Beyond Obamacare: What the ACA has meant for Michigan

Marianne Udow-Phillips

Michigan has always done better by its citizens than most other states when it comes to health care and health insurance. Even before the Affordable Care Act (ACA), Michigan had more people insured than most states and lower average health care spending. Michigan has been characterized by innovation and collaboration when it comes to the design and implementation of health care programs and coverage.

Our state has had a pragmatic emphasis on expanding coverage to provide care to as many citizens as possible while working together to improve the quality and cost of health care. We have consistently developed strong partnerships between the private sector and state government.

President-elect Donald Trump’s incoming administration and the Republican-controlled Congress have made repealing the ACA a top priority following Trump’s inauguration on Jan. 20, 2017. However, their plans for replacing the ACA — including what would be done and when a replacement would take effect — are less clear.

Republicans in Congress have asked state governors for input on an ACA replacement plan, likely signaling the increased role states will play in the design of what comes after the ACA. In that context, it will be essential for citizens to be engaged to assure that health care policies reflect what is important to Michiganders.

Any replacement for the ACA should maintain its accomplishments while addressing it shortcomings. To do that, however, we must start with an understanding of the facts.

The Good

In Michigan, the ACA’s success in reducing the uninsured population has been well reported. In 2013, before the ACA’s coverage expansions, 11% of Michiganders were uninsured. By 2015, that rate had dropped to 6.1%. Together, the Medicaid Healthy Michigan Plan and the Michigan Health Insurance Exchange cover nearly 1 million people. Of those in Michigan who bought coverage through the exchange, 88% receive tax credits to make that coverage more affordable.

The ACA’s benefits to Michiganders go beyond the coverage expansions in Medicaid and the individual market. In Michigan, under the ACA:

More than 70,000 young people are insured thanks to a provision requiring health plans to allow individuals up to age 26 to remain on their parent’s health insurance policies.
More than 200,000 senior citizens and people with disabilities saved more than $1,000 on average per person in prescription drug costs in 2014 as a result of a pharmaceutical agreement to help close the "doughnut hole” in Part D Medicare drug coverage.
More than 4.5 million insured Michiganders have no cost sharing for preventive services like flu shots and other vaccines, mammograms, and screening for heart disease, cancer, depression, diabetes and the like.
Mental health parity was expanded to cover the individual and small group markets. More than 700,000 get health insurance coverage in these markets.
1.8 million women have contraceptive services covered with no cost sharing.
Nearly 1.5 million people have received $91.8 million (or an average of $124 per family) in insurance refunds because of a provision that limits insurers’ profits and administrative expenses.
Hospitals had significantly lower uncompensated care costs in 2014 compared with 2013, resulting in average hospital profit margins improving from -4.2 % in 2013 to -1.5% in 2014, largely as a result of the reductions in the numbers of uninsured because of the ACA’s coverage expansion.
Collectively, organizations in Michigan have received an average of $118 million annually in grants because of programs and initiatives launched by the ACA.
Almost all hospitals, physician groups and communities across the state are involved in testing new ways to pay for health care to improve quality and lower cost through ACA initiatives like Accountable Care Organizations, bundled payments and the State Innovation Model.

The Bad

The ACA is far from perfect. It is a complicated law that is reliant on the marketplace to deliver many of its core programs. The cost of health care continues to rise, making it difficult for many to afford coverage and, for some, their coverage isn’t good enough.

A record number of people have high deductible health plans with average deductibles for individuals with employer coverage in Michigan increasing from $571 in 2006 to $1,431 in 2015, making it difficult for some to afford the cost of care.
The 2017 average Michigan individual market rate increase of 16.7% and the reduction in the number of health plans offering coverage in some areas of the state left some with large premium increases and fewer choices of plans.
Some people cannot find coverage that includes the doctors and hospitals that they want given that more than 80% of plans offered on Michigan's Health Insurance Marketplace in 2017 are plans which have narrow provider networks.
Generally, younger and healthier people now pay more for health insurance than before the ACA, while older and sicker people pay less.
Some people are paying more for health insurance because they have more benefits than before but benefits they may not want or need.

The Future

Under a Trump administration, states will have more flexibility to shape health care coverage and financing than in the past. In particular, Republicans in Congress have discussed redesigning Medicaid as a state block grant or providing other forms of state flexibility. In any future health care design, it will be essential that the citizens of Michigan be engaged. It will be up to us to advocate for priorities that advance affordable, quality health care for all.

Marianne Udow-Phillips is the executive director of the Center for Healthcare Research & Transformation, a nonpartisan health policy center based at the University of Michigan with a mission to advance evidence-based care delivery, improve population health and expand access to care. From 2004 to 2007, Udow-Phillips was the director of the Michigan Department of Human Services under Gov. Jennifer Granholm.