In 2014, the state of Michigan enacted the Healthy Michigan Plan (HMP), designed to be an "alternative approach" to Medicaid expansion. Adults with an income at or below 133 percent of the federal poverty level were able to enroll and receive essential health benefits required by the Affordable Care Act, as well as dental care, home health services, and family planning services. An added bonus of the HMP is that it encourages enrollees to make an appointment with a primary care physician (PCP) in the first 60–90 days of signing up. Susan Goold (M.D. 1987, Residency 1992), professor of internal medicine and of health management and policy in the School of Public Health, and a team of researchers from the U-M Institute for Healthcare Policy and Innovation, conducted a study analyzing responses from 2,104 PCPs, nurse practitioners, and physician assistants to deduce the outcomes of the HMP. The study was published in the June 2018 Journal of General Internal Medicine. 

Medicine at Michigan spoke with Goold about the study. This interview has been edited for length and clarity. 

How did the team conduct this study? 

We looked at the goals of the state and the Center for Medicare and Medicaid Services for evaluation of the Healthy Michigan Plan and put our heads together about how we could best examine its impact on enrollees, families, and communities. We conducted interviews with more than 20 PCPs and then surveyed just over 2,000. Interviews were analyzed to develop items for the survey specifically about Healthy Michigan, and also to hear in more depth about PCPs' and their patients' experiences. 

Why was it important to speak with PCPs, nurse practitioners, and physician assistants? 

We wanted to get an early assessment of the impact of Healthy Michigan, and, particularly given the emphasis on primary care and health risk assessment, thought primary care clinicians would be a good source of information early in the program. They're the front lines of medical care. 

How has care changed for people with chronic diseases on the HMP? 

According to PCPs, there were many people with chronic conditions with health insurance who were not getting the care (including medication) they needed, or were only able to manage their conditions erratically. With HMP, people are getting care they would not otherwise get — that they would otherwise wind up in an ER for. By gaining access to care they didn't have before, their medication adherence also improves. 

One of the things that surprised me was the number of PCPs who had patients who hadn't seen a doctor in many years. Somebody who had been in Michigan his whole life hadn't seen a doctor in 40 years, and they found he had diabetes, hypertension, and had had a stroke at some point. 

It's amazing — if you can't pay for medical care, you don't go unless you're sick. And sometimes you don't even go then. Some people knew they had chronic conditions or other medical problems, but didn't seek care because they couldn't afford it. 

The PCPs said, "The HMP gets patients in the door, and then we can talk to them about the stuff they need to do to change their health." 

How has the HMP affected preventive care? 

Patients on the HMP were getting access to preventive services that they had never gotten before. PCPs also reported patients "finally" getting some preventive services, like colon cancer screening, once they had insurance. Paying for something like that out of pocket, instead of your rent or groceries, is highly unlikely to be a priority. 

How does the HMP affect health care providers? 

PCPs said they hired staff. Some who took care of lots of uninsured people saw their revenues go up. Even though Medicaid doesn't pay as much as other insurers, they pay more than zero. Those are the economic results we found. PCPs also talked about the reward of being able to do prevention, and diagnose and treat patients who previously lacked access. 

What can other states learn from Michigan's example? 

While Michigan's emphasis on cost-sharing and incentives for healthy behavior seems to attract a lot of attention, including from other states, the emphasis Healthy Michigan places on primary care is a huge strength — and an under-appreciated strength. We know from international studies that places that have strong primary-care-centered systems do better. They're healthier, and they're cheaper. 

What was the most important takeaway of the study? 

According to primary care clinicians who care for Medicaid patients, the Medicaid expansion in Michigan has benefitted their patients. It's working.