The Michigan health insurance landscape has changed substantially in the wake of the Affordable Care Act’s coverage expansion provisions. Starting in January 2014, many eligible individuals could enroll in private insurance coverage through the Health Insurance Marketplace and receive financial assistance to lower their cost of coverage. On April 1, 2014, Michigan residents below 138 percent of the federal poverty level who were not previously eligible for Medicaid became eligible for the Healthy Michigan Plan, Michigan’s expanded Medicaid program.1
Using data from two of the Center for Healthcare Research & Transformation’s Cover Michigan Surveys, this brief explores consumer experiences with insurance coverage and access to care within the state of Michigan between mid-2012 and late 2014. The 2014 survey was fielded beginning in September 2014, five months after the first Marketplace enrollment period ended2 and Healthy Michigan Plan enrollment had begun. By the end of the Marketplace’s first open enrollment period in March 2014, 272,000 Michigan residents had selected coverage through the Marketplace.3 By September 2014, 410,000 people were enrolled in the Healthy Michigan Plan, bringing the state’s total Medicaid enrollment to 2.2 million by that time.4
This brief provides evidence of a dramatic change in Michigan’s health care landscape as a result of the first year of the ACA’s coverage expansions. Overall, the number of residents reporting they were uninsured, struggled to pay medical bills and/or delayed seeking needed medical care has dropped significantly compared to CHRT survey findings before the launch of the ACA coverage expansions. While most insured Michiganders reported easy access to primary care, they did, however, report a greater challenge in obtaining access to specialty care in 2014 than they reported before the ACA coverage expansions.
- More people gained coverage—the proportion of adult Michiganders who reported being uninsured was cut in half, from 14 percent in 2012 to 7 percent in 2014.
- Overall, from 2012 to 2014, those with insurance coverage reported access to primary care remained easy. Nearly 90 percent of insured adults reported having very or somewhat easy access to routine primary care appointments in 2012 and 2014.
- Fewer people reported that they had delayed seeking medical care—22 percent of all respondents reported that they had not sought medical care they believed to be necessary in the previous six months in 2014, compared to 29 percent in 2012.
- Between 2012 and 2014, Michiganders also reported fewer financial concerns associated with their health care:
- In 2014, half as many respondents cited cost as a reason for not seeking needed medical care (21 percent, compared to 42 percent in 2012).
- In 2014, 20 percent of respondents reported struggling to pay medical bills, compared to 27 percent in 2012.
- Uninsured adults reported that it was more difficult to obtain primary care between 2012 and 2014. Those who reported very or somewhat easy access to primary care appointments declined from 67 percent in 2012 to 48 percent in 2014.
- More people reported difficulty obtaining access to specialty care in 2014 compared to 2012. Specifically, 34 percent of adult Michiganders reported it was “very easy” to get an appointment with a specialist in 2012, compared to 24 percent in 2014.
Between 2012 and 2014, the proportion of uninsured adults in Michigan was cut in half. Fourteen percent of Michiganders reported that they did not have insurance in 2012, while only 7 percent reported being uninsured in 2014. Figure 1
Among those who had been uninsured sometime in the 12 months prior to the survey, 50 percent reported obtaining their coverage through either Medicaid or by purchasing individual coverage (on or off the Health Insurance Marketplace). Slightly more than one-third of those who obtained coverage reported that they obtained it through an employer. These increases are likely due to the impact of both the ACA’s insurance expansion provisions and an improving economy in Michigan.
Primary Care Providers
Overall, 80 percent of Michiganders reported that they had a primary care provider in 2014, a similar percentage as in 2012 (83 percent). Compared to respondents with any form of health insurance, the uninsured were less than half as likely to report having a primary care provider. In 2014, only 32 percent of uninsured adults reported that they had a primary care provider, a significant decline from 2012. Figure 2
In both survey years, those with Medicare coverage reported the highest rate of having a primary care provider. Medicaid respondents were significantly less likely to report having a primary care provider in 2014 (70 percent) than in 2012 (89 percent). Figure 3
Ease of Obtaining Primary Care Appointments
In 2014, 87 percent of all respondents said it was “very easy” or “somewhat easy” to make routine primary care appointments. However, only 48 percent of 2014 uninsured respondents reported such a high level of ease when making appointments for routine primary care, a significant decline from 2012. Figure 4 A detailed set of frequencies is provided in Appendix 1.
Ease of Obtaining Specialty Care Appointments
The proportion of respondents who reported they had sought specialty care increased between 2012 and 2014, from 88 percent to 95 percent. Perhaps because of the increased demand for appointments, only one-quarter of Michigan residents reported that it was “very easy” to make specialist appointments in 2014, a nearly one-third decline since 2012.
Reported ease of making specialty care appointments declined most among those with Medicaid. Figure 5 A detailed set of frequencies is provided in Appendix 2.
Frequency of Not Seeking Care
Twenty-two percent of Michigan residents reported that they had not sought care they believed was necessary in the six months prior to the 2014 survey, a significant improvement from the 29 percent reported in 2012.
The uninsured and those with Medicaid or individual coverage at the time of the 2014 survey were much more likely to have not sought care they believed was necessary in the previous six months than those with Medicare or employer-sponsored coverage. Overall, all groups except those respondents with individually-purchased and Medicare coverage were less likely to have reported delaying care they thought they needed in 2014 compared to 2012. Figure 6
Among all respondents who reported that they had delayed care in 2014, half as many respondents reported cost as a reason compared to 2012 (21 percent compared to 42 percent in 2012). In 2014, 14 percent of respondents cited a lack of health insurance or the cost of using insurance as their reason for not seeking medical care, compared to 23 percent in 2012. Figure 7
Medical Care Affordability
Twenty percent of respondents to the 2014 survey reported struggling to pay their medical bills during the previous year, compared to 27 percent in 2012. In 2014, Michiganders with employer-sponsored coverage were significantly less likely to report having struggled to pay their medical bills during the previous year compared to 2012 respondents. However, the share of respondents with individually-purchased coverage who reported difficulty affording medical bills did not change significantly between the years.
In 2014, those with employer-based coverage and Medicaid5 were less likely than in 2012 to report difficulty paying medical bills compared to 2012. Those respondents with Medicare and individually-purchased coverage were slightly more likely to report difficulty paying medical expenses in 2014 compared to 2012.5 Figure 8
Consumers Ratings of Insurance Coverage and Cost
Overall, 81 percent of 2014 respondents rated their coverage as “excellent” (21 percent), “very good” (31 percent), or “good” (29 percent) compared to 78 percent in 2012. Important differences exist by type of coverage.
In 2014, 88 percent of those with Medicare rated their coverage as “excellent”, “very good”, or “good”, compared to 84 percent with Medicaid, 81 percent with employer-sponsored coverage and 65 percent with individual coverage. In comparison to 2012, satisfaction with coverage improved for those with Medicare (up from 80 percent in 2012).6 Respondents with Medicare were also less likely to rate their coverage as “fair” or “poor” in 2014 compared to 2012 (12 percent in 2014, compared to 20 percent in 2012). In 2014, those with individually purchased coverage were more likely to have rated their coverage as “excellent”, “very good”, or “good” (65 percent in 2014, compared to 55 percent in 2012)7 and less likely to rate their coverage as just “fair” or “poor” (35 percent in 2014 and 45 percent in 2012).6 Figure 9 A detailed set of frequencies is provided in Appendix 3.
Overall, when asked to compare the quality of their coverage at the time of the survey to the previous year, 71 percent of respondents reported their coverage quality had stayed the same, 17 percent reported the quality had worsened, and 12 percent indicated that the quality improved. Of respondents who had individually-purchased insurance both at the time of the 2014 survey and 12 months previously, two-thirds reported that the quality of their coverage did not change during that time.
Those with employer-sponsored coverage were most likely to report that their health insurance costs had increased since the previous year. Respondents with individually purchased insurance were slightly less likely than those with employer-sponsored coverage to report that their health insurance costs had increased, although this difference was not significant. Nearly 80 percent of adults with Medicaid reported that their health insurance costs stayed the same in the year prior to the survey. Figure 10
Compared to 2012, far more Michiganders reported being insured. Coverage does not guarantee access, but reductions in the number of respondents who reported struggling to pay medical costs or failing to seek care, as well as the stable and high share of Michigan residents who reported ease in accessing routine primary care, suggest that the health care system has been able to meet consumers’ demands for care after the ACA’s coverage provisions went into effect
Cover Michigan Survey 2014:8 The survey data presented in this brief were produced from a series of survey questions added to the Michigan State University Institute for Public Policy and Social Research (IPPSR) quarterly State of the State Survey. The survey was fielded between September and November 2014 and included a sample of 1,002 Michigan adults with a 20.2 percent response rate. The margin of error for the entire sample was ±3.9 percent with design effects. The sampling design, a random stratified sample based on regions within the state, was a telephone survey conducted via landline and cellular phones of Michigan residents.
Cover Michigan Survey 2013: Comparison data presented in this brief were produced from questions added to the State of the State Survey fielded between August and October 2012, which included a sample of 1,018 Michigan adults. The margin of error for the entire sample was ±6.5 percent with design effects.
Analysis: For analytical purposes, survey data were weighted to adjust for the unequal probabilities of selection for each stratum of the survey sample (for example, region of the state, listed vs. unlisted telephones). Additionally, data were weighted to adjust for non-response based on age, gender, and race, according to population distributions from the 2009-2013 American Community Survey data. Respondents who reported both Medicare and Medicaid coverage were considered Medicaid recipients for the purpose of this analysis. Results were analyzed using SAS 9.3 software. Statistical significance of bivariate relationships was tested using z tests or chi-square tests for independence. All comparison tables are statistically significant at p ≤ 0.05 unless otherwise noted.
A full report of the IPPSR State of the State Survey methodology can be found at: http://ippsr.msu.edu/soss/.
Suggested Citation: Smiley, Mary L.; Riba, Melissa; Ndukwe, Ezinne G.; Udow-Phillips, Marianne. Cover Michigan Survey: Coverage and Health Care Access. (Ann Arbor, MI: Center for Healthcare Research and Transformation, March 2015).
Acknowledgements: The staff at the Center for Healthcare Research & Transformation would like to thank Thomas Buchmueller, Matthew M. Davis, Robert Goodman, Helen Levy, Renuka Tipirneni, and the staff of the Institute for Public Policy and Social Research (IPPSR) at Michigan State University for their assistance with the design and analysis of the survey.