medicaid expansion & the aca: the view from...
TRANSCRIPT
Medicaid Expansion & the ACA: The View from Michigan
John Z. Ayanian, MD, MPPInstitute Director
Alice Hamilton Professor of Medicine
Beyond the ACA: Health Policy & Sustainable Health SpendingAltarum Center for Sustainable Health Spending
July 18, 2017
Jim Waterhouse’s Story *
• Diagnoses: diabetes, hypertension, heart disease, sleep apnea
• After becoming uninsured in his early 60’s:
– Reduced visits to primary physician and cardiologist
– Reduced glucose monitoring
– Ignored worsening dyspnea
– Discontinued CPAP for sleep apnea
– Deferred colonoscopy for new anemia
• Complications:
– Delayed visit to primary MD led to $46,000 admission
* Hayes et al. Too Sick to Work, Too Soon for Medicare Commonwealth Fund 2007
“I tried to put off medical care until I became eligible
for Medicare, which complicated my condition.”
-- Jim Waterhouse, after gaining Medicare coverage
Adjusted Mortality Among Middle-Aged Adults
Health & Retirement Study
McWilliams, Zaslavsky, Meara & Ayanian, Health Affairs 2004
12.5
4.5
18.8
5.4
0
5
10
15
20
8-Year Mortality
(%)
Insured
Uninsured
P=0.02
P=0.35
Adults with diabetes, Other Adults HTN or heart disease
The New Yorker
The Diagnosis of Exclusion…
“Unfortunately you have what we call‘no insurance’.”
Changes in Access to Care & Health Status
After Massachusetts Health Reform, 2006-2011:
A Quasi-Experimental Study
Van der Wees, Zaslavsky & Ayanian, Milbank Quarterly 2013
Key Findings (vs. rest of New England):
Cost as a barrier to care
Access to doctors, colonoscopies, Pap & cholesterol tests
-- especially for those <300% of poverty level
Health status beginning in 2010
Changes in Mortality After Massachusetts Health Reform:
A Quasi-Experimental Study
Sommers, Long & Baicker. Ann Intern Med 2014
Key Findings (vs. similar US counties):
2.4% in adjusted all-cause mortality for adults 20-64 (P=0.003)
4.5% in adjusted mortality for non-elderly adults with health care-amenable conditions, including cardiovascular disease (P<0.001)
No change in mortality for elderly adults
Affordable Care Act signing, March 2010
Healthy Michigan Plan signing, September 2013
• One of few Republican-led states to expand Medicaid (w/ AZ, ND, OH, IN)
• Market-oriented reforms: cost-sharing, financial incentives
• Benefits to Michigan:– 650,000 low-income adults
have access to care
– Increased federal $ to pay providers ($3.5B in 2016)
– Hospitals provide less uncompensated care
• Model for bipartisan compromise
Impact of Medicaid Expansion on Michigan Hospitals
• Uninsured discharges:
4 percentage points
• Medicaid discharges:
6 percentage points
• No change in total discharges
Davis, Gebremariam & Ayanian JAMA 2016
Changes in Uncompensated Carein Michigan Hospitals, 2013-2015
• Uncompensated care costs by almost half from 5.2% of costs in FY13 to 2.9% in FY15
• For average hospital, annual uncompensated care expenses from $7.2 million to $3.8 million
• Large Detroit hospital from $35.8M to $19.5M
Buchmueller & Levy, December 2016 report to Michigan Dept of Health & Human Services
February 2, 2017
Key Findings for Michigan Economy with Medicaid Expansion
• Employment with federal Medicaid expansion
spending peaked at ~39,000 jobs in 2016 & projected
to support ~30,000 jobs through 2021
• Personal income associated with new employment
in Michigan: ~$2.2-2.4 billion annually
• Economic activity projected to yield $145-$153
million annually in new state tax revenue
Ayanian et al. N Engl J Med 2017
Will Congress repeal, replace
or repair the ACA?
