L-R, Colin Ford, Dave Sheeran and Dominick Pallone

Dec. 5, 2017 – Six years into the implementation of the Patient Protection and Affordable Care Act (ACA) in Michigan, parts of it have been a resounding success, others disappointments. But members of a panel convened by the Citizens Research Council of Michigan, MIRS News, and the Michigan State Chamber Foundation agreed they’d rather work to improve what’s already in place than start over from scratch.

Meeting at the Michigan Bankers Association in Lansing, panel members represented various stakeholders in Michigan health care, and included: Colin Ford of the Michigan State Medical Society; Dave Sheeran, Meadowbrook Insurance Agency; Dominick Pallone, Michigan Association of Health Plans; Laura Appel, Michigan Hospital Association, and Tim Michling from the Citizens Research Council.

Michling started the discussion with a brief overview of the ACA’s history and enactment. His overview showed how the ACA has altered the health insurance model, how Medicaid expansion has helped more than just those directly covered, and how Michigan is better off than those states that did not adopt Medicaid expansion.

Moderator John Reurink from MIRS asked the obvious opener: “Have patients been protected and is care affordable?” Panelists agreed that patients are better protected; affordability, however, varies. The first answer, from Sheeran: It’s complicated. With deductibles at an average $1,500 for an individual and $4,500 for families, even those with insurance may feel they can’t afford care. While many preventive-care visits are fully covered, that message hasn’t always been heard by customers, he said.

Others acknowledged the problems, but pointed out clear bright spots: a large reduction in the number of people without health insurance,, an emphasis on preventive care, and the end of discrimination for pre-existing conditions, among others.

L-R, Laura Appel, Tim Michling

“Increased access (to care) is easy to get behind,” said Ford. But implementation has been “less clean than we would have liked.” Patients are confused about their plans, and often don’t know what they will be charged in cost-sharing or co-pays until they get a bill, he said, which can hurt the relationship between provider and patient.

Appel acknowledged the advantages reaped by hospitals, which have seen bad debt and uncompensated care plummet with the coverage of more than 650,000 Michiganders under Medicaid expansion and another 320,000 in the ACA’s individual marketplace. Some of these facilities, she said, might have closed without the support offered by the ACA.

The panel identified issues looming at the federal and state levels.  While federal tax reform would eliminate the penalty for not purchasing health insurance, all health insurers are cast as the insurers of last resort and are required to insure individuals without regard to preexisting conditions. This arrangement would allow individuals to buy health insurance only when it becomes clear that health care is needed and doing so would help to defray their own expenses.  This is not a formula for long-term sustainability for health insurers.

A larger question looms over Michigan, which expanded Medicaid via a Section 1115 Demonstration waiver. These allow states to innovate in how they provide and deliver care. The Michigan waiver would allow the state to move individuals off of Medicaid expansion unless they undertake actions to improve their health. Chronic diseases are very costly and are the leading causes of death and disability in the U.S. They are also largely preventable through changes in lifestyle, nutrition, and environment. But without some combination of incentives and/or penalties, it is difficult to reinforce the need for the insured to adopt healthy behaviors.

“The sweet spot between the carrot and the stick” can be elusive, said Pallone. Michling added that social environment, education level, and physical surroundings can all influence health and behaviors, and that support and empowerment are vital to help people make positive changes.

The panel found the ACA fell short of reforming the U.S. system in a way that incentivizes keeping people healthy so that they don’t need expensive medical care. As Appel pointed out, “Deductibles aren’t an issue if you’re basically healthy” and don’t need high-cost care. The ideal situation is when care is an afterthought, but health is a main concern, she said. Social and behavioral factors, exacerbated by poverty and low education levels, continue to diminish Americans’ health, contributing significantly to the (nearly) 1 out of every five dollars that Americans spend on health each year.

The Citizens Research Council of Michigan’s latest report, “Medicaid Expansion: Prescription for a Healthier Michigan” is available for download on its website, free of charge.