michigan Department of Health and Human Services has been working with Medicaid health plans administering the Healthy Michigan Plan to communicate the change in coverage to enrollees and to determine the best methods of collection.

In addition, some of the coverage gains under the plan will be challenged as a result of work engagement requirements adopted by the Michigan legislature and signed by Michigan's governor in 2018. Under these requirements, the law mandates non-elderly, non-disabled Healthy Michigan Plan enrollees ages 19-62, who do not meet other exemptions, to document an average of 80 hours of work per month to maintain eligibility for Medicaid benefits. The implementation for work requirements began January 1, 2020, and is currently being challenged in court. The legislature decided to move forward instead of waiting for the court decision to determine whether or not work requirements would be enforced.

While not supportive of these work requirements, Catholic health care organizations in Michigan worked with other stakeholders to include a number of category exemptions and qualifying activities. As a result, exemptions exist for those age 63 and older, the disabled and medically frail, full-time students, caregivers, pregnant women, those who were recently incarcerated, those with medical conditions resulting in work limitations, those receiving unemployment compensation, former foster care youth and those who qualify for a good cause exemption. A number of qualifying activities also were included that satisfy work requirements such as job training, community service, education, unpaid workforce engagement (such as an internship), tribal employment program or drug treatment. Despite this, there continues to be significant concern, based on the experiences of other states, of significant loss of coverage due to the imposition of work requirements. Loss of coverage could lead to relatively minor conditions becoming more serious, and those with chronic conditions may experience interruption in their care and health complications in the future. Furthermore, conditions that might be identified in a preventive screening could be missed. Loss of coverage (due to "non-compliance") puts enrollees at a disadvantage and curtails gains they may already have made by having health insurance provided to them.

There is also continuous risk in the change of the policy itself. This is true especially because expansion in Michigan is predicated on seeking a Section 1115 waiver, which allows a state to expand Medicaid managed care while preserving hospital funding, provides incentive payments for health care improvements and directs more funding to hospitals that serve large numbers of uninsured patients. Evaluation of the waiver by the Centers for Medicare and Medicaid Services happens approximately every three to five years.

Medicaid expansion is a step in the right direction to improve circumstances for those in need and struggling most. However, we can assist in efforts to enhance its opportunity for success. We should encourage eligible people to sign up during open enrollment periods, despite barriers that may present themselves due to changes to the Healthy Michigan Plan. As Catholic health care providers, it is not only our calling, but also our duty to provide an environment in which we effectively communicate changes people might experience with the Healthy Michigan Plan. We also need to assist our patients in successfully navigating those changes — whether by providing education about the Healthy Michigan Plan or explanations of programs our health systems offer to help enrollees live the fullest, healthiest lives possible. As Catholic health care providers, we are committed to doing our part — whether in the state Capitol or in our hospitals — to ensure everyone has an opportunity to access quality health care.

ALISHA COTTRELL is vice president, advocacy, for Ascension Michigan. SEAN D. GEHLE is vice president, advocacy, for Trinity Health – Michigan Region. LINDA ROOT is chief mission integration officer – Ascension Michigan Ministry Market.

NOTES

  1. Susan Dorr Goold et al., "Primary Care, Health Promotion, and Disease Prevention with Michigan Medicaid Expansion," Journal of General Internal Medicine, December 2019.
  2. Jesse Cross-Call, Michigan Medicaid Proposal Would Harm People in All Parts of the State, Center on Budget and Policy Priorities, May 21, 2018.

 

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