Medicaid expansion meant better health for the most vulnerable low-income adults, U-M study finds

The most vulnerable residents of the nation’s 10th most populous state say their health improved significantly after they enrolled in Michigan’s expanded Medicaid program, a new study finds.

Michiganders with extremely low incomes, those who live with multiple chronic health problems, and those who are Black, got the biggest health boosts year over year among all those enrolled in the safety-net health coverage program, the study shows. 

But participants of almost all ages, backgrounds and in all geographic regions reported improvements in health over time.

Writing in the new issue of JAMA Network Open, a team from the University of Michigan reports the results of a survey that asked more than 3,000 enrollees in the Healthy Michigan Plan about their health, at two time points a year apart. 

The new paper adds to a growing body of evidence about the impacts of Michigan’s Medicaid expansion, compiled by a team from the U-M Institute for Healthcare Policy and Innovation with funding from the Michigan Department of Health and Human Services.

The IHPI team just unveiled a summary of findings based on the final report from the first five years of their evaluation of the Healthy Michigan Plan. The new paper is the latest in a series of peer-reviewed, data-driven articles that the team has published in academic journals based on their evaluation work. 

Michigan’s experience might inform states where Medicaid has not yet been expanded, or is about to be – including Missouri which has a ballot proposal up for a vote in early August, Oklahoma, whose voters just approved expansion last week, and Nebraska, which is preparing to start its program this fall. Twelve other states have not expanded their Medicaid programs.

Reductions in poor health

The new paper’s lead author is Minal Patel, Ph.D., M.P.H., an associate professor at the U-M School of Public Health who analyzed data from the longitudinal survey of participants who had been enrolled in the Healthy Michigan Plan for at least a year before the first time they were surveyed. 

The percentage of respondents who called their health fair or poor dropped from nearly 31% in 2016 to 27% in 2017. Larger decreases were seen among those with the very lowest incomes, those who were Black, those who had two or more chronic conditions, and those who live in the Detroit metropolitan area. 

Additional survey data contained in a new report showed that the percentage who said their health was fair or poor dropped further, to 25.6% by 2018.

The average number of days in the past month when the respondents said they had been in poor physical health dropped by more than a day in many groups, including those with two or more chronic health conditions. But there was no significant change in days of poor mental health or days when respondents said their health interfered with their usual activities.

Nearly one quarter of respondents who answered the survey in 2016 were no longer enrolled in the program when surveyed in 2017. 

Enrollees had incomes below or just above the federal poverty line, but 57% said they were employed or self-employed. Just over half had incomes less than 35% of the federal poverty level, which was $11,880 for a single adult in 2016. 

“Our study showed that sub-groups who would benefit the most from greater access to care through Michigan’s Medicaid expansion reported improved health over time,” says Patel. “Better access is indeed translating to better health.”

The emphasis that the Healthy Michigan Plan places on primary care and prevention, as well as the inclusion of dental and vision care that can address long-unmet needs, likely played a role, she adds. 

“It is rare to find a change in health policy that actually improves health of a target population in merely one year,” says Susan D. Goold, M.D., MHSA, M.A., study co-author and professor of internal medicine at U-M. “The Healthy Michigan Plan model of expansion, which emphasized both insurance coverage and primary care, built on what we have learned from health systems around the globe.”

Five years in, some key findings

The economic effects of COVID-19 have likely led more Michiganders to seek coverage from the safety net of the Healthy Michigan Plan. As of this week, more than 751,000 people are enrolled in the plan, up from 675,000 in February before COVID-19 struck Michigan. 

“This new study adds to the large body of evidence on Medicaid expansion that our team at the University of Michigan has developed over the past five years,” says IHPI director and study co-author John Z. Ayanian, M.D., M.P.P.

Some other key findings documented in the five-year summary brief: 

•    Before enrolling in the Healthy Michigan Plan, half of those surveyed said they had a doctor or clinic they could see for regular care. By 2018, that had climbed to 83%.
•    The percentage who said that emergency rooms were their usual source of care dropped from 12% to 3%.
•    85% of enrollees had seen a primary care provider in the last year, 84% had received a preventive medical service such as a cancer screening, and nearly half had seen a dentist.
•    40% of enrollees surveyed said their dental health had improved since enrolling
•    85% of enrollees said they had fewer problems paying medical bills since they enrolled
•    The percentage of enrollees who said they were employed or enrolled as a student grew to 61% in 2018, up from 55% in 2016.
•    43% of enrollees said they had completed a Health Risk Assessment, a special feature of the Healthy Michigan Plan. Of these, 91% said it motivated them to be more responsible for their health.
•    Enrollees with incomes above the poverty level pay a contribution of 2% of their household income for their Healthy Michigan Plan coverage. Some services have co-pays. 88% of enrollees said that the amount they pay for their coverage seems fair. Among those who were billed for contributions or copays, the average quarterly statement amount was $16.85.

The IHPI team continues to study the impacts of Medicaid expansion on Michigan’s enrollees. Learn more about IHPI’s Healthy Michigan Plan evaluation: https://ihpi.umich.edu/featured-work/healthy-michigan-plan-evaluation