Medicaid Archives

Clear language and human-centered design can help Medicaid enrollees keep their coverage

A Medicaid form with "Approved" stamped on it. Michigan’s expanded Medicaid program, the Healthy Michigan Plan (HMP), has provided health insurance coverage to hundreds of thousands of Michiganders since its launch in April 2014. However, in 2019, the state passed a work requirements bill, which introduced more steps needed to retain HMP coverage. The bill asked HMP enrollees to report a minimum of 80 hours of work per month to keep their insurance benefits. Consequently, to reduce the number of people who might lose coverage due to lack of reporting their hours, MDHHS developed a robust communication strategy. Their strategy used input from users, and applied a human-centered design. The Center for Health and Research Transformation (CHRT) at the University of Michigan evaluated this work. Results from the evaluation are published in this month’s JAMA Health Forum.

The CHRT team led 11 focus groups and fielded a survey to collect data from community health navigators, who help enrollees complete the paperwork needed to obtain and maintain coverage. Navigators reported that many of the steps taken by the state to improve the implementation of the bill for those on HMP insurance were helpful.

While Medicaid communications are traditionally text heavy and technical, MDHHS used simplified language, streamlined the format, and employed attention-grabbing colors and icons in letters to beneficiaries.

Findings

“MDHHS worked with external communication experts and this novel approach had a very positive impact,” said Patrick Kelly, lead author of the evaluation, who completed the survey while serving on CHRT’s research and evaluation team. “Respondents reported that traditional Medicaid form letters may get lost in the shuffle and be challenging for beneficiaries to understand…With the revamped letters, it appeared that beneficiaries’ attention was drawn to the envelopes. Many even brought the letters with them when meeting with navigators to discuss next steps.”

While navigators reported overall improvements from traditional Medicaid communications, they were concerned that the policy itself was very complex to understand, and therefore to apply. This included some challenges regarding the communication around exemptions and concerns about internet, telephone, computer, and language barriers.

Research shows that administrative burdens can lessen the utility of public health programs. The state of Michigan took steps to shift the administrative burden from individual beneficiaries by using administrative data where possible to automatically exempt and deem people in compliance with the policy. “This is a great improvement for the enrollees who are not always in a position to handle administrative requirements,” said Kelly.

In spite of these efforts, had Michigan continued to enforce the policy, it would have revoked health insurance coverage from about 80,000 enrollees.

Conclusions

Public agencies could apply this study’s results to other public benefit programs and policies. This would improve implementation and ensure that everyone can receive their authorized benefits.

“As the federal public health emergency will soon end and many individuals will need to re-apply to maintain Medicaid coverage, state Medicaid agencies can learn from Michigan’s experience by using enhanced human-centered design approaches to communicating with beneficiaries,” says Dr. Renu Tipirneni, a widely regarded expert on the impact of health reform policies and programs on low socioeconomic status, aging, and other vulnerable populations, and on delivery of care in the health care safety net.

Cited article:
Kelly RP, Marcu G, Hardin A, Iovan S, Tipirneni R. Health Navigator Perspectives on Implementation of Healthy Michigan Plan Work Requirements. JAMA Health Forum. 2022;3(6):e221502. doi:10.1001/jamahealthforum.2022.1502

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

Yellow road sign reading "Health insurance changes ahead", referring to the changes to the Healthy Michigan Plan.

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.

The proposals that the fact sheet compares are: ACA 2.0, which increases Marketplace financial assistance, restores outreach and assistance funding, and creates a reinsurance program; Public Option, which creates a publicly-administered health insurance plan offered for purchase on the Marketplace; Medicaid Buy-In, which provides certain individuals with the opportunity to purchase Medicaid coverage; Medicare Buy-In, which provides certain individuals with the opportunity to purchase Medicare coverage; Medicare for America, which provides an option and incentives for all US citizens to switch to Medicare coverage; and Medicare for All, which replaces the current health insurance system with universal Medicare coverage for all U.S. citizens.

For each health care proposal, the sheet considers who would be affected, what would be covered, what cost-sharing would look like, how it would impact other types of coverage, how it could impact health care providers, how it would be financed, and how much it could cost. The fact sheet also lists the specific bills and proposals for each health care option.

This fact sheet combines information on all the recent health care proposals in a straightforward, objective format so the proposals can easily be compared and considered.

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Michigan Physician Survey: Primary care physician perspectives and practice trends

CHRT has been surveying primary care physicians (PCPs) in Michigan since 2012—tracking key trends in practice patterns, capacity, payer mix and care team composition. Our 2019 Michigan Physician Survey also asked physicians about care continuity and Medicaid work requirements legislation.

PCPs are a key component of a successful, high quality healthcare system. As the baby-boomer generation ages and the needs of this cohort increase, there is ongoing concern about how well the health care workforce can meet the increasing demands of an older and presumably sicker population.

Additionally, primary care is on the front lines of improving care delivery, such as increasing care management for complex cases, integration of behavioral health care and identifying and addressing social determinants of health.

Key findings of our 2019 Michigan Physician Survey include:

Primary care capacity in Michigan is good today, but there is some evidence it may decrease in the future. Capacity to accept new patients is high and has increased across all payer types since 2016. Almost two-thirds (62%) of PCPs indicated capacity for new Medicaid patients and over 80 percent reported capacity for Medicare and privately insured patients. However, 45% of PCPs indicate they intend to stop practicing medicine within the next 10 years— raising important questions about new PCPs or other practitioners in the training pipeline, and the need to continue tracking capacity over the next decade.
PCPs report more multi-disciplinary care team members than in 2016. Practices with a relatively higher volume of Medicaid patients were almost twice as likely to have Community Health Workers (CHW) and co-located psychiatrists on the care team. And, for the most part, hospitals and groups practices were more likely to have support staff, such as care managers and nurse practitioners, than single physician practices.
High deductibles and other cost issues threaten continuity of care. PCPs see cost and insurance-related issues as the biggest barriers to maintaining continuity of care with their patients; along with lack of transportation and limited health literacy.
The majority of PCPs are concerned about the impact Medicaid work requirements may have on care continuity and the complexity of the certification process. They are more evenly split in their opinions about how the new Medicaid work requirements could change the number of Medicaid patients in their practices, whether they would need to hire more staff, and the ethical issues of determining if someone is able-bodied.

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Projected impacts of Medicaid work requirements: An overview of current state proposals

Several brown file tabs, with the center one reading "Requirements", referring to the new Michigan Medicaid work requirements.

As of January 2019, 14 states have submitted proposals to the federal government requesting permission to establish work requirements in their Medicaid programs. To date, the U.S. Centers for Medicare and Medicaid Services (CMS) has approved Medicaid work requirements for seven states, and two states (Arkansas and Indiana) have begun implementing these requirements for Medicaid beneficiaries. This overview examines the projected impacts of these Medicaid work requirements.

In June 2018, Michigan enacted work requirements for many enrollees in the Healthy Michigan Plan (HMP), Michigan’s expanded Medicaid program for low-income adults.

Beginning in January 2020, HMP enrollees under age 63 will be required to report 80 hours of work per month or obtain an exemption (see CHRT’s previous fact sheet, Proposed Medicaid Work Requirements in Michigan).

The Michigan House Fiscal Agency initially estimated that the impact of Medicaid work requirements would result in approximately 80 percent of enrollees subject to the requirements, while 20 percent would qualify for an exemption. More recently, an independent analysis by Manatt Health projected that 39 percent of HMP enrollees would be automatically exempt (based on age, pregnancy, medically frail, or incarceration status; or because they are already meeting SNAP/TANF work requirements), while 61 percent would be required to report work hours or obtain an exemption. This analysis estimated that 9 to 27 percent of all HMP enrollees could lose coverage over a one-year period.

Most of the 14 states that have requested federal permission to establish Medicaid work requirements have projected that some current Medicaid enrollees will lose coverage as a result of these changes. While estimates vary, states have projected that anywhere from 5 percent to 50 percent of the populations subject to work requirements (i.e., those who are not currently working and do not qualify for an exemption) are estimated to lose coverage. The Kaiser Family Foundation has estimated that, if a work requirement were implemented at the national level, approximately 1.4 to 4 million enrollees (6-17 percent of non-elderly, non-disabled adult Medicaid enrollees) would lose coverage.

Early experience from Arkansas indicates that administrative or structural barriers may prevent individuals from complying with work requirements. According to a recent report from the Kaiser Family Foundation, many Medicaid enrollees were unaware of the new requirements and unable to navigate the state’s online-only reporting system. In addition, enrollees may face a lack of jobs (especially in rural areas), transportation, and/or internet access to obtain information about job and volunteer opportunities.

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Cover Michigan Survey: Use of Health Care Benefits in Michigan

Data from the Center for Health and Research Transformation’s (CHRT) 2018 Cover Michigan Survey show health benefits that Michiganders with health insurance coverage have used in the past year ⁽¹⁾Survey participants were asked whether or not they or other family members covered by their plans used each health care benefit in the past 12 months.. Detail on the Cover Michigan Survey and analysis methodology can be found on CHRT’s website. In addition to findings on overall use of health care benefits, this brief focuses on three key areas: dental and vision, reproductive health, and mental health care.

Nearly all Michiganders used some kind of health benefit over the last year. To understand differences in the use of health care benefits, several variables were examined by demographics including gender, age, race, insurance type, income, and employment status.

Preventive care: The highest utilized benefit was routine, preventive primary care This was consistent across all groups.
Dental and vision care: There is high use of these benefits even though they are not generally core offerings of most insurance
Reproductive health care: Michigan women, especially younger women, use these health benefits at a significantly higher rate than men and older women. Reproductive health care represents 11 percent of younger women’s health care utilization.
Mental health care: Younger women and people who are unemployed reported significantly higher use of their mental health care or substance use treatment coverage.

Other findings include:

Aside from dental and inpatient care, women consistently utilized more health care benefits than men.
African Americans were the least likely to visit a doctor and use vision care benefits compared to other races, while white Michiganders were the most likely to use inpatient services.
Regardless of insurance type, respondents use doctor visits at similar rates, however those with employer-provided insurance were the most likely to use dental care health benefits.
Medicaid beneficiaries had the highest utilization of pediatric care, contraceptive/family planning, mental health/substance use, and maternity/newborn care benefits; and Medicare beneficiaries made the most use of the prescription drug benefit. These differences are likely due to the unique populations that make up membership in these plans.
Compared to those with lower household income, Michiganders with incomes of $50,000 or more per year were far more likely to use dental care, doctor visits, and vision benefits.
The unemployed population was more likely to use inpatient care, mental health/substance abuse services, and maternity/newborn care than those who are working or in school.

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References[+]

References
↑1	Survey participants were asked whether or not they or other family members covered by their plans used each health care benefit in the past 12 months.

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.

With the expansion of Medicaid and the launch of the Affordable Care Act’s individual Health Insurance Marketplace, the numbers of uninsured Michiganders have been considerably reduced since 2013. Yet Michigan policy makers will still face numerous policy issues and decisions related to health care coverage, health disparities, and access to care in the years to come. Our state will continue to struggle with complex health issues such as substance use and access to mental health services.

Michigan policy leaders, local public health agencies, and the private sector are engaged in many innovative initiatives to address these issues and improve the health of communities. In particular, the state has committed to programs that are intended to improve health equity and focus on the social determinants of health.

All of this work is being conducted at a time of great political change and considerable turmoil at the federal level. The new governor and the 100th Legislature will be faced with both tremendous responsibility and opportunity to shape the health policy landscape for years to come.

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Proposed work requirements for Medicaid in Michigan: June 7, 2018

A white sheet of paper with writing. A green highlighter is highlighting the word "legislation", referring to new Michigan Medicaid work requirements.

At the start of 2018, the U.S. Centers for Medicare and Medicaid Services (CMS) announced a major shift in federal policy that would allow states to request permission to establish, and test the impact of, work and community engagement requirements for able-bodied adults receiving Medicaid health insurance coverage. In the last five months, work requirement proposals have been approved in four states; formal applications have been submitted by seven more, and a number of others are preparing proposals. Michigan is among the states proposing Medicaid work requirements.

In April, the Michigan State Senate took the first step toward establishing work requirements by passing Senate Bill 897. The Michigan House of Representatives passed an updated version of the bill on June 6. And on the morning of June 7, the Michigan Senate approved the revisions and sent the bill to the Governor’s office for signature.

In this fact sheet, we compare the characteristics and projected impact of Michigan’s most recent Medicaid work requirement proposal against the characteristics and projected impact of approved work requirement proposals in Kentucky, Indiana, Arkansas, and New Hampshire. We also describe new requirements for Healthy Michigan Plan enrollees who wish to maintain coverage after four years, and a series of triggers that would terminate the Healthy Michigan Plan if CMS fails to approve these requirements.

To learn more, read our Consumer’s Guide to the Medicaid work requirements.

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Proposed work requirements for Medicaid in Michigan: April 20, 2018

A stack of red and yellow files and notebooks. On the top notebook, "Proposal A-2136" is written in black marker, referencing Michigan's proposed Medicaid work requirements.

At the start of 2018, the U.S. Centers for Medicare and Medicaid Services announced a major shift in federal policy that would allow states to request permission to establish, and test the impact of, work and community engagement requirements for able-bodied adults receiving Medicaid health insurance coverage. In early March, Michigan state senators took the first step toward preparing a Medicaid work requirement proposal of their own by introducing Senate Bill 897. The bill passed the Michigan State Senate on April 19.

In the last three months, work requirement proposals have been approved in three states; formal applications have been submitted by seven more; and a number of others are preparing proposals.

In this fact sheet, we compare the characteristics and projected impact of Michigan’s Medicaid work requirement proposal against the characteristics and projected impact of approved work requirement proposals in Kentucky, Indiana, and Arkansas.

The characteristics we compare include: target Medicaid populations, Medicaid enrollment, populations exempt from the new work requirements, the hours of work required, activities counted as work, and loss of coverage rules. It is difficult to project the impact of work requirements on the Medicaid population because there is no precedent program, but we discuss some possibilities.

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For updated information, read our article from June 7.

Changes in Payer Mix for Michigan Primary Care Physicians: The Impact of Medicaid

After Michigan’s Medicaid expansion, the state’s Medicaid population increased from 1.95 million in March 2014 (19 percent of the population) to 2.4 million in December 2016 (24 percent of the population). As a result, Medicaid has become a substantial part of Michigan primary care physician (PCP) practices. Policy changes related to Medicaid should take into account the breadth of impact on physician practices as well as on beneficiaries.

Data from the Center for Healthcare Research and Transformation’s (CHRT) Physician Survey show that the proportion of primary care physician (PCPs) who reported having a large volume, or greater than 30 percent, of patients covered by Medicaid increased by 11 percentage points from 2014 to 2016. The impact of Medicaid on these physician practices needs to be considered in policy discussions.

The survey data presented in CHRT’s Physician Survey briefs were produced from a mail survey of primary care physicians practicing in Michigan. The physician samples were randomly generated from the American Medical Association (AMA) Physician Masterfile, a comprehensive list that includes both AMA members and non-members. Physicians who responded but reported they were no longer practicing primary care were removed from the analysis.

The 2016 survey was conducted between July 2016 and October 2016 and included a sample of 1,500 primary care physicians practicing in Michigan. Potential respondents received up to three mailings, with $10 included in the first mailing to encourage response. The mailing included information on how to complete the survey online via Qualtrics, rather than by hard copy, if respondents preferred this option. Both surveys returned by mail and online were merged to create a final data file.

The final sample included physicians from two primary care specialties: family medicine and internal medicine. The survey had a response rate of 40 percent (603 physicians) and has a margin of error of ±2.5 percent.

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The impact of the ACA on community mental health and substance abuse services: Experience in three Great Lakes states

The Affordable Care Act (ACA) allowed states to expand Medicaid coverage to low-income childless adults, many of whom receive specialty mental health and substance use services through community mental health systems. Leading up to the passage of the ACA, community mental health providers and their professional associations were generally supportive of expanding Medicaid under the ACA. Medicaid covers specialty services central to quality mental health and substance use care, as well as other physical health services that many in the serious mental illness (SMI) and substance use disorder (SUD) populations lacked before 2010. This brief examines the impact of the ACA Medicaid expansion on community mental health.

To date, 32 states have expanded Medicaid (including the District of Columbia), while the remaining 19 have not. This brief, which was developed with support from the Commonwealth Fund, examines the impact of the ACA on public mental health and substance use systems in three Midwestern states: Michigan and Indiana, both Medicaid expansion states, and Wisconsin, a non-expansion state.

The experience from these three states suggests that Medicaid expansion has had an important and overall beneficial effect in particular for the substance use population. The favorable impact is particularly important in light of the opioid epidemic.

Key findings include:

Prior to the Medicaid expansion, state and local funds paid for many services for the SMI/serious emotional disturbance (SED) and SUD populations. In Medicaid expansion states, most funding shifted to the federal government, providing both advantages and disadvantages: more people in need received insurance coverage, but that coverage was less flexible for SMI/SED populations than prior funding mechanisms.
Funding for substance use services improved substantially in Medicaid expansion states, serving a particularly important role in enabling states to provide more services in the wake of the opioid crisis. In these states, many more individuals had Medicaid SUD treatment benefits than before expansion and federal block grant funds were freed up to provide additional substance use services. As a result of the additional funding provided, Michigan was able to increase the numbers of those who received SUD care by 14%.

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Publications

Findings

Conclusions