Brandella Nettle has seen the impact of Obamacare from two different perspectives.
The 28-year-old Ferndale resident experienced the benefits of the expansion of Medicaid as a consumer without health insurance and facing a pregnancy. And now, as a nurse, she’s working with patients, many of whom are getting health care coverage for the first time.
“It’s scary to think about not having it,” she said about the Affordable Care Act. “I know how important it was for me and now I’m seeing a lot of people coming in who haven’t seen a doctor in 20 years.”
But the future of what's known as Obamacare, which includes the expanded Medicaid program that has helped more than 650,000 low-income people in Michigan, is in doubt as Congress debates repealing and replacing the ACA.
The proposal would freeze Medicaid expansion on Jan. 1, 2020, and replace it with a program that would give states a pre-determined amount of money for Medicaid patients.
“The Medicaid program is so complex. The size, scope and expectations are so big, so we’re carefully looking at the details,” said Chris Priest, the Medicaid director for the state’s Department of Health and Human Services. “We’re not only looking at what happens with the Medicaid expansion, but what happens in the core program as well.”
In addition to the 656,744 low-income adults who have enrolled in Michigan’s expanded Medicaid plan since 2014 — dubbed Healthy Michigan — 1.2 million children, 380,000 people with disabilities and 148,000 seniors get their health care coverage through Medicaid.
The expansion proved to be controversial for the state, one of 32 in the nation that accepted federal Medicaid expansion funds. It took months and several votes to pass the plan, which Gov. Rick Snyder championed, in 2013. The traditional Medicaid program basically covered children, the elderly and people with disabilities. But the expansion brought insurance to low-income adults, many of whom hadn't been able to afford insurance.
Under the program, the federal government paid 100% of the expansion costs in the first three years. That fell to 95% last year, which translated into a $152-million tab for the state, and it will go down to 94% for the 2018 fiscal year that begins on Oct. 1, costing the state $200.4 million. Under the original program, the state price tag would rise to $363.8 million by 2020, but no one is sure what the federal changes will bring before then.
“Our impact across the state has been humongous,” Priest told state senators last month.
By many measures the program has been a success:
Initially projected to have an enrollment of 470,000, the number of eligible adults — those within 133% of the federal poverty level of $16,000 for a single person or $33,000 for a family of four — who actually enrolled had topped more than 654,000 as of Jan. 1.
Of the total number of enrollees, 590,337 had received a primary care visit with a doctor, 465,449 had preventative health care visits, 53,314 babies — 46% of the births in the state — were born to women on Medicaid, 321,816 adults had at least one dental visit and 251,797 mammograms were covered.
Uncompensated care at hospitals dropped dramatically in the first full year of the expansion, according to a study by the University of Michigan, from 26,259 cases in 2012 to 9,093 in 2014.
But it’s now up to the Legislature as it begins to craft the 2018 fiscal budget to try and grapple with what the future holds.
Legislative leaders, who hope to complete work on the budget by early June, don’t think there will be much of a change for the fiscal plan they’re working on now, but there are some congressional Republicans in Washington who would like to see the Medicaid expansion end much sooner than 2020.
No matter when the expansion is frozen, costs are likely to go up for the state, Priest said. Federal reimbursement rates will be much lower — perhaps 60-65% — for Medicaid recipients who are able to leave the program for a period of time because they got a job or for some other reason, but then have to return. If new people aren't allowed into the Medicaid program after 2020 and low-income residents can't afford insurance, uncompensated care costs are expected to increase dramatically. It's unknown whether or how long current Medicaid expansion recipients will be able to stay on the insurance plan.
“And will that trigger provisions in the state law for us to wind down the program altogether?” Priest asked, noting that Michigan’s law says that if the costs of the Medicaid expansion outweigh the savings to the state, the program will end.
Some legislators argue that the program has been a worthy expenditure.
“The program is accomplishing one of the major things we wanted it to do and that’s to keep people out of the emergency room as their primary care provider,” said Sen. Jim Marleau, R-Lake Orion, who is chairman of the Senate Appropriations subcommittee on the Department of Health and Human Services. “The clinic is where they need to go or the doctor’s office, whatever their choice is. The emergency room is extremely costly.”
Snyder has been the chief advocate for the Healthy Michigan program and delivered that message to Washington earlier this month, but he has remained mum on the plan introduced last week by Republicans in the U.S. House of Representatives. His spokeswoman, Anna Heaton, said he wants to see what direction Congress takes before he weighs in.
But other Republicans say they believe that changes in the Medicaid expansion plan are inevitable and probably needed.
“We need to be preparing for 2020. We should not live like everything is going hunky dory until then,” said state Rep. Ed Canfield, R-Sebewaing, a doctor and chairman of the House Appropriations subcommittee on the Health and Human Services budget.
“When the time comes that we can’t afford to cover those people anymore, and if that coverage that those people are getting is better than the average middle-class American can get, then I think we’re going to look at it and we’ll have to re-evaulate this,” he added.
Lost in the numbers is the impact of the program for people like Nettle.
In 2013, she was working as a full-time home health aide and her employer paid for her insurance. But when she went back to school to get a nursing degree, she had to scale back to part-time work and lost her insurance.
She went without insurance for two years as she completed her nursing studies at Oakland Community College, but then became pregnant in 2015.
“The day I found out, I knew I needed to do something,” she said, adding that a sister lost a child shortly after the birth because of a congenital defect. “I wanted to make sure I had a healthy baby. Getting that insurance was peace of mind for me.”
She was only on the expanded Medicaid coverage for four months, until she got a full-time nursing job at Beaumont Hospital in Royal Oak, where she now works in the neonatal intensive care unit. But it was enough to get ultrasounds, obstetrics appointments and vitamins she needed to ensure a healthy delivery.
“Thankfully, I had a normal pregnancy and now I have a 16-month-old son (Easton) who is amazing,” she said. “But you never know what could have happened if you don’t have that kind of care.”
Contact Kathleen Gray: 313-223-4430, firstname.lastname@example.org or on Twitter @michpoligal