more than five dozen individuals attended the WHI’s 10th anniversary Stakeholders Meeting, which was a time to reflect on the focus of the WHI, what has been accomplished by WHI volunteers over the years, AND the work that’s left to do.
HISTORY
Norman Herbert, founding co-chair of the WHI, kicked things off by discussing the history of the initiative.
“Washington didn’t provide a template for the Affordable Care Act rollout in 2010,” said Herbert. The community had three years to plan for implementation and a concern that those new to coverage would access health care through hospital emergency departments, which leaders anticipated would be very costly. The group also knew that Medicaid-eligible residents were not enrolling in Medicaid, and wanted to understand why and what could be done to support them.
The first co-chairs of the WHI were Bob Guenzel, retired county administrator, and Norman Herbert, retired finance administrator at the University of Michigan. Peter Jacobson, a professor of health policy at the University of MIchigan School of Public Health, helped develop the WHI statement of organizational and operational principles, which positioned the WHI as a voluntary collaboration of cross-sector stakeholders which, with facilitative support from the Center for Health and Research Transformation (CHRT), would allow the organization to put its time and resources into the work, rather than the administration.
Herbert shared a list of the organizations represented on the first Steering Committee, and the individuals who led the early work groups on Medicaid and Marketplace Insurance Enrollment and Eligibility, Dental, Primary Care Capacity, and Mental Health and Substance Use. He spoke about the importance of the stakeholder group, and all of those who participated as members of the planning group, and those who adopted the WHI charter. “This was important at the outset to gain commitments from community organizations,” he said. Herbert also reviewed early funders for the work, including St. Joe’s and Michigan Medicine, who remain primary funders for the work today, as well as the United Way of Washtenaw County, the Washtenaw County Board of Commissioners, the Ann Arbor Area Community Foundation, Ann Arbor City Council, Ypsilanti City Council, and Saline City Council.
Next, Herbert reviewed a chronological list of WHI accomplishments, moving from 2012 through 2019. These included providing data to the Governor regarding local readiness for and interest in Medicaid expansion, supporting a pilot for the treatment of mild-to-moderate mental health concerns, becoming a community health innovation region, launching and leading a care coordination demonstration project for frequent emergency room utilizers, assessing the county’s unmet mental health needs, convening local leaders to improve the county’s SUD treatment system, supporting the development of a senior services network, convening partners to address the county’s opioid crisis, supporting diversion activities to prevent people from entering the homeless response system, and supporting area hospitals as they assessed community health needs and planned for hospital investments.
Panel discussion
Sharon Moore, current co-chair of the WHI, facilitated a panel discussion with Deborah Vinson, a lifelong Ypsilanti resident and a person with lived experience as uninsured; Ruth Kraut, deputy health officer of the Washtenaw County Health Department; Brian Keisling, director of the Bureau of Medicaid Policy, Operations, and Actuarial Services at the Michigan Department of Health and Human Services; Rebecca Fleming, director of community health initiatives at Packard Health; Iris Proctor, director of integrated services at Hope Clinic; and Jeremy Lapedis, director of the Washtenaw Health Plan.
The panelists were asked to speak about what’s changed since the passage of the ACA (and the launch of the WHI) and what are the most pressing challenges that remain.
Deborah Vinson spoke about her challenges with insurance. After leaving UPS in 2002, she lost employer-sponsored health insurance coverage. She fractured her hand at one point, and broke her ankle at another. Her health costs for the ankle alone were $26,800, which she paid off for many years. In early 2014, Vinson was able to buy insurance on the ACA Health Insurance Marketplace due to the new tax law. She paid $550 per month but never used it. Her time without coverage was devastating financially, but by December of 2015 she was able to secure ACA coverage which she kept until 2018 when she moved to Medicare. She said the coverage has been a blessing.
Ruth Kraut spoke about how the ACA has affected everyone in the U.S. “Those of you who have kids who are under the age of 20 may remember that before the ACA you had to pay for your kids’ vaccines, and there are a lot of children’s vaccines, so that could be expensive,” said Kraut. “You may remember paying for birth control, pregnancy wellness visits, colonoscopies, mammograms; these all had copays and were subject to deductibles. A lot of people don’t remember because we have short memories, but there’s been a really, really big difference, particularly in the range of preventive care.”
The Marketplace plans are still not perfect, said Kraut, referring to narrow networks, limited coverage for mental and oral health, churning as people switch jobs, and confusion for immigrants and others for whom English is not the primary language. But the ACA, she said, has saved a lot of lives.
Brian Keisling spoke about the evolution and expansion of Medicaid. Initially, he said, Medicaid was a program for the poor-plus population, particularly moms, babies, and the disabled. But when the state expanded Medicaid, the benefits quickly skyrocketed. In 2014, when the Healthy Michigan Plan was initiated, Keisling and his colleagues thought that maybe, in their “wildest dreams,” they’d get 450 to 500 thousand enrolled within two or three years. But six months after expansion, they had a half million people and the number kept growing until it stabilized at just under 700,000 people statewide on the Healthy Michigan Plan alone, which is for individuals up to 138 percent of the federal poverty level. Keisling said he was always shocked to learn that at times, up to half of that population had no income whatsoever.
Today, said Keisling, the Healthy Michigan Plan has 948,000 Michiganders enrolled. Keisling expressed concern about what will happen when the public health emergency ends (it’s now been extended at least through the middle of January) and MDHHS begins the process of Medicaid redeterminations. “We’re gonna lose some people,” he said, asking for the WHI to reach out to these clients to make sure that if they still qualify for Medicaid, they send MDHHS the information it needs to keep them on the program.
Rebecca Fleming spoke about Packard Health’s role as a federally qualified health center. “We have a large uninsured and underinsured population,” said Fleming. “A good third of our clients prefer a language other than English; 40 percent reside in the 48197 or 48198 zip codes, which are areas that score high on social vulnerability. And of those who did report race or ethnicity, over 35% identified as Black or Latino.”
Speaking of milestones, Fleming pointed out that Packard secured FQHC status in 2015 (an element of the ACA), which opened the doors for expansion to meet the growing needs of the community through a new Ypsilanti location, a growing partnership with the Delonis Center, a larger clinic on Pauline Boulevard, a Medication Assisted Treatment program for individuals with opioid use disorder, and more. And of course, said Fleming, “a huge milestone has been participation in the MI Community Care program of the Washtenaw Health Initiative, which has been beneficial in terms of collaborating with the community, but also reducing unnecessary ED utilization.”
Iris Proctor spoke about Hope Clinic, which is focused on the uninsured. Proctor spoke about the ways that Hope Clinic tries to keep the barriers to entry as low as possible. “We’re constantly in conversation with legal and HIPPA advisors to see how we can reduce the paperwork.”
In terms of challenges, Proctor spoke about the need for dentists and other specialists to work with clinic patients (“we have 1,200 volunteers and not even 50 staff–that’s how we work, volunteer run”); of the need for patient advocates who can work alongside clients; and of clients who are unable to get to their appointments due to lack of transportation.
Jeremy Lapedis spoke about challenges individuals face trying to access care. “Our system works well if you have a lot of time on your hands, and you speak English, and are highly educated. And it does not work well if that’s not the case.” The solutions, said Lapedis, “require putting patients, putting people, putting those that are underserved at the center of things–really doing that, as opposed to putting ourselves and our organizations at the center of it.”
Lapedis shared that in 2013, about 8 percent of Washtenaw County residents were uninsured, but that today, it’s about 4 percent. But the uninsured, he said, are disproportionately people of color, with about 11 percent of the county’s Latinx residents uninsured. Additionally, about 10 percent of Washtenaw County residents have reported that they’ve avoided care because it’s been too costly. And there are parts of the county where 23 percent of residents are uninsured. So while the overall numbers look good, there are a lot of disparities, he said.
Lapedis is also worried about the redetermination process. “We now have 66,000 people on Medicaid. In March of 2020, we had about 54,000. So that’s about a 22 percent increase from before the pandemic. And in January, or whenever Medicaid starts communicating with folks that they’ll close them out or require redeterminations, there’s going to be a lot of work to make sure that those that are eligible for Medicaid stay on insurance.” Lapedis hopes that the redetermination process will be better than it has been in the past, and mentioned that he has been reading about automatic Medicaid renewals based on tax data, wondering if that is something that the state of MIchigan could expand. “That’s an administrative thing that we could do to relieve the burden.”
Current and recent WHI accomplishments
Deana Smith shared some of the work that has been happening recently in the WHI, and work that the WHI has embarked on this year. “This year largely centered around emphasizing equity, advancing active projects in the work groups and affiliated projects, launching new and promising initiatives, leveraging investments from the health systems to attract new ones, and documenting the WHI’s impact over the last ten years.”
In terms of equity, Smith spoke about the intentional commitment the WHI made this year to elevate diversity, equity, and inclusion in the WHI including increasing diversity among the Steering Committee and staff, updating the WHI mission statement to emphasize diversity, updating the WHI operational principles and member commitment forms, and launching a new initiative to analyze disparities in health care utilization–specifically in Medicare annual wellness visit participation–which could serve as a template for conversations and solution-building around health and racial disparities.
Smith shared a number of work group accomplishments, including the expansion of MI Community Care, which provides patient-centered, coordinated care to individuals with complex medical, behavioral, and social needs; a newly formed Healthy Aging Collaborative, which will be providing support to Washtenaw County’s Commission on Aging; and new county policies, influenced by the Opioid Project, that decriminalize possession of medications used to treat opioid use disorder.
Finally, she talked about the Vital Seniors Initiative’s successful home nutrition pilot, which recently provided home-based assessments, medically friendly meals, and referrals to community-based services to more than 100 seniors and individuals with disabilities. The program was shown to increase health and wellness and reduce falls and unnecessary hospitalizations. Now, with new outside grants, the WHI is pleased to report that the work will expand to cover a larger geographic region.
collaborative health impact award
Liz Conlin and Gregory Powers presented the WHI’s inaugural collaborative health impact award. “This award epitomizes the spirit of the WHI in encouraging collaboration to accomplish amazing things,” said Conlin. “We had five wonderful projects nominated, all with a significant and positive impact on community health during the pandemic.”
- “Hoteling those experiencing homelessness during the pandemic”
- “Increasing food distribution during the pandemic”
- “Distributing masks to Spanish-speaking populations”
- “Expanding health services for young adults during the pandemic”
- “Door to door outreach in Ypsilanti”
Conlin and Powers described each of the initiatives briefly, then announced the winning collaboration with 65 percent of the vote: Hoteling those experiencing homelessness during the pandemic.
“During the early days of the pandemic,” Conlin said, “those experiencing homelessness were at a much higher risk of infection and mortality. The collaborative assembled a formal plan to ensure safe, physically distanced housing for those in need, and placed many in individual hotel rooms to ensure their safe shelter while diminishing the spread of COVID-19 in the community. The hotel rooms offered more than beds and showers. They also acted as a home-base for residents who rarely have one, allowing staff from multiple agencies to check in daily to coordinate physical and mental health, as well as social services.
Kate D’Alessio accepted the award on behalf of the Delonis Center, saying that the partnership and collaboration was amazing and that partners helped sustain the work for over 14 months at two different hotel locations, serving over 164 guests. The transmission rate was less than 15 clients agency-wide during the whole time frame.
Future
Brent Williams and Sharon Moore spoke about the future of the Washtenaw Health Initiative. Initially, said Williams, the energy was hospital-centric, with limbs that reached out to a wide variety of community entities. In phase two, the leadership was still health center/health system associated, though the range of work groups had diversified and the SIM care coordination grant funding had come in. The health systems were still providing the bulk of funding, but the energy had moved into more community-centered leadership. The third phase, said Williams, has been a reaffirmation of the mission and a more intentional focus on equity. These conversations have taken place at more of a distance from the health systems.
“We’ve evolved towards a model that’s really much more like a collective impact model,” said Williams, speaking about ways the WHI works with groups to identify a common agenda, shared measurement systems, and mutually reinforcing activities while providing continuous communications and backbone support.
Sharon Moore spoke about her evolving relationship with the WHI. Initially, as a new Steering Committee member, she says she wondered if members were just talking. Later, she says she started to look more closely at the ideas that were brought to the table. “I realized that there were many things being done in the community that I wasn’t aware of,” she says. At her first Stakeholders Meeting, Moore says she encountered people she knew from a range of organizations sharing the work that they were doing that was successful, and the work that they were doing that wasn’t as successful. It made her realize that groups were turning to each other for information, guidance, and collaboration.
Now, said Moore, the WHI is reflecting on DE&I and will continue to do that. Moore urged stakeholders and Steering Committee members to coalesce around the work; to ensure that DE&I is not only talked about, but that it’s advanced; and to put community needs at the center, with a focus on expanding insurance coverage, helping the community access care, and improving the experience for individuals interacting with local health and social service systems.