After the political debate around Affordable Care Act-enabled Medicaid expansion in Michigan settled down and people began enrolling, some of the state’s health policy experts discovered a rather stunning phenomenon—the number of people who enrolled in the expanded program's first 100 days was what planners had expected for the entire first year.

And, that number has just kept growing. University of Michigan statisticians estimated 328,000 people enrolled in the first three months. One year after the program, called the Healthy Michigan Plan, became effective in April 2014, they estimated that number at 603,000.

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Such an influx of new patients into the health system is bound to have profound effects on care delivery and budget assumptions, and researchers at the university's Institute for Healthcare Policy and Innovation (IHPI) feel a sense of great responsibility—and realize a great opportunity to guide policy makers—as they undertake a five-year evaluation of the expanded plan and its ramifications.

“Responsibility is a great word for it,” said Sarah Clark, an associate research scientist at the IHPI.

The politics of Medicaid expansion, in the beginning, was based on people’s guesses and sometimes assumptions about what would happen, Clark said. The IHPI evaluation, required by the Centers for Medicare and Medicaid Services due to the flexibility granted the state in customizing its expansion plan, will provide policy makers quantifiable data to guide further actions.

Because the state’s lawmakers crafted what IHPI director John Ayanian, M.D., in an article in the New England Journal of Medicine, called a “pragmatic pathway” that featured both Democrat and Republican priorities in attempting to ensure quality care and cost containment, a large scale analysis of value-based care design across a variety of plan types could provide widely applicable insights.

“Our group, as well as groups doing similar evaluations in other states, have an opportunity and responsibility to say, ‘OK, good and bad—and sometimes we can’t tell if it’s good or bad yet—but here’s how it played out,’” Clark said.

She said the evaluation will be a mixed method approach using a number of data sources, including Medicaid utilization data and other elements from different state agencies in the state's data warehouse, as well as primary data such as surveys that will be completed by beneficiaries and providers across a range of different care delivery settings. Clark said the research team will be on the lookout for possible patterns to emerge, such as linking beneficiaries with similar characteristics based on survey responses, to utilization patterns. Such information may indeed be critical, given the great increase in the number of people who have entered the state’s delivery system through Medicaid expansion.

“Where were these people previously?” Clark asked. “Did they go nowhere? Just the sheer number, 500,000 in one year—who is absorbing that, and how are those practices and health plans dealing with that increased patient load?”

One of the study’s arms will evaluate patient engagement and retention, including the efficacy of having patients fill out mandatory health risk assessments upon enrollment and preferred methods of outreach. Clark said the data may help dispel possible stereotypes that Medicaid patients “don’t do technology.”

“We have some young people at the very beginning of their work careers who are in those starter jobs, without employer sponsored benefits, not making a ton of money, so they are eligible,” Clark said. “We don’t expect they’ll stay in this program forever, but I think those folks might engage differently than some of those folks who have more of a long-term pattern of having very little or no income. Or those who don't do technology.”

The findings from the evaluation will be released in an iterative way, Clark said. She expects the researchers will have some sort of handle on utilization data toward the end of the year. The first providers’ survey is in it final weeks of preparation, and some patients who have reached the six-month mark are being surveyed about their experience in understanding the paperwork required in meeting their financial responsibilities and the resources available to help them.

“It may be too early to say ‘the big picture is this, good or bad,’ but what we can feed back to our partners at the state is an idea of people's experiences at this point, so they can make necessary adjustments based on positive and negative response,” Clark said. “If we waited until the end of five years they wouldn’t have the opportunity to make those changes or to make information more clear if necessary.”

Additionally, Clark said the state’s use of term limits means some of the lawmakers involved in the process of establishing the Healthy Michigan Plan are no longer in the statehouse. The IHPI work, then, will help guide a new cohort of Michigan's legislators in shaping the future of health policy.

Those lessons may indeed spread farther than the borders of the Wolverine State. As Ayanian wrote in his NEJM article, “The best prospects for achieving greater efficiency and equity in healthcare may arise from states such as Michigan that can blend public and private approaches to healthcare reform, with bipartisan support.”

The IHPI work could be a big step in confirming that sentiment.

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