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Addressing health inequities for racial and ethnic minority populations is challenging. After passage of the Affordable Care Act, Michigan launched its Healthy Michigan Plan, which expanded Medicaid eligibility in the state. Our evaluation of the expansion provided the opportunity to study its impact on racial and ethnic minority groups, including Arab American and Chaldean American enrollees, an understudied population. Using data from telephone surveys collected in 2016, 2017, and 2018, we conducted an analysis to study the plan's impact on access to a regular source of care and health status among racial and ethnic minority groups. More than 90 percent of respondents of all racial and ethnic groups reported having a regular source of care after plan enrollment compared with 74.4 percent before enrollment. Respondents who identified as non-Hispanic White, African American, and Hispanic reported improvements in health status after plan enrollment. Our study demonstrates the potential of health insurance access to narrow health inequities between racial and ethnic groups.

BACKGROUND: It is uncertain how Medicaid expansion under the Affordable Care Act influences the diagnosis of chronic health conditions, and the care and health of enrollees with chronic conditions. OBJECTIVE: Describe the prevalence of new and pre-existing chronic health conditions among Medicaid expansion enrollees. Examine whether perceived changes in specific types of access and self-rated health status differed between enrollees with chronic conditions and those without. Examine how gaining Medicaid coverage affected chronic disease management and well-being. DESIGN: Mixed-methods study including a telephone survey and semi-structured interviews. SETTING: Michigan’s Medicaid expansion, the “Healthy Michigan Plan” (HMP). PARTICIPANTS: 4090 survey respondents (response rate 54%) with ≥ 12 months HMP enrollment and 67 interviewees with ≥ 6 months enrollment. MAIN MEASURES: Self-reported chronic condition diagnoses, changes in physical/mental health, and healthcare access. Descriptive survey data were adjusted for survey design and nonresponse. Semi-structured interview questions about how gaining HMP coverage led to changes in health status. KEY RESULTS: Among enrollees, 68% had a self-reported diagnosis of a chronic health condition; 42% of those were newly diagnosed since HMP enrollment. In multivariable models, enrollees with chronic conditions were significantly more likely to report improved physical (adjusted odds ratio (aOR) 1.70, 95% CI (1.40, 2.07)) and mental health (aOR 1.75, (1.43, 2.15)) since HMP enrollment than enrollees without chronic conditions. Among enrollees with chronic conditions, the strongest predictors of improvements in health were having seen a primary care physician, improved mental health care access, and improved medication access. Interviewees with chronic conditions described how increased access to health care led to improvements in both physical and mental health. CONCLUSIONS: Enrollees with expanded Medicaid coverage commonly reported detection of previously undiagnosed chronic conditions. Perceived health status and access improved more often among enrollees with chronic health conditions. Improved access was associated with improved physical and mental health among this vulnerable group. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-019-05323-w) contains supplementary material, which is available to authorized users.

To investigate self-reported improved oral health and its mediators, and job-related outcomes, of Medicaid expansion beneficiaries in Michigan.This cross-sectional mixed-methods study of adult "Healthy Michigan Plan" (HMP) Medicaid expansion beneficiaries included qualitative interviews with a convenience sample of 67 beneficiaries enrolled for ≥6 months, a stratified random sample survey of 4,090 beneficiaries enrolled for ≥12 months; and Medicaid claims data. We examined unadjusted associations between demographic variables and awareness of dental coverage, self-reported dental care access, dental visits, and self-reported oral health; and between improved oral health and job seeking and job performance. Multivariate analysis examined factors associated with self-reported oral health improvement, adjusting for sociodemographic characteristics, prior health insurance, and having at least one dental visit claim.Among surveyed beneficiaries, 60 percent received ≥1 dental visit and 40 percent reported improved oral health. Adjusted odds ratios (aOR) for improved oral health were higher for African-American beneficiaries [aOR = 1.61; confidence interval (CI) = 1.28-2.03] and those previously uninsured for ≥12 months (aOR = 1.96; CI = 1.58-2.43). Beneficiaries reporting improved oral health were more likely to report improved job seeking (59.9 percent vs 51 percent; P = 0.04) and job performance (76.1 percent vs 65.0 percent; P 0.001) due to HMP. Interviewees described previously unmet oral health needs, and treatments that improved oral health, functioning, appearance, confidence, and employability.Michigan's Medicaid expansion contributed to self-reported improved oral health, which was associated with improved job outcomes. Policymakers should consider the importance of Medicaid dental coverage in reducing oral health disparities and improving the health and socioeconomic well-being of low-income adults and communities when considering this optional benefit.

Medicaid “community engagement” requirement (work, school, job training, job searching, or volunteering) waivers have received CMS approval in nine states, but there are little data on current trends in Medicaid enrollees’ engagement in these activities. Our objective was to assess longitudinal changes in enrollees’ employment and student status after implementation of Michigan’s Medicaid expansion, which expanded coverage in 2014 and now covers ~664,000 individuals. We conducted a longitudinal telephone survey in English, Spanish, and Arabic with a cohort of Medicaid expansion enrollees at 3 time points in 2016 (N = 4090, RR = 53.7%), 2017 (N = 3104; RR = 83.4%), and 2018 (N = 2608, RR = 89.4%). Survey items measured employment status and student status; demographic characteristics were obtained from Michigan Medicaid program files. We used mixed models with year as a fixed effect to assess changes in the proportion of enrollees who were employed or students, incorporating weights adjusting for sample design and nonresponse. Enrollees aged 19‐64, with incomes up to 133% of the federal poverty level (FPL). Most respondents had incomes under 100% FPL (61.7% with 0‐35% FPL, 22.9% with 36‐99% FPL, and 15.4% with 100‐133% FPL), 89.3% had at least a high school diploma/equivalent, and respondents ranged in age (39.6%, age 19‐34; 34.5%, age 35‐50; and 25.9%, age 51‐64). From 2016 to 2018, the proportion of enrollees who were employed or students increased from 54.5% to 61.4% (P

This survey study examines the self-reported health of enrollees in Michigan’s Medicaid expansion, the Healthy Michigan Plan, among respondents to surveys in 2016 and 2017., Key Points Question What longitudinal changes in self-reported health status and days of poor health among racial, ethnic, urban/rural, and very-low-income subgroups of enrollees are associated with Medicaid expansion? Findings In this survey study of 3097 respondents, reports of fair or poor health and days of poor physical health decreased over time among enrollees, especially among non-Hispanic black enrollees and those with very low incomes. There were no statistically significant differences in the number of days of poor mental health or the number of days of usual activities missed owing to poor physical or mental health over time. Meaning These findings suggest that within Medicaid expansion, the health of vulnerable populations is improving., Importance Evidence about the health benefits of Medicaid expansion has been mixed and has largely come from comparing expansion and nonexpansion states. Objective To examine the self-reported health of enrollees in Michigan’s Medicaid expansion, the Healthy Michigan Plan (HMP), over time. Design, Setting, and Participants A telephone survey from January 1 to October 31, 2016 (response rate, 53.7%), and a follow-up survey from March 1, 2017, to January 31, 2018 (response rate, 83.4%), were conducted in Michigan, which expanded Medicaid in 2014 through a Section 1115 waiver permitting state-specific modifications. Four thousand ninety HMP beneficiaries aged 19 to 64 years with at least 12 months of HMP coverage and at least 9 months in a Medicaid health plan were eligible to participate. Data were analyzed from April 1 to November 30, 2018. Main Outcomes and Measures Surveys measured demographic characteristics and health status. Analyses included weights for sampling probability and nonresponse. Comparisons between 2016 and 2017 included those who responded to both surveys (n = 3097). Results Of the 3097 respondents to the 2017 follow-up survey, 2388 (77.1%) were still enrolled in HMP (current enrollees) and 709 (22.9%) were no longer enrolled when surveyed (former enrollees). Among all follow-up respondents, a weighted 37.5% (95% CI, 35.3%-39.9%) were aged 19 to 34 years, 34.0% (95% CI, 31.8%-36.2%) were aged 35 to 50 years, and 28.5% (95% CI, 26.7%-30.3%) were aged 51 to 64 years; 53.0% (95% CI, 50.8%-55.3%) were female. Respondents who reported fair or poor health decreased from 30.7% (95% CI, 28.7%-32.8%) in 2016 to 27.0% (95% CI, 25.1%-29.0%) in 2017 (adjusted odds ratio [AOR], 0.66 [95% CI, 0.53-0.81]; P

Introduction Michigan is one of 3 states that have implemented health risk assessments for enrollees as a feature of its Medicaid expansion, the Healthy Michigan Plan. This study describes primary care providers’ early experiences with completing health risk assessments with enrollees and examines provider- and practice-level factors that affect health risk assessment completion. Methods All primary care providers caring for ≥12 Healthy Michigan Plan enrollees (n=4,322) were surveyed from June to November 2015, with 2,104 respondents (55.5%). Analyses in 2016–2017 described provider knowledge, attitudes, and experiences with the health risk assessment early in Healthy Michigan Plan implementation; multivariable analyses examined relationships of provider- and practice-level characteristics with health risk assessment completion, as recorded in state data. Results Of the primary care provider respondents, 73% found health risk assessments very or somewhat useful for identifying and discussing health risks, although less than half (47.2%) found them very or somewhat useful for getting patients to change health behaviors. Most primary care provider respondents (65.3%) were unaware of financial incentives for their practices to complete health risk assessments. Nearly all primary care providers had completed at least 1 health risk assessment. The mean health risk assessment completion rate (completed health risk assessments/number of Healthy Michigan Plan enrollees assigned to that primary care provider) was 19.6%; those who lacked familiarity with the health risk assessment had lower completion rates. Conclusions Early in program implementation, health risk assessment completion rates by primary care providers were low and awareness of financial incentives limited. Most primary care provider respondents perceived health risk assessments to be very or somewhat useful in identifying health risks, and about half of primary care providers viewed health risk assessments as very or somewhat useful in helping patients to change health behaviors.

BACKGROUND: Medicaid expansion in Michigan, known as the Healthy Michigan Plan (HMP), emphasizes primary care and preventive services. OBJECTIVE: Evaluate the impact of enrollment in HMP on access to and receipt of care, particularly primary care and preventive services. DESIGN: Telephone survey conducted during January–November 2016 with stratified random sampling by income and geographic region (response rate = 53.7%). Logistic regression analyses accounted for sampling and nonresponse adjustment. PARTICIPANTS: 4090 HMP enrollees aged 19–64 with ≥ 12 months of HMP coverage MAIN MEASURES: Surveys assessed demographic factors, health, access to and use of health care before and after HMP enrollment, health behaviors, receipt of counseling for health risks, and knowledge of preventive services’ copayments. Utilization of preventive services was assessed using Medicaid claims. KEY RESULTS: In the 12 months prior to HMP enrollment, 33.0% of enrollees reported not getting health care they needed. Three quarters (73.8%) of enrollees reported having a regular source of care (RSOC) before enrollment; 65.1% of those reported a doctor’s office/clinic, while 16.2% reported the emergency room. After HMP enrollment, 92.2% of enrollees reported having a RSOC; 91.7% had a doctor’s office/clinic and 1.7% the emergency room. One fifth (20.6%) of enrollees reported that, before HMP enrollment, it had been over 5 years since their last primary care visit. Enrollees who reported a visit with their primary care provider after HMP enrollment (79.3%) were significantly more likely than those who did not report a visit to receive counseling about health behaviors, improved access to cancer screening, new diagnoses of chronic conditions, and nearly all preventive services. Enrollee knowledge that some services have no copayments was also associated with greater utilization of most preventive services. CONCLUSIONS: After enrolling in Michigan’s Medicaid expansion program, beneficiaries reported less forgone care and improved access to primary care and preventive services. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-019-05370-3) contains supplementary material, which is available to authorized users.

BACKGROUND: Health risk assessments (HRAs) and healthy behavior incentives are increasingly used by state Medicaid programs to promote enrollees’ health. OBJECTIVE: To evaluate enrollee experiences with HRAs and healthy behavior engagement in the Healthy Michigan Plan (HMP), a state Medicaid expansion program. DESIGN: Telephone survey conducted in Michigan January–October 2016. PARTICIPANTS: A random sample of HMP enrollees aged 19–64 with ≥ 12 months of enrollment, stratified by income and geographic region. MAIN MEASURES: Self-reported completion of an HRA, reasons for completing an HRA, commitment to a healthy behavior, and choice of healthy behavior. KEY RESULTS: Among respondents (N = 4090), 49.3% (95% CI 47.3–51.2%) reported completing an HRA; among those with a primary care provider (PCP) (n = 3851), 85.2% (95% CI 83.5–86.7%) reported visiting their PCP during the last 12 months. Most enrollees having a recent PCP visit reported discussing healthy behaviors with them (91.1%, 95% CI 89.6–92.3%) and were more likely to have completed an HRA than enrollees without a recent PCP visit (52.7%, 95% CI 50.5–52.8% vs. 36.2%, 95% CI 31.7–41.1%; p

Understand enrollment patterns in Medicaid expansion and how churn and disenrollment affect access to care. We conducted telephone surveys with a cohort of Medicaid expansion enrollees at 3 time points in 2016, 2017, and 2018 (N = 2,608, RR = 89.4%). Surveys measured health, access to care, and insurance status. Respondents who had no HMP/Medicaid enrollment for > 3 consecutive months but re‐enrolled (according to state records) were categorized as “churned off/on”; those who had disenrolled from HMP/Medicaid for > 6 months were categorized as “off for > 6 months”; the remainder were categorized as “stayed on.” We used Pearson chi‐square tests to compare groups and mixed models with year as a fixed effect to assess changes over time, incorporating weights adjusting for sample design and nonresponse. HMP beneficiaries with ≥ 12 months of HMP coverage in 2016. As of 2018, 74.2% stayed on HMP/Medicaid, 9.8% churned off/on, and 16.0% were off for > 6 months. Going off HMP/Medicaid for > 6 months was more likely for men than women (17.7% vs. 14.6%), those age 19‐34 and 35‐50 compared to 51‐64 (17.1%, 17.0%, and 13.3%), those who were married/partnered compared to those who were not (18.6% vs. 14.3%), those with compared to without a chronic condition (18.9% vs. 14.3%), and those without compared to with a mental health condition or substance use disorder (22.1% vs. 12.6%) (all, P 6 months (21.7% vs. 5.2%, P 6 months had a period of uninsurance in 2017 or 2018. Respondents who were off > 6 months were less likely than those who stayed on to report having a regular source of care (84.6% vs 93.9%), more likely to report forgone health care for financial reasons (17.0% vs. 3.2%) and more likely to report problems paying medical bills (32.6% vs. 17.5%). Those who churned off/on were also less likely than those who stayed on to report having a regular source of care (83.6% vs. 93.9%) more likely to report forgone health care for financial reasons (7.5% vs. 3.2%) and more likely to report problems paying medical bills (40.4% vs. 17.5%). In a longitudinal study of Medicaid expansion, approximately a quarter of enrollees had either churned off and on HMP/Medicaid or had extended disenrollment over a three‐year period. Those who had experienced churn or extended disenrollment were more likely to report forgone health care, not having a regular source of care, and problems paying medical bills. Many Medicaid enrollees who experience churn or disenrollment have difficulty maintaining health insurance and face financial obstacles to care. Michigan Department of Health and Human Services.

This survey study assesses the association of Medicaid expansion in Michigan with enrollees’ employment or student status., Key Points Question Is Medicaid expansion associated with changes in enrollees’ employment or student status? Findings In this survey study of 4090 Michigan Medicaid expansion enrollees conducted after Michigan’s Medicaid expansion, 54.3% of respondents were employed or students in 2016 and 60.0% were employed or students in 2017. Meaning Employment or student status increased among Michigan Medicaid expansion enrollees 2 to 3 years after the state expanded Medicaid and before implementation of community engagement requirements., Importance Medicaid community engagement requirements (work, school, job searching, or community service) are being implemented by several states for the first time, but the association of Medicaid coverage with enrollees’ employment and school attendance is unclear. Objective To assess longitudinal changes in enrollees’ employment or student status after Michigan’s Medicaid expansion. Design, Setting, and Participants This survey study included 4090 nonelderly, adult Healthy Michigan Plan enrollees from March 1, 2017, to January 31, 2018. Main Outcomes and Measures Self-reported employment or student status. Proportionate sampling was stratified by income and geographic region. Mixed-effects regression models with time indicators were used to assess longitudinal changes in the proportion of enrollees who were employed or students. Results The response rate for the initial survey was 53.7% and for the follow-up survey was 83.4%. Of the 3104 respondents to the 2017 follow-up survey (mean [SD] age in 2017, 42.2 [13.0] years; 1867 [53.0%] female), 54.3% were employed or students in 2016, and this number increased to 60.0% in 2017 (percentage point change, 5.7; P

BACKGROUND: Michigan expanded Medicaid under the Affordable Care Act (Healthy Michigan Plan [HMP]) to improve the health of low-income residents and the state’s economy. OBJECTIVE: To understand HMP’s impact on enrollees’ health, ability to work, and ability to seek employment DESIGN: Mixed methods study, including 67 qualitative interviews and 4090 computer-assisted telephone surveys (response rate 53.7%) PARTICIPANTS: Non-elderly adult HMP enrollees MAIN MEASURES: Changes in health status, ability to work, and ability to seek employment KEY RESULTS: Half (47.8%) of respondents reported better physical health, 38.2% better mental health, and 39.5% better dental health since HMP enrollment. Among employed respondents, 69.4% reported HMP helped them do a better job at work. Among out-of-work respondents, 54.5% agreed HMP made them better able to look for a job. Among respondents who changed jobs, 36.9% agreed HMP helped them get a better job. In adjusted analyses, improved health was associated with the ability to do a better job at work (aOR 4.08, 95% CI 3.11–5.35, p