CLOSE TO A MILLION PEOPLE in Michigan depend upon the Affordable Care Act for health insurance with significant financing from the federal government. For instance, the Healthy Michigan Plan, costing $3.6 billion for FY 2016, was primarily financed by the federal government. According a recent study, ongoing federal funding for Michigan’s Medicaid Expansion could benefit the state by (1) reducing annual expenditures for prison health programs and mental health services by $235 million; (2) increase jobs in the healthcare, manufacturing and retail sectors and fuel increases in income and sales tax revenues linked to those jobs; and (3) redirect low-income consumer spending into food, transportation and housing (instead of healthcare expenses).
Other reports have found that hospitals have experienced declines in unpaid hospital bills from $1.1 billion (2013) to $913.5 million (2014)—and much of this has been attributed to the increase in health insurance coverage via Medicaid Expansion and the Marketplace, the provision of subsides/ tax credits, and removal of pre-existing conditions. Detroit and Wayne County residents have some of the highest enrollments in the Healthy Michigan (175,000 in Wayne County enrolled in Healthy Michigan Plan).85 The net effect on the state budget has been estimated to be $553.9 million in FY 2016.
If repealed or replaced close to a million people could lose health coverage. Michigan stands to lose $3.4 billion in federal funds and cuts in jobs in hospitals, clinics, construction and retail associated with the Healthy Michigan Plan. The state also stands to lose tax revenue from insurance companies and hospitals (estimated at $194 million in FY 2016).86 The defunding of Planned Parenthood will disproportionately impact low-income women of color in Detroit and severely effect women’s health services (including cancer, HIV, and STI screenings and prevention, reproductive health services, free birth control, and LGBT health services).87 65% of Planned Parenthood patients in Michigan are low-income.
While Medicaid Expansion (and the private option of the ACA) does provide increased coverage and access to much needed acute and preventative clinical care and relief to state and hospital budgets it is primarily conceptualized as an austerity-based biomedically oriented and financed response to community well-being. The plan exists without a robust relationship to social services that can address health impacted by the material conditions of vulnerable Detroiters.
With an expansive understanding of health and the places where well-being flourishes, and modification of financing models, road maps to health equity can gain more inroads. Here are some promising experiments:
First, while the Centers for Medicare and Medicaid Services’ (CMS) compensation policies continues to disregard critical nonclinical resources/ services as contributing towards health or the care giving and labor of non-clinicians as not reimbursable within the clinical hierarchy, many states and organizations are revisiting the important relationship between housing and health. For example, states and various organizations have developed and implemented “supportive housing” projects for chronically homeless persons.
Studies have pointed out that chronically homeless88 people are more likely have high rates of uninsurance, have co-occurring complex mental and physical health conditions, visit ERs and have longer hospitals stays (if admitted). The ACA Medicaid expansion offers an opportunity for states and local governments to further this link. Examples include: New York Medicaid utilizing, $260 million state-Medicaid dollars to create new housing units, rental subsidies and other housing pilot projects for homeless Medicaid enrollees; Massachusetts launching housing pilot programs in 2014 for chronically homeless persons through “Pay for Success” contracts leveraging private and philanthropic funds for Medicaid enrollees; and more closer to home in Ann Arbor and Ypsilanti similar efforts have been initiated with the assistance of the Corporation for Supportive Housing and the Social Innovation Fund (a White House initiative).89
Secondly, the city of Detroit’s commissioned report, the Blue Ribbon Panel, recommended that the city look into water and sanitation assistance program equivalent to the federal low-income home energy assistance program (LIHEAP). This would be another concurrent policy that could begin to address the water and housing health crisis in the city.
And, last, the Trump administration’s “repeal, replace and rebranding” or Trumpcare guarantees more austerity and “personal responsibility” from marginalized communities. This includes a much harsher version of Medicaid Expansion emerging in the form of block grants, defunding of Planned Parenthood, uncertainty with the private option and social services. This poses a timely issue for multiple stakeholders and community members to collaborate in solidarity with all Detroit residents.
This paper concludes with next questions that could be further examined and explored.
- What do stakeholders in the city of Detroit (and regionally) need to prepare for as with the “repeal and replace” of the ACA moves forward (particularly with the block granting of Medicaid Expansion and removal of funding for Planned Parenthood)?
- What would a blueprint of leveraging health in Detroit most affected neighborhoods via equitable housing and water services revitalization look like? And, how would this blueprint take into account intergenerational experiences of Detroit’s low to moderate-income communities?
- How does the “eds, meds, and feds,” approach to economic and community revitalization and health in Detroit compare to other US cities? What development and growth models challenge existing models of unequal development?
- Healthcare jobs demonstrate extreme occupational segregation (particularly by race, gender and income). And, in addition to occupational segregation, the neoliberal universities are increasingly out of reach for many low-income students. How would the “eds, meds and feds” approach of economic development for Detroit (and the region) work equitably under these circumstances?
- The ACA requires tax-exempt hospitals to create a hospital community health needs assessment (CHNA) every three years. Hospitals and other entities (such as the Health Authority) are conducting these assessments. How beneficial is this to the community of Detroit?
- 85. This also includes Flint (and Genesee County) and several counties in north - ern and upper Michigan.
- 86. John Ayanian, et al: “Economic Effects of Medicaid Expansion in Michigan,” The New England Journal of Medicine, Feb. 2, 2017;
- 87. Jamila Taylor: “How would women be hurt by ACA Repeal and Defunding of Planned Parenthood,” Center For American Progress, Jan 18, 2017.
- 88. Chronic homelessness is regarded as people who are experiencing either repeated episodes of homelessness or continuous, long-term homelessness of five years or more, and typically with more barriers.
- 89. In 2014, there were 3,300 people in Detroit experiencing chronic homeless - ness and 2,223 people were assisted by permanent supportive housing, according to a community database managed by HAND. More and more Detroit seniors face eviction as their contracts with HUD were coming up for renewal. The Detroit News, May 11, 2015; Martha Hostetter & Sarah Klein: “In Focus: Using Housing to Improve Health and Reduce the Costs of Caring for the Homeless,” The Commonwealth Fund, Oct/Nov. 2014; and Kathy Moses and Rachel Davis: “Housing Is A Prescription for Better Health,” Health Affairs Blog, July 22, 2015.