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Picture of Health Care in Washtenaw County

Doctor and patient

Improving the Health of our Citizens – Now and in the Future

Much of the discussion around the implementation of the Patient Protection and Affordable Care Act (ACA) has centered on activities and decisions necessary at federal and state levels, especially in preparation for the Medicaid expansion and health insurance exchanges that begin in 2014.

But health care is delivered at the local level, and it will fall to local providers and community groups to cope with the demands of increased Medicaid enrollment and to help patients better navigate the health care system after the major provisions of the Act go into effect in 2014. In Washtenaw County, a group of community leaders are working together to plan for a successful transition to the health care world of 2014, when as many as 28,864 individuals who are currently uninsured in Washtenaw County may become insured via Medicaid or health insurance exchanges. Even if the Act never goes into effect, it is apparent that much can and needs to be done to improve access to integrated and coordinated care for the current low-income, uninsured, and Medicaid populations in Washtenaw County.

The Washtenaw Health Initiative is a voluntary, county-wide collaboration with representatives from the University of Michigan Health System, Saint Joseph Mercy Health System, VA Ann Arbor Healthcare System, health plans, county government, community services, physicians, and safety net providers to assess the situation in Washtenaw County and address key gaps wherever possible.

In the initial phase of this project, leaders developed core baseline information using survey information, expert opinion and other sources1 around how the Medicaid enrollment and eligibility process works today, demographics, the current health care delivery system in Washtenaw County, and the challenges it faces in meeting demand in key areas – both today and in 2014.

Health Care Coverage Overall

Most Washtenaw County residents have good health coverage through the private insurance system, but there are many in the county who are uninsured or covered by Medicaid today. Many more will become eligible for Medicaid in 2014. Most notably:

  • In 2010, 69.9%2 of county residents had private health insurance coverage.
  • 11.7% were covered by Medicare.
  • Another 11.3% were covered by Medicaid.
  • In 2010, approximately 2,745 individuals were eligible for Medicaid but not enrolled.
  • An estimated 28,864 individuals were estimated to be uninsured in 2010. Of those, approximately 13,138 individuals are expected to be newly eligible for Medicaid in 2014; of the remaining 15,726, approximately 10,728 will most likely purchase coverage through the exchange, many of them receiving subsidies to do so. The remaining 4,998 will remain uninsured.

Enrollment and Eligibility in Medicaid

Many individuals think of Medicaid as a program for the poor. Yet, statewide, Medicaid (and Children’s Health Insurance Program) today covers only 16% of the non-elderly poor.

Medicaid today is also a very complex program with 42 different eligibility categories and an overwhelming caseload. In Washtenaw County, as of January 2011, there were over 55,000 total public assistance cases “in progress” with just 59 workers to process all these cases in addition to existing caseloads of 850 per worker.

While 2014 will simplify some parts of the eligibility system, it will also bring an influx of new enrollees that will place increasing demands on the Medicaid eligibility and enrollment system.

A Picture of Health Care Capacity

Primary Care

Overall, Washtenaw County has excellent, high quality medical care with major health care systems and 983 primary care providers that provide the majority of care in the county. In addition, there are more than a dozen safety net clinics providing essential services to those who are uninsured. However, many in need are not getting optimal care today, and the increase in the Medicaid population in 2014 will increase pressure on the delivery system. Of note:

  • More than 33,000 uninsured people appear not to be connected to primary care at this time.
  • If, through the expansion of coverage, all these individuals become connected to the primary care system, it is estimated that 35,545 additional visits annually would be sought in Washtenaw County. This additional demand is not likely to be able to be absorbed by the current primary care work force in the county.

Mental Health: A Special Challenge

Approximately 42,000 Washtenaw County residents (21% of adults ages 18-54) had diagnosable mental disorders in 2007. In a 2005 survey, approximately 27,000 residents (10% of all adults) reported poor mental health for more than 10 days in a month, yet only one quarter of those were being seen by a mental health professional. Access to mental health care for the low-income, uninsured, and the Medicaid population is extremely limited.

Under the Medicaid program today, beneficiaries enrolled in managed care health plans with mild to moderate mental health needs have coverage for 20 outpatient visits but often have difficulty finding providers in Washtenaw County who will accept Medicaid payments. Beneficiaries not enrolled in managed care have even more limited benefits: fee for service Medicaid individuals only have coverage for 10 visits and that care must be provided by an MD or DO.  Even for those beneficiaries in managed care plans, individuals with more serious mental health and/or substance abuse treatment needs have a mental health benefit that is “carved out” of the Medicaid program and includes inpatient mental health services as well as case management and outreach services. These services are delivered through the Washtenaw Community Health Organization’s community mental health programs. This “carve-out” was intended to contain costs and allow those with serious mental health needs to be treated by providers who have expertise working with this population.  However, this approach also means there may not be integration or continuity of care for these individuals with the primary health care provider.

Those who are uninsured with mental health needs may be screened and assessed by community mental health programs, but if they do not meet severity criteria are generally referred to local social services organizations operating on sliding fee scales. If they do meet severity criteria, they may be treated through community mental health programs if there is adequate capacity. This means that primary care providers in Washtenaw County who make mental health referrals face the complexity of multiple delivery systems, and patients face challenges related to accessing appropriate and timely care.

Substance Abuse:  Critical Shortage of Capacity Today

In 2008, approximately 1,150 Washtenaw County residents were hospitalized for substance abuse treatment. Because detox often requires medical oversight, patients must be hospitalized when no other medically supported detox services are available in county treatment centers.

In 2010, over 2,700 individuals with substance abuse or co-occurring disorders were treated in emergency departments. Over 800 of those could have been served in other venues in the community if they had access to medically supported crisis services. The vast majority of those treated or assessed in emergency departments (roughly 2,000) were sent home instead of to detox or treatment facilities. If capacity was available in the community, these individuals could have avoided the costly use of the emergency services altogether.

Dental Care for Low-Income Adults: Lacking and In Great Need

18,417 adults in Washtenaw County had Medicaid coverage with dental benefits in 2010. Yet, in a 2007 survey of community dentists, only 15% said they accepted Medicaid benefits and only 8% (five practices) said they were accepting new Medicaid patients (more practices accept Medicaid benefits for children under 18 years old). Medicaid’s low per case reimbursement is one of the main reasons dentists said they do not accept Medicaid coverage.

While there are some community outreach efforts, just three clinics (Hope Clinic, Community Dental Center and the U-M dental school) currently provide low or no cost dental care on a routine basis to adults in the county. Restrictions on who can receive care at such clinics further limit patient options.

Emergency departments recorded 4,667 dental-related emergency visits in 2008. The 28 hospital admissions with disorders to the teeth and jaw cost about $534,000 – about $19,000 per patient.

Conclusion

Although a recent report ranks Washtenaw County’s health outcomes as the fifth best in the state, it is clear that even this county – with relatively robust health care delivery systems and access to care – is challenged to meet the health care needs of its residents today and in the run up to full implementation of the Affordable Care Act in 2014. Easier ways to enroll in Medicaid, more access to patient centered primary care that integrates mental health and other critical services, and improved availability for low-income residents to key services such as substance abuse detoxification and dental care will be key to achieving the ultimate goal of improving the health of our citizens, today and in the future. The Washtenaw County Health Initiative is focused on building partnerships and identifying collaborative action that can move us toward that goal.

  1. Sources for usage data and estimates available upon request.
  2. Total coverage does not add to 100% due to rounding effects and because those that report having multiple types of insurance (i.e. Medicare or Medicaid) are included in each category.