Housing and Health
WHAT WAS INITIALLY EXPERIENCED as “redlining”34 and blockbusting in the housing and lending markets in 1940s and 1950s, by Black Detroit residents, the 1990s and 2000s offered subprime, predatory, or “ghetto loans” to residents remaining in these redlined areas (later broadened to include more women, seniors, and other racial/ ethnic communities). The later practice has been referred to as “reverse redlining.”
Later on in the 1990s and 2000s, larger private banks and investment companies with the assistance of government deregulation and lack of oversight—brought new forms of profitable discrimination and re-segregation in Detroit.35 Journalist and activist, Laura Gottesdiener has pointed out that companies like Wells Fargo would often hire and incentivize Black salespeople to go to Black churches (already established redlined zip codes) to aggressively recruit clients to sign up for predatory risky “ghetto loans.”36 From 2005-2015, Detroit experienced nearly 140,000 foreclosures, or 1 out of 3 homes, in the city.37
Forced geographical and racial segregation simultaneously increases community isolation, exclusion from quality social services, and surveillance/policing by the criminal justice system. Isolation, systemic indifference, surveillance and policing deepen individual and community poverty. In addition to the stripping away of social safety net and infrastructure, forcibly segregated communities are divested of wealth and opportunity building resources of quality reliable transportation, housing and educational security, meaningful work opportunities, and nutritious food. For instance, 93% of the housing stock in Detroit was built before 1978 and these homes can expose or poison the city’s children to lead based paints and dust. (The Affordable Care Act now covers lead testing for children in the Medicaid and Women Infants and Children (WIC) program as a preventative service.38
Detroit’s residential and commercial landscape (such as homes, buildings and lots) has often been described in terms such as vacancy, abandonment, and blight. All of these phenomena have been marked by systemic forces that have pushed people out of homes, communities, schools and work—such as foreclosures, subprime or predatory lending, reverse redlining, redlining, absentee landlords, the flight of capital and work, mass incarceration, the dismantling of social services, and racial and class injustice. This kind of turbulent and insecure relation to one’s home, place, neighborhood and place of safety and rest takes an extraordinary toll on one’s well-being.
In addition to redlining another practice of the “housing disassembly line”—where the housing industry contractors overproduced and supplied new houses in the suburbs—pulled more and more people away from city homes into the suburbs and new neighborhoods.39 These practices contributed to the increases in vacant structures, high neighborhood turnover rates, reductions in property value in the city, and reductions in the property and income tax base.40
Additionally, urban studies scholar, Margaret Dewar, has pointed out that “residential abandonment” since the 1970s has been most acutely felt in US cities that have high concentrations of racially and ethnically marginalized and low-income residents. In addition to “residential abandonment” cities like Detroit have experienced relinquishment of commercial buildings and land in its downtown neighborhoods. These concentrations of vacant structures and land coincide with what many urban researchers have noted about postWorld War II cities (particularly in the Midwest and Northeast): depopulation, loss of work, racial divisions, disinvestment and deindustrialization.
Nine of fifty US cities were depopulated in every decade between 1950 and 2000—and Detroit made this list. Detroit lost more than 50% of its population between 1950 and 2010. (In 1950, with a population of 2 million, Detroit was the 4th largest US city and by 2010 had lost 61% of its total population).41 Furthermore, while Detroit spans about 139 square miles, about 18% of its area was vacant with 90,000 vacant lots in 2001. More recent figures, provided by urban studies scholar, George Galaster, states that 30% of the city is comprised of either vacant land or buildings—where homes cannot be brought back to the “housing stock” due to its condition.
In both 2007 and 2008, Detroit topped the rates of national home foreclosures of US cities.42 In 2008 alone, Detroit experienced about 94,000 property-tax foreclosures.43 In the first quarter of 2009, one out of 275 housing units in Detroit faced foreclosures. By 2010 Detroit had a housing vacancy rate of 23%.44 Laura Gottesdiener has argued that the loss of 25% of Detroit’s population between 2000-2010 wasn’t entirely a volunteer migration. This particular phase of depopulation was driven by bank foreclosures that piggybacked on “subprime” loans and high-risk financial instruments. She points out that 100,000 homes were foreclosed upon in Detroit between 2000 and 2012 and that from 2004–2006, “73% of the new mortgages in the city were predatory loans, compared to 20% nationally.”45 With more and more foreclosures, residential property values declined (in many instances residents “owed more than 20 times what their property was worth”), which in turn catalyzed more foreclosures.
Another report point to the increased “return on investment” for Wayne County due to increasing numbers of auctions due to foreclosures in the city. A recent report has shown that since 2002, Wayne County has foreclosed upon over 160,000 properties. Foreclosures and auctions now have become a way for counties that were financially struggling earlier due to declining property tax revenues to now balance their budgets. According to the report, counties such as Wayne County borrow from banks/investors at low interest rates and charge administrative fees and high interest on back taxes owed.46 Some have raised concerns about inflated property taxes directed towards lower value assessed properties in Detroit. For example, Bernadette Atuahene has argued that over assessed property taxes in Detroit have resulted in illegal foreclosures in the city.47
Foreclosures also cost the local government “…$220 million in lost property revenues and as much as $2 billion in government-absorbed foreclosure costs.”44 The costs associated with foreclosures and new waves of depopulation have accelerated the decline in municipal revenues and ability to provide consistent public services (for instance: fire, police, and garbage collection) for residents living in effected areas. And, the remaining impoverished residents continue to have to deal with increased utility rates (for water and sewage) and due to a “shrinking city” trying to cope with deteriorating infrastructure. Homeowners also have had to deal with over-assessments on their property-taxes on their undervalued homes and have been subjected to foreclosures.
Researchers have noted that the recent housing bubble (1996-2006), the current reincarnation of predatory lending (in the late 1990s and early 2000s), ongoing deregulation policy implementation (particularly under Regan and Clinton)48 and the Great Recession affected Detroit earlier and harder than other regions.
For instance, in the 1960s Detroit neighborhoods began to face high rates of abandonment and foreclosures when many African American homeowners couldn’t meet their mortgage payments on their FHA (Federal Housing Administration) insured mortgages. Many of these homes required repairs that the owners could not afford and were appraised and underwritten under fraudulent conditions.49 Additionally, journalist John Gallagher has pointed out that the lower “quality of housing stock” wooden houses rapidly produced for lower income southern and Appalachian migrants hard a much harder time keeping up with humidity of the area and high rates of basement flooding due to a “high water table.”50 Decades of redlining policies coupled with lower quality houses have confined and contained low-income communities of color in the city.
In the 1990s, what has been described as one of Michigan’s “largest securities fraud case,” thousands of residential foreclosures and “blight” came about in the city due to the bankruptcy of RIMPCO Financial Corporation that generated high-risk mortgages to Detroiters.51
Homeowners who left the city for the suburbs often sell their property to local landlords who minimally improved or maintained the property for city renters. When renters also began to move on from the city or stopped renting local landlords began to abandon properties. In many recent cases, new renters often inherited the unpaid water bills of their absentee landlords. Detroiters, who inherited property from elderly relatives did the same when they couldn’t rent, sell or keep up with maintaining the property.52 In other instances speculators and landlords (including large banks and businesses) have practiced “blight violations” and have not paid property taxes.53
Maurice Cox, Detroit’s new Director of Planning and Development, has recently raised important questions about Detroit’s blight, vacant land and buildings. He points out that “…the question of blight is a really complex one. One person’s blight is another’s rehabilitated building. We have to very intentionally towards the preservations on not just single buildings … but of entire neighborhoods at the same time.” Cox has pointed out that a large part of the effort at restoring Detroit’s neighborhoods (such as increasing quality affordable housing; improving safety, security and lighting; having an eclectic mix of single and multi-family housing; and mix use spaces) for those outside of the downtown and midtown, in equitable and new ways, involves restoring neighborhood health to Detroiters who have had to weather through historical waves of turbulent times.
Housing & Health
The place of one’s dwelling embodies emotion, policy, and systems of privilege, equity or inequity. For instance: (1) the physical space of a home could provide a person an emotional, psychological and physical sense of safety, security, intimacy, shame, self-worth, and control both from outsiders and insiders; (2) the physical space of one’s home is marked by the quality and property value of the physical structure and foundation; the presence or absence of mold, infestation, sanitation, water, clean water, lead paint, etc.; or the need for home repairs; (3) one’s home is impacted by the quality and safety of your immediate neighborhood, the people and structures around you; the availability of walking areas, streets, street lights, amenities, public services, parks, grocery stores, schools, businesses in the area, garbage collection and sanitation services and degree of racial and class segregation; and (4) one’s home is the historical product of economic, political and social policies in the housing and health sectors—that produces intergenerational wealth and well-being.54
With higher numbers/rates of vacancy and abandonment residents are forced to face isolation, fear and anxiety for one’s safety, stigma and helplessness, and loss of neighborly interaction and ties. Studies have indicated that vacant and abandoned neighborhoods produce spaces where there is elevated risk of fires and property damage, increase in stigmatized unauthorized economies, fewer people taking walks, dumping, and buildup of trash and animals searching trash.55
Added to this scenario of isolation is increased taxation on utilities such as sewage and water services that has a declining infrastructure and severely ineffective city services (garbage collection, street lights, businesses, schools). The impact of this kind of abandonment can be severely troubling and stressful for the mental and physical health of individuals that have to stay on.56 In addition to losing property values and individual credit worthiness, local economies and governments face costs associated with maintaining or not maintaining the properties and neighborhood that have stopped being a reliable source of tax revenue.
The literature on foreclosures and health points to the vicious cycle of how (1) poor health can accelerate foreclosures; (2) foreclosures increase the risk of poor (mental and physical) health –particularly in low-income, vulnerable, communities of color that are juggling various financial obligations,57 and (3) economic downturns and financial crises are associated with austerity programs where social services and safety-net programs are cut. Robust literature exists linking negative health outcomes to foreclosures, particularly in high foreclosed upon areas. A spike in foreclosures has been associated with higher than usual ER use and unscheduled hospital visits.58 This spike builds upon histories of racial and class. Subsequently, the devastating stress of defaulting and loss of one’s home (often associated with feelings of shame, poor character and stigma— where home and home ownership can mean a lot more than the “American Dream”) has “potential to exacerbate existing social disparities in mental health.”59 60
Medicaid Expansion and Traditional Medicaid
Like many Republican dominated state legislatures, when Michigan Governor Snyder proposed Medicaid Expansion, in April 2013, the Michigan legislature did not initially appear to be supportive. The legislature softened their opposition to federal funds as long as Michigan’s Medicaid Expansion population would show “some skin in their game,"61 meet “free-market” conditions, and demonstrate savings and revenue for the Michigan state budget.
On April 1, 2014 Michiganders started enrolling for Medicaid Expansion, the Healthy Michigan Plan (see Figure 5), under the ACA. Michigan Governor Snyder signed the Healthy Michigan Plan into law on September 16, 2013.62 Michigan applied for a Section 1115 waiver to the federal government (Secretary of HHS) for a demonstration/pilot project that would “promote the objectives of the Medicaid and CHIP programs” under the ACA Medicaid expansion, instead of going for a straightforward ACA Medicaid expansion.
Healthy Michigan under the ACA provided an opportunity for the state to also cover newly eligible low-income able-bodied adults without children, who were not-pregnant, 19-64 years old, and between 0—138% FPL.63 Prior to the ACA traditional Medicaid program provided little or no coverage to this population. Michigan’s Medicaid Expansion program expanded through a Section 1115 demonstration program (or waiver) that replaced and updated an existing waiver program called the “Medicaid Nonpregnant Childless Adult Adults Waiver” or the “Adults Benefits Waiver (ABW).”64
Nearly 2/3rds of Detroiters have incomes below 138% of the FPL (or a one-person household earns $16,643 annually for Medicaid eligibility in 2017).65 Increased enrollment in Medicaid has been associated with economic downturns, decline in income, and loss of employment. The Medicaid Program (enacted under Title XIX of the Social Security Act) was created simultaneously with the Medicare Program in 1965. Medicaid is a jointly funded federal-state program and was designed to provide healthcare coverage primarily for certain categories of individuals with low-income and limited resources—initially for families with dependents and blind and disabled individuals receiving cash assistance. Since its passage many other categories of persons (at varying income levels) have qualified for it, such as children, parents, pregnant women, and “aged, blind and disabled” individuals.
The federal government establishes general guidelines and minimum standards and states establish their own criteria for benefits, eligibility and what is paid to providers.66 The federal government matches every dollar that the state invests in Michigan. Michigan implemented its Medicaid program in 1966, and currently the federal share of funds is at 65.60% and Michigan’s share is 34.4%.67 So for every dollar the State of Michigan puts in for its traditional Medicaid program, the federal government will match it with $1.91.68
The federal matching rate for Medicaid Expansion under the ACA is more generous than traditional Medicaid. For newly eligible Medicaid enrollees, the federal government would cover 100% of the share from 2014 to 2016. In 2017, the federal government would drop its share to 95%, 94% in 2018, 93% for 2019 and from 2020 and beyond it would cover 90% of the cost.69
Prior to the passage of the ACA, Michigan Medicaid primarily covered children, pregnant women, and some seniors, parents and individuals with disabilities. Of the 1.9 million eligible Michiganders, almost 1,050,000 were under 21 years and almost 413, 600 were seniors and people with disabilities. Some have pointed out that Michigan’s eligibility standards adopted some of the lowest income levels in the Midwest. For example, single parents were covered at 50% of the Federal Poverty Level ($5, 418 annually for an individual) and childfree adults were covered at 35% of the Federal Poverty Level (just under $3,800 per year for an individual).
Medicaid in Michigan has been (and continues to be) a critical safety-net program for (1) low-income seniors and certain individuals with disabilities—in the payments to nursing homes and other institutionalized care (Medicaid paid for 70% of nursing home care); (2) children’s healthcare—particularly in areas dealing with asthma and dental disease (3) maternity care—in 2010, Medicaid paid for more than half the births in Michigan.70 In many ways Medicaid in Michigan is the largest public payer of healthcare and for long term care.
Children in Michigan have also benefits from an upgraded Medicaid program—State Children’s Health Insurance Program (CHIP). CHIP builds upon the traditional Medicaid program and was created in 1997 as a federal-state partnership to cover children 19 years and under in families with incomes too high to qualify for Medicaid and too low to afford private insurance. The federal matching rate for CHIP is higher than traditional Medicaid. The implementation of CHIP has reduced national rates of uninsurance for children from 25% (in 1997) to 13% (in 2012). In Michigan, children in families up to 200% of the Federal Poverty Level are covered through a combination of Michigan’s CHIP program (or MIChild) and Medicaid (Healthy Kids).71 While MIChild has been seen as providing very good healthcare coverage, Healthy Kids has come under some criticism in cities such as Detroit where access to kids dental care has not been limited.72 CHIP was reauthorized in 2009 under the Obama administration (as the legislation known as CHIPRA) and under the ACA till 2019.
Skin in the Game
Some of Healthy Michigan’s “cost-sharing” requirements include: (1) enrollees make income based premium contributions (2% income for those between 100-138%); pay some amount of co-pay and co-insurance; and make income based contributions to Health Savings Accounts required for 100-138%. Evidence of “personal responsibility” could reduce some of these cost-sharing requirements such as co-pays.
The official goals of the demonstration project include whether or not there has been: (1) reductions in the number of uninsured in Michigan; (2) the encouragement of “personal responsibility” among enrollees by the promotion of “healthy behaviors” to result in healthy outcomes;73(3) improvements in access to healthcare; (4) reductions of “uncompensated care” and subsequently Disproportionate Share Hospital (DSH) payments to hospitals; (5) an impact on premium rates and rate filings; and (6) improvements in “effectiveness and performance” of the Medicaid program. In order to evaluate these goals certain government departments (Department of Community Health, Dept. of Insurance and Finance) as well as universities (UM Institute of Health Policy and Innovation) have been tasked to perform evaluations.
The emphasis on “personal responsibility” only by people who have been systematically disadvantaged by corporate and government policies is particularly troubling. While being accountable for one’s own actions or getting baseline clinical tests for your ongoing healthcare or even the possibility of “shared responsibility” can be helpful and fair—it is disconcerting that only low to moderate-income people and/or ordinary Americans are scapegoated to maintain a healthcare system that often avoids financial transparency and accountability.
Personal responsibility is variously referred to as “cost-sharing” or “skin-in-the-game” by some policy makers and follows what private insurance companies have long practiced before the ACA. This includes various patient fee deductions, such as: paying a percentage of income for premiums, co-pays, deductibles and co-insurance; and taking health risk surveys, demonstrating healthy behaviors (reducing one’s weight or smoking) and taking annual health exams to qualify for reductions in cost sharing. Another consequence patients face is disenrollment if one fails to pay premiums and bar them from enrolling the next six months. Significant research has shown that such extra fees and costs are barriers and deterrents for many low-income people to maintain health coverage.74 However, the short-term goal of cost-containment and profit is met for the insurance companies and the payer (or the state using public funds). Through waivers many state legislatures and governors have altered and weakened federal Medicaid rules to use public funds to purchase private-sector products (such as through the Marketplace) that may be less rich in benefits and shift more financial liability onto vulnerable individuals.
Policy makers and state/city officials view the infusion of these federal funds as a much “needed economic stimulus to the state” by directly and indirectly benefitting the Michigan economy.75 Directly by paying: hospitals, physicians, universities, clinics, insurance companies, and pharmaceutical industry (or what some call the “Eds, Meds & Feds” approach to economic revitalization of distressed cities).76 The argument is that as certain industries (such as auto and manufacturing) have left cities like Detroit other large employers have taken root and serve as anchors for the city. These new institutions are clinical and educational centers such as hospitals and universities who indirectly and directly receive federal dollars. Medicaid expansion and other provisions of the ACA are key ways in which federal dollars can be infused into municipal and state governments, hospital systems and institutions of higher education.
Studies also project that expansion will reduce state spending on “uncompensated care” programs and reduce “cost-shifting” practices by hospitals and the insurance industry on to individuals and employers (by raising premium rates).77
Even though the Healthy Michigan program was approved until December 31, 2018—Michigan had to apply for and got a second waiver approved by December 31, 2015. This second waiver would continue the Medicaid expansion program but would heighten more “free market” and “skin-inthe-game” conditions. The federal government had to approve Michigan’s plan to ask those enrollees, who have been on Medicaid for 48 months, between 100 -138%FPL to either purchase coverage from the health insurance exchange or “marketplace” or remain in Medicaid with increased cost-sharing (contribute up to 7% of income to premiums and increase HSA contributions to 3.5% of income).78 Reports suggest that about 15-18% of the expansion population (on a monthly basis) have incomes above 100% of the FPL.79 If this second waiver was not approved Medicaid coverage for the expansion population will be terminated on April 30, 2016 and 600,000 Michiganders would have been at risk of losing health coverage through Medicaid expansion.
As of March 7, 2017, the Healthy Michigan Plan has 651,508 enrollees. The majority of enrollees (over 500, 000) are at or below 100% of the federal poverty level (or an individual whose income is $12, 060 or less in 2017).
The Private Option (or the Marketplace)
A central goal of the Patient Protection and Affordable Care Act (ACA), passed on March 23, 2010, was to increase access to affordable and quality health coverage. This objective relied on two key routes (1) Medicaid Expansion and (2) the so called “private option” or the “Health Insurance Marketplace.”80 Michiganders began to enroll in the “Marketplace” on October 1, 2013 for coverage beginning on Jan 1, 2014. As of December 2016, 313,000 Michigan residents had private health insurance through the Marketplace.
It was estimated that over 71% of the uninsured in Michigan would be eligible for Medicaid or the “private option” subsidies. And, based on the income demographics of Michigan’s uninsured population, was projected that Medicaid would be the primary route. A study by the Urban Institute/ RWJF estimated that Detroit would experience a 66% reduction in the uninsured by 2016. By early 2015 the Detroit Depart of Health and Wellness Promotion reported that the rate of uninsurance in Detroit was down by 50% (100,000 Detroiters were since without health insurance coverage).
According to the Health Authority (formerly Detroit Wayne County Health Authority) prior to the passage of the ACA, adult Detroiters (ages 18 -64 years) were twice as likely to be uninsured compared to other Michiganders.81
Adults in Detroit reported a higher prevalence of chronic conditions including asthma, high blood pressure, disability, activity limitation and diabetes. Infant mortality rates were twice as higher than the state indicating the convergence of multiple inequalities and related stressors of poverty such as gender, income, and race. A study by the Health Authority study pointed out that individuals making less than $20,000 reported poorer health status and Latino/as reported the worst health status (about 41% of the Latino/a community).
In addition to supporting Medicaid expansion Snyder also supported a state-run Health Insurance Marketplace (or “Marketplace”). Michigan received federal funding for planning for a statebased marketplace but this provision of the ACA was an issue that could not pass the Michigan Senate. Instead, Michigan applied and was approved for a “State-Federal Partnership Marketplace” by the US HHS on March 5, 2013.
A report by Families USA pointed out that 1 in 4 Michiganders (2.4 million people between 18-64 years) had been diagnosed with (or treated for) pre-existing conditions that could lead to denial of coverage.82 Wayne County was reported have 1.55 million people with pre-existing conditions. Nearly 50% have a medically diagnosed pre-existing condition in Michigan in the 55 to 64 year group.
The ACA’s removal of “pre-existing” conditions was coupled with the requirement that health insurance was mandatory requirement for all eligible individuals. In many ways the removal of “pre-existing” conditions eroded practices of “health status redlining” pursued by the medical underwriting industry. And, since it was mandatory, the issue of affordability was intended to be addressed by subsidies for those who fell between 139 to 400% FPL. On June 2015, the US Supreme Court, ruled in favor of the ACA subsidies, that enrollees in states (like Michigan) who have a federally run “Marketplace” qualified for these subsidies or premium tax credits.83 Had the US Supreme Court ruled against the ACA subsidies in King versus Burwell, 228,000 Michiganders would have been at risk of losing their subsidies and premiums could have gone up by 294%.84
- 34. Benjamin Howell, “Exploiting Race and Space: Concentrated Subprime Lending as Housing Discrimination,” California Law Review, Vol. 94, Issue 1, January 2006.
- 35. “Lost Ground, 2011: Disparities in Mortgage Lending and Foreclosures,” Center For Responsible Lending, November, 2011; Laura Gottesdiener, A Dream Foreclosed: Black America and the Fight For A Place To Call Home, Zuccotti Park Press, 2013.
- 36. See Joel Kurth and Christine MacDonald, “Volume of Abandoned Homes ‘Absolutely Terrifying,’” Detroit News, May 14, 2015.
- 37. Heather A. Moody, et al: “The Relationship of Neighborhood Socioeconomic Differences and Racial Residential Segregation to Childhood Blood Lead Levels in Metropolitan Detroit,” Journal of Urban Health, 93:5, October 2016; Child Lead Poisoning Elimination Board, November 2016; https://www.michigan.gov/documents/snyder/CLPEB_Report--Final_542618_7.pdf.
- 38. Galaster notes that every year since the 1950s the housing industry produced 10,000 new homes in an unplanned, unregulated manner in excess of actual number of households and demand. George Galaster: Driving Detroit, 2012.
- 39. Galaster points out that property values in the city have gone down by 79% since the 1950s. And, that since 1972 the value of income taxes collected dropped by ¾.
- 40. The City After Abandonment, ed., Margaret Dewar and June Manning Thomas, pg. 4, University of Pennsylvania Press, 2013. The authors define abandonment “of a property as occurring when the owner stops taking responsibility for it. ‘Neighborhood abandonment’ or ‘city abandonment’ refers to places where large levels of population and household loss have led to large amounts of property abandonment, manifested in a high percentage of vacant houses, buildings, lots and/or blocks, which jeopardize the quality of life for remaining residents and businesses.” Colin Gordon: “Blighting The Way: Urban Renewal, Economic Development, and the Elusive Definition of Blight, “Fordham Urban law Journal, Vol 31, Issue 2, 2003.
- 41. Ibid, page 195.
- 42. “ Activists, neighbors hope to block Detroiter’s eviction,” Bill Laitner, Detroit Free Press, Aug. 14, 2015.
- 43. Ibid, pg. 195
- 44. Laura Gottesdiener, A Dream Foreclosed: Black America and the Fight For A Place To Call Home, 71, Zuccotti Park Press, 2013.
- 45. See, "Sorry we foreclosed your home. But thanks for fixing our budget," Joel Kurth, Mike Wilkinson, Laura Herberg, Bridge Magazine, June 6, 2017.
- 46. See "Detroit's Tax Foreclosures Indefensible," Bernadette Atuahene, Detroit Free Press, September 1, 2016.)
- 47. Ibid, pg. 73. Other sources report that between 2009-2013, over 70,500 Detroit properties have been foreclosed, resulting in $744.8M in lost city property taxes (Detroit Blight Removal Task Force Plan).
- 48. For instance the deregulation of the savings and loans industry under Ronald Regan and the banking industry under Bill Clinton.
- 49. Dewar, 5.
- 50. John Gallagher: Reimagining Detroit: Opportunities for Redefining an American City, pg. 24-25, Way
- 51. Ibid, pg.5 and http://www.metrotimes.com/detroit/all-fall-down/Content?oid=2188200.
- 52. Detroit has a residential vacancy rate of 27.8 percent and 22.8% poverty rate (2010) and has gone through 55,000 foreclosures since 2005. The city experienced another wave of foreclosures after the lifting of temporary moratoriums. (pg. 3, Dewar)
- 53. http://www.crainsdetroit.com/article/20161016/NEWS/161019896/state-law-c....
- 54. “Where We Live Matters For Our Health: The Links between Housing and Health,” Robert Wood Johnson Foundation, September 2008.
- 55. Jennifer Guerra: “Abandoned homes affect your health. But here’s what can help,” State of Opportunity, July 20, 2016; and the Detroit Neighborhood Health Study.
- 56. “The Social Costs of Deindustrialization,” Center For Working Class Studies, Youngstown State University.
- 57. Kimberly Libman: “Housing and Health: A Social Ecological Perspective on the US Foreclosure Crisis,” Housing, Theory and Society, 2012. Craig Pollack and Julia Lynch: “Health Status of People Undergoing Foreclosures in Philadelphia,” American Journal of Public Health, 99:10, October 2009.
- 58. Janet Currie & Erdal Tekin: “Is there a Link between foreclosures and health?,” National Bureau of Economic Research, Working Paper 17310, August 2011.
- 59. Jason Houle: “Mental Health in the Foreclosure crisis,” Social Science and Medicine, 118, 2014.
- 60. Amy Schultz, et al: “Discrimination, Symptoms of Depression and Self-Rated Health Among African-American Women in Detroit: Results From A Longitudinal Study,” American Journal of Public Health, 96:7, 2006; R. Morello-Frosch: “Understanding The Cumulative Impacts of Inequality in Environmental Health,” Health Affairs, 30:5, 2011; Sepideh Modrek, et al: “A Review of Health Consequences of Recessions International and US and a synthesis of the US Response during the Great Recession,” Public Health Reviews, 35:1, 2013.
- 61. “Michigan’s Medicaid Expansion Experiences: A presentation to the Civic Federation and the Federal Reserve Bank of Chicago,” Christopher Harkins, Director, Office of Health and Human Services, Michigan State Budget Office, April 4, 2016.
- 62. On December 30, 2013 Michigan obtained approval from the CMS for the “Healthy Michigan” Plan. The Public Health Act 107 of 2013 established the Health Michigan Plan. “Approved Demonstrations Offer Lessons for States Seeking to Expand Medicaid Through Waivers,” Jesse Cross-Call and Judith Solomon, Center on Budget and Policy Priorities, Aug.20, 2014.
- 63. This includes childfree adults between 0-138%, childfree adults who were covered at 35% (with asset limits up to $3000) and working (64%) and non-working parents (37%).
- 64. In the ABW program able-bodied childfree adults could be Medicaid eligible if they were at or below 35% FPL.
- 65. “The ACA and America’s Cities,” the Urban Institute/RWJF, June 2014; “Why the ACA Matters for Women: Improving Healthcare for Women of Color,” National Partnership for Women and Families, Sept. 2014.
- 66. It is overseen by the Centers of Medicare and Medicaid Services (CMS), which is located within Health and Human Services (HHS).
- 67. Ibid, “Reinventing Michigan’s Health Care System,” Submitted to CMS by Governor Rick Snyder, 24 January 2014.
- 68. “Federal Medical Assistance Percentage (FMAP) for Medicaid and Multiplier,” SY 2016, Kaiser Family Foundation, 2015.
- 69. The ACA initially required all states to expand Medicaid coverage to individuals with incomes at or below 138% FPL. The US Supreme Court, in June 2012, ruled that Medicaid expansion would be left up to the states and thus optional.
- 70. Jan Hudson: “Understanding Medicaid: Complex, Compassionate, Cost Effective,” Michigan League for Human Services, October 2011.
- 71. “Michigan CHIP Fact Sheet,” National Academy for State Health Policy, 2012.
- 72. Sheila Hoag & Cara Orfield: “Congressionally Mandated Evaluation of the Children’s Health Insurance Program: Michigan Case Study,” Final Report, Mathematica Policy Research and The Urban Institute, Nov.1, 2012.
- 73. Healthy behaviors include: taking the annual health risk survey from the Michigan Department of Community Health—to determine “risk factors” such as substance and alcohol abuse, tobacco use, immunizations and obesity.
- 74. “Medicaid Expansion, the Private Option, and Personal Responsibility Requirements: The Use of Section 1115 Waivers to Implement Medicaid Expansion Under the ACA,” Jane Wishner, John Holahan, Divvy Upadhyay and Megan McGrath, The Urban Institute and RWJF, May 2015; and “The ACA and recent Section 1115 Medicaid Demonstration Waivers,” Robin Rudowitz, Samantha Artiga and MaryBeth Musumeci, The Kaiser Commission on Medicaid and the Uninsured, February 2014.
- 75. Reports prepared by various policy makers and researchers report that Medicaid expansion federal funds will benefit Michigan in the following ways: (1) yield savings of $389 million through FY 2015 for the State by replacing State general revenue funds with federal funds to address mental health programs, public health programs and healthcare services for prisoners; this includes projected savings of $190 million in FY 2015 by “by transitioning enrollees in a state-funded program that provided services for the seriously mentally ill into the new adult group” and reduction in state spending of $13.2 million in FY 2015 for hospital inpatient costs for prisoners and (2) produce revenue gains of up to $26 million through FY 2015 through fees and assessments on the state’s Health Insurance Claims Assessment. Other reports foresee other benefits since the federal matching rate for Medicaid expansion is much more generous than traditional Medicaid. “States Expanding Medicaid See Significant Budget Savings and Revenue Gains,” Robert Wood Johnson Foundation, Issue Brief, April 2015.
- 76. “Eds, Meds, and the Feds: How the Federal Government Can Foster the Role of Anchor Institutions in Community Revitalization,” Tracey Ross, Center For American Progress, 2014.
- 77. According to the study projected benefits include: Michigan receiving $1.4 billion in 2016, approximately 18,000 new jobs, which in turn would increase economic activity by nearly $2.1 billion in 2016. A $351 million in savings for the state in “uncompensated care” costs from 2013 to 2022. “Michigan’s Economy will Benefit from Expanding Medicaid,” Families USA and Michigan Consumers for Health Care, 2013.
- 78. The research is still mixed on the quality, affordability and richness of “marketplace” plans relative to the Medicaid ones and how much it would benefit or harm Medicaid expansion enrollees to switch into the private Marketplace. However, a recent study pointed out that Medicaid plans are superior and more comprehensive compared to Marketplace plans as far as mental health, alcohol and substance abuse, and behavioral health coverage go and plays an important role for the expansion population. Medicaid finances a quarter of national health spending on behavioral health (which include mental health, substance and alcohol use). And, if 35% of the Medicaid enrollees had a chronic behavioral health condition prior to the ACA (in 2009), the chances of the excluded expansion population having undiagnosed conditions are even higher. From: “Adult Behavioral Health Benefits in Medicaid and the Marketplace,” Ken Cannon & Jenna Burton (Econometrica, Inc.) and Mary Beth Musumeci (Kaiser Family Foundation), pg.4, The Kaiser Commission on Medicaid and the Uninsured, June 2015.
- 79. Jan Hudson: “Health Michigan Plan Second Waiver,” Michigan League For Public Policy, August 2015.
- 80. The ACA is also attributed with having “triple aims:” (1) increasing access; (2) lowering the costs of healthcare and services; and (3) improving the quality of care. For the “triple aim” to work individuals, with eligible citizenship requirements, are required to purchase health coverage referred to as the “individual mandate” of the healthcare law.
- 81. The State of Population Health Report 2015, pg. 5. Or, 32% of Detroit adults in compared to 17% of Michiganders.
- 82. The study mentions that this does not address the issue of undercounting of the underinsured and uninsured.
- 83. King versus Burwell, 25 June 2015.
- 84. “King versus Burwell,” Families USA, June 2015.