Playlist: Michigan

The “Healthy Michigan Plan” turns one: How is expanded insurance coverage affecting stakeholders and communities?

April 7, 2015 1:24:30
Kaltura Video

Laura Appel, Robert Fowler, Erin Knott, Kim Sibilsky and Ken Sikkema discuss the first year's impact of the Healthy Michigan Plan. April, 2015.


>> Hello everybody and welcome.  I'm Susan Collins, the Joan and Stanford Weill Dean here at the Gerald R. Ford School of Public Policy, and I'm delighted that you could join us for what I am sure you agree is a very important conversation about the Healthy Michigan plan that is now 1-year old.  

Today's program would not have been possible without generous support from the Gilbert S. Omenn and Martha A. Darling Health Policy Fund, and so we very much appreciate that support.  

In a moment, Dr. Matt Davis will introduce today's panel more formally, but before we begin I want to say just a few words about him.  In addition to teaching appointments at the University of Michigan's Health System and also here at the Ford School, in fact he just came straight from teaching a class here at the Ford School, Matt serves as the Chief Medical Executive for the State of Michigan.  In this role, Matt provides the Michigan Department of Community Health with professional medical expertise on public health issues and development related policy.  That really is a critical public service role and that perspective is particularly valuable for the citizens of Michigan and also for the conversation that we will have here this afternoon.  And today's event really is his brain child and so I just wanted to really express my gratitude and appreciation for putting together a phenomenal group to talk about this important set of issues.  So thank you.

But I've got a couple of other things I wanted to say.  

[ Laughter ]

Today's panel includes representatives from multiple perspectives and I will just list them.  They will be introduced in just a few moments and so please don't applaud right now although, of course, they are all very worthy of applause.  

So, first we have Ken Sikkema, who is a Michigan alum and Senior Policy Fellow at the Public Sector Consultants.  He is a former long-term member of the Michigan Congress.  Next to him we have Rob Fowler, who is President and CEO of the Small Business Association of Michigan.  Then we have Erin Knott who is Michigan State Director for Enroll America.  Next to her we have Laura Appel, another Michigan alumna, who is Senior Vice President for First Strategic Initiatives at the Michigan Health and Hospital Association.  And then we have Kim Sibilsky, who also studied at the University of Michigan and is the CEO of the Michigan Primary Care Association.  Last but not least here who will be joining us shortly we have Dr. John Ayanian, who will moderate this very impressive panel.  John is Director of the university's Institute for Health Policy and Innovation as well as a faculty member both in medical school and here at the Ford School.  

So, please join me first in a warm welcome to all of our discussants.  

[ Applause ]

Just a very brief word about today's format before we begin.  First, Matt Davis will provide us with an update about the 1-year Healthy Michigan plan and then next Dr. John Ayanian will introduce our panelists and have some individual opening remarks and then moderate the discussion.  We will save about half an hour for questions from the audience and I do encourage you to share your questions with us.

If you have a question, please write it on a card, you should have received cards when you entered the room, and Ford School volunteers will be circulating around 4:40 and they will continue to do so to gather the cards. If you are watching online, please Tweet your questions to us using the hash tag policy talks.  Our Masters of Public Policy students, Megan Foster Freedman and Ruth McDonald, will read the questions later and so I welcome them here as well.  With no further ado, Matt, the floor is yours.  Again welcome.

>> Thank you, Susan, and good afternoon everyone.  Good afternoon to those of you here in the room and to those of you watching on the web.  I'm particularly grateful to all of you who have dedicated the time this afternoon and to members of our panel to talk about a very celebrated birthday.  I won't have us all singing Happy Birthday but reaching 1 year of age in many cultures around the world is a reason for a [inaudible].  We're here to ask today about the Healthy Michigan plan as it reaches its first birthday and what that means for the health, health care and health policy in our state.

I have the privilege of providing some background remarks today so that we're all on the same page with regard to what the Healthy Michigan plan means and where it currently stands.  Before I go any farther, I want to acknowledge something that Dean Collins just mentioned which is that I have a couple of different roles.  I'm a faculty member here at the university, which is the primary role I have today behind the microphone.  I also serve as the Chief Medical Executive for the State of Michigan and any remarks that I make today should not be interpreted as official stance of the Department of Community Health or of Governor Snyder.  If I'm asked to respond to a question as a member of the Department of Community Health, I will officially make a gesture like this putting on a hat of that role.  Otherwise, I am speaking as a faculty member here today.  

To understand where we are we need to understand a bit where we've been.  So let me take us back 50 years to when Medicaid was born and we have here President Johnson signing Title 19 of the Social Security Act with Lady Byrd Johnson at his right and to his left former President Harry Truman and Bess Truman.  

That was a milestone that today we almost take for granted in our system that Medicaid is a foundational bedrock of the government role in our health care system, but as a foundational bedrock, we have continued to have subsequent policies that have tried to do different things with Medicaid.  And so 5 years ago the Patient Protection and Affordable Care Act was born and when President Obama signed the ACA, there was perhaps first and foremost certainly among the major goals expansion of Medicaid.  You see him surrounded in a very different signing ceremony not by previous presidents and spouses but by the Democratic leadership, which indicated the polemic nature of political support at the time this act was signed.  

Three years ago, so we've got from 50 years ago to 5 years ago now 3 years ago the Supreme Court upheld the ACA in one decision but in a [inaudible] decision just a few minutes later permitted states to choose whether to expand Medicaid and there began a cleaving of the support for Medicaid across different states and by state dominance [phonetic].  And so states when given permission to differ as they tend to did differ and we have here on the left the 2012 Presidential Election map separated out in the usual blue and red distribution and then on the right current status of state Medicaid expansion decisions.  

You don't have to be an artist to recognize the similarities here and that is a common story we have about Medicaid expansion under the Affordable Care Act that it has strongly followed political lines in terms of the leadership at the state level and the governor's mansion and the state legislatures.  

February 2013 so less than 2 years ago or about 2 years ago Governor Snyder announced his support for Medicaid expansion in Michigan at the time saying that Medicaid expansion was a way to improve health and save money in our state, to provide greater assets to care and lower business costs among beneficiaries.  These are themes that you will hear from our panelists today has the Healthy Michigan plan delivered on those promises and what have we seen as expansion of Medicaid has occurred in our state?  You'll notice I circled here in the first paragraph that the estimate of benefit was to about 320,000 residents first year.  Keep that number in mind.  

Just a few months later, May 2013, Representatives Lori and Petroka [phonetic], were the first to sponsor House Bill 4714, which later became the Healthy Michigan Act.  This was clearly a connection to Title 19, which I have circled here on your slide Title 19 of the Social Security Act, which had been the original Medicaid program, but there was a definite effort to not talk so much about Medicaid expansion but rather fashion a different approach to expansion in Michigan, something that was going to lead to a healthier population.  

Let's talk a bit now about the navigation and negotiations that occurred during the Summer of 2013 to take the Bill 4714 and help it become a public act a few months later.  The advantages that were put forth were to cover uninsured Michiganders to reduce uncompensated care meaning the care that providers would provide and would not have been paid for by uninsured individuals; to control health care costs, which Michigan is no different, have been rising in the private markets and the public markets; and to have our managed care plans, which have been a big part of the Medicare story in our state, a big positive part, help be part of the Healthy Michigan plan by having all enrollees in the Healthy Michigan plan be enrolled in managed care plans.

The perceived disadvantages by [inaudible] of the Healthy Michigan Act were that this was really unnecessary government spending.  It wasn't a wise way to spend otherwise scarce dollars and the worries were expressed that the federal government through the Affordable Care Act might not sustain this enhanced match.  Meaning the federal government was going to cover the full costs of the program for the first 3 years and a slightly decreased amount [inaudible] but that may not actually be how it plays out.  That will leave Michigan vulnerable in terms of its overall budget and a plan that perhaps it wasn't prepared to pay for.  

This [inaudible] of advantages and disadvantages led to some focused compromises.  The first was cautionary [phonetic] beneficiaries because if you're trying to create a less vulnerable program, you need to have beneficiaries with more role in that program to pay for its costs.  This cautionary is unusual for Medicaid and, therefore, require 2 different waivers.  Waiver 1 was for people over 100% of the federal poverty level up to the limit of 133% to share 5% of their income on the order of a few hundred dollars per year.  

And then Waiver 2, which is currently in preparation is for individuals with over 100% of the federal poverty level income to share up to 7% of their income after being in the program 48 months.  There was also, and this is on healthy behaviors trying to focus on the fact that individuals in Michigan, and we know this from population health measures, tend to be less healthy than some other states.  We need to try to reduce our levels of obesity, reduce our levels of tobacco use, et cetera.  There's an idea to implement health risk appraisals to encourage a conversation between patients and their physicians about how to try to improve their behaviors overall.  

The legislature asks that [inaudible] set up something new called the My Health Count for individuals in the Healthy Michigan plan to help them understand how dollars from the state government and federal government were being spent on their behalf in the health care system.  And finally there were specific triggers for program termination written into the act that said if this happens or this does not happen, then that will be the end of the Healthy Michigan plan.  

With those compromises on September 16, 2013, Governor Snyder signed the Healthy Michigan Act here in yet another signing ceremony and with only 1 person in common between the signing ceremony of the ACA and the signing ceremony of the Healthy Michigan plan that being Representative Angle, Sharron Angle [phonetic], who although last time I checked wasn't directly responsible for state policy we all know he is out there.  

[ Laughter ]

That leads us then on April 21, April 1, 2014, to the Healthy Michigan program launching and on April 1, 2015, the Healthy Michigan program that is providing not to 320,000 individuals, not to 400,000 individuals, not even 500,000 individuals, but more than 570,000 Michiganders ages 19 to 64.  Far more than were anticipated even over a 5-year rollout of the program.  You can see here the different age groups that are involved and their different composition of the overall Healthy Michigan beneficial group.

So when you have a program that was passed through a contentious debate leading to some [inaudible] compromises and then it's subscribed to by over 50% more individuals than were expected, what we have then in terms of questions going forward that's what we had the pleasure of hearing about from our panelists today, our distinguished panelists, and for that discussion, which I'm looking forward to I hope as much as you are, I turn to John Ayanian to give us some more formal introductions.  Thank you.  

[ Applause ]

>> So I would like to join Dean Collins and Dr. Davis in welcoming our panel and all of you to our session today and, of course, a lively discussion.  As Dean Collins mentioned, each of our panelists moving from your left to right will have an opportunity to speak for about 5 minutes sharing their opening perspective on where we stand at the 1-year anniversary of the Healthy Michigan plan and then we will open it up for questions from the audience for about 40 minutes and as mentioned those questions can be passed down to our students here in the front and then presented to the panel for their input.  

So, with no further ado I'd like to introduce our first speaker, which is Mr. Ken Sikkema, Senior Policy Fellow at Public Sector Consultants where he focuses on public finance environment and energy policy.  And prior to joining the firm he served in Michigan House of Representatives for 6 terms and in the Michigan Senate for 2 terms and in the House he served as the Republican leader from 1997 to 98 and in the Senate he served as the Majority Leader from 2002 through 2006.  Mr. Sikkema.

>> Thank you and thanks for the Ford School for hosting this, thanks for the invitation.  I'm going to make 3 just very quick observations first about what I think this achievement is, a very remarkable achievement in terms of the politics, why it happened from my point of view and then a note about the future, but I think I want to start with a caveat I'm like a lot of people that are actually on this panel I wasn't involved in the day-to-day, you know, trench warfare of getting this passed.  I watched it and observed it close up at times but because of that, you know, there's a plus and minus to that.  I might actually get something wrong about what actually happened and I would urge my fellow panelists to correct me if I do.  

>> It will be our pleasure.  [Laughter]

>> Well, and I was just going to say that I've worked with a couple of these people in the past and they've never needed encouragement from me to correct me.  So, with that disclaimer let me just make 3 observations.  From a political perspective this should not have happened.  I don't mean it's a bad idea I'm just saying given that very bitter and really visceral politics of the Affordable Care Act from the beginning I'm glad that Matt had these slides about President Johnson signing Medicaid in 1965 and President Obama signing the Affordable Care Act in 2010.  

The Affordable Care Act passed with no single Republican vote.  None, zero.  Medicaid in 1965 almost half of the Republicans serving in the US Senate and the Congress voted for both Medicaid and Medicare.  So, from the beginning of the politics of the Affordable Care Act have been very bitter and they've just gotten worse since.  

Really if there's any kind of association with the Affordable Care Act on the Republican side, it's almost like your Republican and your conservative credentials are being questioned.  So, from that point of view the fact that any red state, and I think there's maybe 10, maybe 10 of them that have Republican governors have expanded Medicaid, but from that standpoint the fact that any red state expanded Medicaid because it's connected to the Affordable Care Act, that's a remarkable political achievement so that's my first comment.  

My second comment is, well, okay, why did this happen?  And, you know, first of all I think some people that are on this panel and others have to take credit for the work they did in getting it passed, but I really don't think that's kind of what got Medicaid expansion over the top here in Michigan.  I would think, I would say and suggest that it goes back to a very specific event where the Speaker of the House Jase Bolger, asked then Representative Mike Shirkey a very etiologically conservative almost Tea Party legislator in the House to take a look at this issue and render his opinion as to whether it ought to pass or not.  And it was Mike Shirkey and sort of what I would call some like minded very conservative legislators that said, you know, this really does make sense for Michigan and we ought to pass this.  And I think if it weren't for that the embracement of this expansion by Mike Shirkey, who is now in the State Senate and chairs a health committee on the State Senate, I don't think it would have passed.  

Now, you know, can't prove a negative, but maybe it would have maybe it wouldn't but he gave it the conservative credential it needed here in Michigan.  Now, if he were sitting here as opposed to me and you asked him why did you do it, you know, why did you come to this conclusion, I think he would say the following.  First of all he would probably start by saying from his standpoint it was the lesser of two evils.  Not wild about the Affordable Care Act but from his standpoint kind of 3 things stood out.  

One is sort of it's like the stages of grief.  He accepted the fact that the Affordable Care Act wasn't going to mysteriously and magically disappear, and I think that's, he made a departure from his conservative colleagues in that sense.  He sort of accepted the fact it was here to stay at least in the near term.

Secondly from a conservative fiscal standpoint it just kind of made sense.  I mean the federal government is going to pick up 100% of the cost for the first few years and then promises to pick up 90% after that and so from his standpoint and sort of a conservative political standpoint, fiscal standpoint, it doesn't make sense for Michigan to forego those dollars.  I mean we're sending out tax dollars to Washington, there's probably taxes associated with the Affordable Care Act, some people claim it's 2 billion coming out of Michigan.  I don't know if that's right or not, but from his standpoint, you know, if we're sending that money to Washington, why should it just go to other states?  Why not recoup some of that?

So, stages of grief, acceptance, fiscal argument it made sense but finally, and this is I think the clincher, is legislators, Republican legislators in Michigan, looked upon this as a chance to reform Medicaid; that's how they saw this.  And so they basically took the approach of, you know, we're going to do this on our terms.  We're not going to just accept the traditional Medicaid program, we're going to create an alternative.  So, they put in probations [phonetic] that emphasized individual personal responsibility and kind of ownership of this, the co-pays, the premiums, and the health savings account approach.  So that was a big piece of this.  Kind of personal ownership, personal responsibility, which would require a federal waiver, which was granted.  

The second big piece that they insisted that this not be a lifetime program.  They didn't want this to be another lifetime entitlement.  And so Michigan has a 48-month limit and after which various provisions kick in and the federal government has not yet approved that waiver or that approach or that probation and I think you will hear from others on the panel that that's as pretty iffy proposition as to whether they'll approve it or not.  

Then finally I think they looked at it from a almost a, you know, being able to create a Michigan specific program reforming Medicaid.  They also wanted to look at it from a taxpayer standpoint and, you know, what's the return on investment if we do this?  And there are various studies that are going to, have been done that are going to be done over time.  There's going to be a big study that comes out in September I think of this year about, you know, is this really working and what changes maybe Michigan, what changes ought to take place to make this work for Michigan and it make sense from a taxpayer standpoint.

Now there are other arguments but I want to kind of bring my comments to a close.  The future, well, you've got the second federal waiver that's, you know, kind of sitting out there that if Michigan doesn't get according to the statute that expanded Medicaid the program stops within 90 days.  I think that's an example of sort of the larger issue that is going to play out over time and that is how much flexibility is a specific state like Michigan going to have to craft the program they think will work over time.  I think that's going to be one of the factors that people ought to watch even beyond the second federal waiver because from a Republican standpoint one of the sore parts about Medicaid is the limitations on crafting a state-specific program and they looked on this as an opportunity to do that and if that gets taken away over time, I think there's going to be a dramatic lack of enthusiasm to continue it.  Thank you.  

>> Thanks.  So our next speaker, Rob Fowler, is the President and CEO of the Small Business Association of Michigan, a role he has had since 2003.  And the Small Business Association serves over 23,000 member companies from all of Michigan's 83 counties promoting entrepreneurship, leveraging buying power and engaging in political advocacy.  He also serves as the chairman of the Michigan Health and [inaudible].  Please welcome Mr. Fowler.

[ Applause ]

>> Thank you.  Great analysis.  You did good.  [Laughter]

>> Thank you.  Is the other shoe about to drop?

>> No, no, no.  So, maybe just a little bit about the Small Business Administration of Michigan maybe even where we've come at this a little perspective on where we typically are in this debate.  In fact, I remember a press conference at the very beginning when the governor actually sort of invited himself to a press conference that was already going to take place at the Hospital Association at Sparrow Hospital and we had already had a conversation with the governor's office and expressed to them that we would be supportive of Medicaid expansion and so I was also invited to that press conference.  And I remember standing there with, you know, the traditional press conference all these people standing up behind all the supporters of Medicaid expansion standing in a hospital it was maybe appropriate to remember when I was growing up sitting in a waiting room at a doctor's office there was always a magazine called Highlights, you all remember Highlights magazine, one of the puzzles was to look at a picture and figure out what doesn't belong.  [Laughter]  

Well, I figured it was me at that press conference.  The business voice in this group of supporters of Medicaid expansion actually was either me or Republican governor.  And in many ways I think a role that we had played throughout this whole thing has been a unique voice, an unusual argument in what is otherwise group of people who are advocating for either the poor of the health care system in general.  

Again, I should also say we did not support the Affordable Care Act, I'm on the board of our national association.  I started all of my testimony with we didn't support the Affordable Care Act.  It gave me a little bit of credibility I think with conservative legislators.  

So, and I often say, you know, I think people would think of us as a kind of right leaning organization.  We are strategically bipartisan, an important element I think even in this debate.  I think it gave us entre to both sides of the aisle that maybe other business organizations don't have, but you know I speak Tea Party fluently except for the crazy dialogue.  I don't really have that down pat, but you know, we tend to be an organization that relates to conservative policymakers.  I would say we had a partner in the State Chamber of Commerce also came along and supported 2 business organizations again that would traditionally be aligned with sort of conservative politics.  

I think that's important as we think about how this played out, but again, I think it's important to understand our interest in this issue and much like then Representative Mike Shirkey when we had to come to the sort of reality that the Affordable Care Act was the law of the land and what we needed to do was to figure out how to best play it out in the State of Michigan for our members and for others.  

So you may be aware of this.  There's something that's been happening, you know, if you're an advocate for small business in Michigan, we had been worried about the cost of health care for a very long time.  It's rising at a rate we simply can't sustain it, the cost of health insurance is how it manifest itself to our members as rising at a rate faster than any other business expense they have and they're trying to hold on to that benefit so they can attract and retain good employees but it's become so, so expensive.

So we've been talking about costs for a very long time.  In fact, we've been a student are what are the things that drive the cost of health care up.  And what we know is one of those things is the phenomenon of cost shifting.  People show up in our health care system and if they don't have coverage, they get care and that care is actually sort of absorbed by the health care system and passed along to paying customers.  

I joked with my friends at the hospital association all the time they talk about charity care.  Well, hospitals don't go out of business they literally pass it along and this is a, you know, this doesn't happen because it's the public policy.  Nobody said, you know, hospitals you can pass them along so much to your paying customers it's happened by default.  It's the only place when you squeeze this thing it can come out.  

So one of the drivers of the cost of health insurance today is uncompensated care that gets passed along to paying customers.  According to Kaiser, the family foundation, at least when this debate was going on it was about 14% of current premium are the result of uncompensated care or under compensated care.  

So, we knew this was a big issue and so if people were able to show up into our health care system with coverage, then we believe that those costs will not be passed along.  Now that's a big bet and frankly we have taken that bet, but maybe more importantly and I want to be careful about taking too much credit, I think we had an influence on Mike Shirkey in that whole debate.  I think Mike Shirkey was a former hospital board member and he understood this issue of cost shifting.  About what happens when people show up in our health system without coverage of any kind.  He saw it firsthand that those costs absolutely get passed along and if we could do anything about it he was in and as Ken has said the opportunity to sort of reform Medicaid at the same time really was what brought him to this table.  

So, we became one of the voices of the coalition and we testified both in the House and a couple of the hearings and in the Senate were part of the coalition.  As it went through, we were at press conferences when the governor was embarrassing Republican state senators for not voting when he was, you know, challenging them to take a vote not a vacation.  There was a really tough summer involved in this whole thing, but and I will tell you the vice president for government affairs for our organization today at the time was the Chief of Staff for the Senate Majority Leader.  And he said, and a former Senator and a former House Member, and he said it was the toughest, toughest issue he has ever, ever been involved in.  

Now I only say that to say we won it by 1 vote in the Senate.  The old saying in our business is you've got to have 56/20 and 1.  You have to have a majority in the House and Senate and you've got to have the Governor who will sign it.  This got 56/20 and 1.  And let me just foreshadow something that what I hope we don't have to do is go back to this same legislature, which is more conservative today than it was then.  More probably stridently ideological about this issue in particular than it was then.  And there are a couple of scenarios where we might actually have to go back to them.  So something I hope we'll talk about.

Again I think the hope for us is that it will affect cost.  And there's some follow up to be done.  If you put a $1.5 billion to $2 billion into our health care system from outside that would have otherwise been uncompensated, it ought to have an effect on the finances of a hospital and the finances of insurance companies, you know, to all providers and insurance companies.  

We believe that some of that needs to come back upstream to the payers and that is the hope and the promise and the reason that we got involved in this in the first place.  And so Dr. Ayanian's [phonetic] work of measurement of the impact and out of the outcomes of the Medicaid expansion is really going to be important in its sustained, our ability to sustain it.  

Let me just say one more thing and then, again, we can talk about this a little bit in the Q&A.  Michigan was one 1 of only 2 states actually that has a Republican House Senate and Republican Governor that passed Medicaid expansion.  So, while this is a blue state in presidential elections this is a red state in local politics and other states are watching what goes on here.  I was at a meeting at an organization called Grant Makers in Health with my health endowment fund hat on and I can tell you that there are a lot of other states watching us.  I've had a chance to talk to business organizations in other states about our arguments, about why we supported it.  And I think Michigan really will be a pivotal state in this whole thing.  I think if we begin to slide backwards I see other states going the same way and that's what's at stake here is really I think Michigan plays an absolutely critical role in the future of Medicaid expansion.  

>> Thank you.  We're off to a great start.  Our third speaker is Erin Knott.  She's the Michigan State Director for Enroll America, which is a national non-profit organization focused on maximizing the number of Americans who are enrolled in and retain health coverage.  She's an accomplished organizer who has dedicated over 15 years to working on legislative and public education and organizing strategies.

>> Thanks.

[ Applause ]

So I was saying to my friend Laura here that I feel like one of us doesn't belong on this panel and it's me because I don't have a stake on the policy side.  I mean in a previous career I did, but for the last 2 years almost I've been the implementer, the boots on the ground in communities across the State of Michigan.  And we're here today to talk about Healthy Michigan but for Enroll America we just started coming off and still kind of recovering from that second historic open enrollment period, which concluded in February and we're culminating all those lessons learned and applying it, you know, to special moment periods and Healthy Michigan and so it's been a wild ride, and I'd like to step back just to say at the conclusion of that second open enrollment period I think that Enroll America particularly in Michigan has emerged as a go-to organization that the uninsured we call consumers know that they can go to and eliminate the political rhetoric and just get the facts about their coverage options related to the Affordable Care Act.  

You know Republican, Democrat, it doesn't really matter what your political ideology is when you get cancer or when your kid falls in the parking lot, you know, and you don't have coverage.  And that's kind of how I approach folks across the state when we sit down and talk to them because there is so much baggage still associated with the Affordable Care Act but everybody has a family member, a neighbor, somebody that they worship with that had an unexpected illness and then they dealt with those kind of financial consequences that go along with not having coverage.  

So, again, we're the [inaudible] at Enroll America and how did we accomplish what we've done to date?  We celebrate hundreds of thousands of actual conversations with consumers talking about their options and then linking them to either in-person assistance or to other kind of avenues to obtain that coverage.  We've had just over 10,000 outreach and enrollment events here in Michigan.  Again, talking about whether it be Marketplace or Healthy Michigan and we're supported by over 5,600 volunteers right here in Michigan and those are folks that don't just do one event with us they are repeated volunteers that run our phone banks, that canvass with us that table and communities.  

We are a non-partisan, non-profit organization but we run very much like a political campaign utilizing the tactics that you would think about when you think about an electoral campaign.  We're very, very focused on data and analytics, and I want to talk briefly about our database real quick.  

We have a database that uses models and propensity scores that are way out of my pay grade and leave that helps us drill down and find the uninsured and so that helps us focus our work.  So instead of just blanketing a community and blindly door knocking, I can pull a list and say based on this propensity score these 4 homeowners on Grant Street we believe are uninsured and over 2 enrollment cycles and lots of work to update the model we now can separate Marketplace, uninsured eligible consumers and Healthy Michigan consumers, which again helps us focus our efforts.  We work with hundreds of partners across the state to get their information, contacts of consumers that they talk to.  

We have something called the commitment card that people fill out and kind of tell their story.  Again, the database is constantly being updated, which allows us to track consumers whether or not they're still uninsured, if they enrolled and now as we move forward whether or not they have utilized their coverage.

A couple more data points real quick to talk about before I kind of give a little bit of background about our experience.  I mentioned in-person assistance a few minutes ago.  In-person assistants are critical particularly for those hard to reach populations.  Folks that have never had health coverage before they don't understand it, heck, I don't understand my coverage that was just recently updated, right?  So, in-person assistants have been critical for African Americans, Latinos and young adults to kind of cut through that noise of what this means and we know that in-person assistance has resulted in consumers twice as likely to enroll when they're meeting with somebody face-to-face in their community.

We also know that repeated contacts with consumers was critical to the success of enrollment whether it be the Marketplace or Healthy Michigan.  Again, the most hard to reach kind of populations African Americans, Latinos and young adults respectively 4 contacts were needed to drive them out to the Marketplace or to Healthy Michigan.  

The legislature and the governor did, they did a great job.  We are 1 of those only red states that have Healthy Michigan or extended Medicaid, but it was a nightmare last year for us particularly at Enroll America because we were knee deep in the first open enrollment period and there was suddenly this appetite for coverage.  There was a ton of noise out there and people were wanting to enroll and we had to tell people that we believed to be eligible for Healthy Michigan you're out of luck.  Come back on April 1 because the legislature didn't pass immediate effect.  And so we tried to help those folks as best we could by capturing their information, putting them into a what we call a chase list contact on April 1, but it was a really difficult time to navigate, your friend got coverage and got financial assistance and has a quality plan now in March but you can't do anything until April 1.  

So my colleagues across the country took a break on March 31 when open enrollment closed we were ramping up for what was an explosion of another unknown like what's going to happen, what's the demand going to be for Healthy Michigan?  And I've got to say that the State of Michigan really got it right by taking some of the lessons learned from the tragic rollout of the Marketplace and putting systems in place on the upfront to troubleshoot, to respond to constituents in-person assistance groups like Enroll America about some of the snafus and we didn't see, you know, whether it was on the phone or on the web, any of those kind of problems that the Marketplace experienced particularly in October and November.  

A couple of more just kind of quick points.  It's great that we're high fiving each other that over 900,000 folks in Michigan have coverage now for the first time through the Affordable Care Act whether it's Marketplace or Healthy Michigan, but that doesn't necessarily make a community healthy.  Having that health insurance card I got my Blue Cross Blue Shield card in my pocket but that doesn't make me healthy.  So, at Enroll America particularly the team that I'm organizing here in Michigan we're working with hospitals and other providers to figure out how can we through our scope of service, which is again talking to consumers, help break down some of the obstacles that still exist to making communities healthy.  So there's lots of obstacles that I'm not going to go into but what I can do is take our field tactics, our database, our 5,600 volunteers and now start drilling into communities and funding those folks that have coverage and help them access their coverage finding a medical home.  

We know that it's just under 10% of consumers that have Healthy Michigan plans haven't completed their health risk assessment.  So, how do we engage them in the process of, you know, again establishing a medical home, you know, getting the services that they need so that they're not in the emergency room or that they're not going untreated.  

And the last point I'll make on that is to be continued we're doing a pilot project particularly in Southeast Michigan where we have kind of 2 brackets, 2 populations if you will.  We have the young adults.  I'm not sick so why in the world would I go to the doctor to get my health risk assessment, right?  And then you have folks that have lived in, you know, institutional poverty for decades and there's behaviors and patterns and we need to break those down.  So we're doing a pilot project at Enroll America in Southeast Michigan where we're going to use our database and drill down and find those folks, those 2 segments, and see if we can produce some outcomes where people are actually getting out of the emergency rooms and establishing medical homes.  Thanks.

>> Thanks.  Our next speak is Laura Appel.  She is Senior Vice President for Strategic Initiatives at the Michigan Health and Hospital Association, and she focuses on health care policy, hospital finance, legislation and governance and communications.  At the federal level she represents interest of Michigan hospitals and health systems in both the legislative and regulatory arenas on key issues including federal health reform and Medicare.  

>> Thank you.  I wanted to first respond to a couple of things that Ken Sikkema said.  I absolutely agree that we needed that conservative Republican lawmaker to help us get Healthy Michigan done, but I also think that it wouldn't have happened without then Senator Roger Kahn, who is also a physician who also nowhere near as conservative but definitely Republican, chaired appropriations in that [inaudible] Senate and a physician and he I think just decided we're doing this and that made a huge difference.

The other thing is I should have mentioned, I should have put this in my prepared remarks, but I'll start with it now, which is immediately following the Affordable Care Act, which some of my members, my members are pretty much described to people well who do you represent?  Everybody with an emergency department is my member.  So, if you've got, if you've ever been to an emergency room, you've probably been to somebody that's in my membership now.

And especially trinity and [inaudible] systems were hugely supportive of the Affordable Care Act.  It was extremely important to them from a mission perspective and about 2 weeks after the bill was signed into law, my policy department prepared a series of statistics and spreadsheets that showed just how much money every hospital was going to cough up to pay for this, which my Catholic members were not too excited about when they saw that in our lawmaker's offices, but over 10 years the first in over 10 years is that Michigan hospitals would forego $7 billion of Medicare reimbursement.  

So, yes, we had already paid at the office and we were very, very excited to get those people covered to perhaps earn some of that back and most importantly to get people organized about their health.  Last month the Center for Health Care Research and Transformation reported that they saw the number of people without health insurance go down by 50%.  We have some very good data about in-patient care.  Our data show that in the first 2 quarters of '14 that we had the plan, so April through October, we are seeing 50% fewer people presenting without any form of coverage.  So people are coming in with some kind of card even if it's a Medicaid card.

It's too early to tell you how this is going to specifically impact our costs of reimbursement, but I will unequivocally say and my state policy people have run some numbers this is absolutely reducing the shortfall between Medicaid costs and Medicaid payment for the majority of hospitals.  It is, it is raising all votes but some votes were under water to begin with and the reason for this is that in Michigan to finance Medicaid we are hugely dependent on provider taxes.  Michigan puts about the same, Dick Miles is here and you can probably tell us exactly, but we put almost the same amount of money in general fund into our Medicaid program as we did in the Year 2000 or 2002 and we had in Year 2000 or so about a million people covered and now we have 2.5 million people covered.  

Well, how did we do that with the same amount of money.  Certainly there's the federal money to support the expansion but the state doesn't have the match for an awful lot of money so hospitals pay taxes to do that.  We put up the state match and that works really well because it generates a lot of federal money.  The problem is under federal law that has to be redistributive.  Some hospitals must pay more in tax than they get back in Medicaid payments.  So, for those hospitals they have, they are living on the same amount of money that they had in 2002 or 2003 and they are way under water and continue to be.  Of course, they're also the ones who had the fewest amount of Medicaid originally.  

The other thing I would say is again reiterating this is making a huge difference in hospital finances.  The executive budget recommendation this year said, well, we see this is making a difference, you know, I can show you our estimate that as close as we're getting to covering costs we're not there yet so we're still losing money on every patient, which makes it hard to make it up for in volume, but the executive budget recommendation this year said for Fiscal Year 2016 since you guys are doing better than you were, we should take $92 million of general fund out of your support.  Well, it doesn't make a lot of sense to try and get us up to the place where we're going to help Rob's members and then yank it back down by about 10% of that.

And, of course, we can replace some of the provider taxes but I just mentioned that whenever I do this on a tax basis, I have to make somebody get less money back than they put in.  So, it's not a great long-term strategy.  The other point that I want to make is, and I hospitals know this and we're working on it.  We need to work on it but that is we're not very good at providing enough value for what people are paying whether it's a third party payout or a person with a high deductible or a person with a low deductible; our value needs to improve.  

And to call 900,000 people in Michigan but do it all the same way we've done it for the last 35 or 40 years, that is not an improvement.  We know there's overutilization in some places, we know there's a lot of preventable harm.  We're working really hard to try and identify that and end it but that really has to be part of what makes health care better in Michigan.  It's not simply getting people, you know, we can't line everybody up and give them a card and say this is it, you know, it's great now.  The same practice patterns or expenditures that we're making and the population was already insured, it did not lead to the best outcomes that we would like to see.  We can't just repeat that in this newly covered population.  We have to make changes and we have to do better and we have a long way to go on that.  We've come a long way but we still have a long way to go.  So that's my comment about my first [inaudible].

>> Thanks.  So our fifth and final speaker is Kim Sibilsky, who serves as the Chief Executive Officer in Michigan Primary Care Association; a role she has had since 1994.  In this role, this works on state and national health system development, planning strategies to improve access to care and working with public and private stakeholders to reduce all disparities in Michigan.  

>> Thank you very much.  Unlike Erin, I feel like I'm very much this panel.  I think almost on every front I'm a political geek kind of not to say that [inaudible] is a geek, but he is a geek, political.  We're major employers in the communities in which we reside and so I've always felt a strong alliance to Rob.  Certainly our folks were extremely involved in outreach and enrollment and I'll demonstrate that for you as I get into my prepared remarks and like Laura in the hospitals we're deep into provision of care, provision of uncompensated care and have great need actually to make this work I think.

So, health centers as I'm hoping a few of you know reserve approximately, we're moving towards 700,000 Michiganders today all of those in health professional shortage areas dramatically underserved areas.  So as beautiful as these garden spots are, they're not really usually the most economically viable types of places.  So 91.5% of our patients are at 200% of the poverty or below.  That was 91.5% 200 or below.  In the 100 to 200% range, which tends to be our target here, 21.6% of our patients are within that window.  Now that's not the exact window we're talking about but it sort of gets you close to this.  

These numbers I have to apologize are 2013 numbers.  They don't allow us to illustrate what [inaudible] has allowed us to do, but I think that it will give you a sense of how these folks are very much in the crosshairs of the work that we're talking about here.  Forty-four point seven percent of our patients prior to the Healthy Michigan plan were covered by Medicaid.  So almost half.  Thirty-one point four percent were uninsured.  So, in terms of the work that we needed to do as health centers in terms of outreach and enrollment we actually had a big in reach job and we projected that we would probably pull about 130,000 people through in reach.  

Our sense is we didn't do too poorly with those folks because even I called a number of our numbers of over the past few days to get a little better credibility behind my presentation, always a good idea I think as an association number.  One of our smaller health centers literally has converted 38,000 of their patients from uninsured into insured and what we see that being able to do for us is allows us to open up to more of the uninsured that we have not been able to take care of and that is the dynamic that we believe that we will begin to see more as time rolls on because providers are taking certain numbers of Healthy Michigan plan patients but our sense is they'll fill their ranks and some of their uninsured of private providers who have always taken a few, but if they can [inaudible] and sort of not, we believe that that's what we'll begin to see.  

So right now our uninsured rolls tend to be shrinking but as was the situation in Massachusetts when they were full coverage or almost as close as you can get community health centers still have 30 to 35% uninsured folks.  The other interesting thing is about 58% of our patients are between the ages of 18 to 64, which kind of has not always been a profile that we have had and that very much is the demographic that's being reached out to.  

So uninsured within that age frame we're kind of like the right folks to do the work in partnership with Erin's group, with Laura's group the stuff that Rob really chewed us on in terms of outreach and enrollment to make this grand experiment if you will work.

We had historic, well, since [inaudible] actually health centers have been recognized as being very competent in outreach enrollment.  We have received national attention for the outreach and enrollment work that we have done.  We took that work and we rolled it into the Marketplace where it [inaudible] and then we really had impetuous to move into Healthy Michigan plan enrollment.  

At the high point, we had 265 certified application counselors distributed throughout the some 260 sites that we have through in the State of Michigan.  At this point in time we're down to about 230 outreach and enrollment folks, which is extremely exciting for us because, one, we've still got work to do in terms of outreach enrollment, but the work that Erin talked about in terms of person to person advocacy and support these are people who are very much queued up for the new work that we have before us that focuses on community health workers and moving out into communities and helping to address the social determinants of health.  So we're very, very excited about that work.

So, what are our health centers seeing with these newly insured patients that they have been seeing and with the newly insured patients who have been going to the emergency rooms or not seeking care at all?  I think one of the things that Laura's [inaudible] done celebrating the things of this program you cannot transform a system and save immediately and to folks that we are seeing coming to care for chronic conditions that have not been treated ever or the people who have advanced breast cancer who were not diagnosed originally.  A number of my members said some of what you're seeing is really heartbreaking and it sure is not money saving.  These are folks that are starting to come to care and it will be a bolus of expenditure.  Hopefully at some point in time we'll be able to see that bolus start to level and healthier people and healthier communities.  That is certainly what you're looking for.

In terms of the objectives for Healthy Michigan plan, I think that it's really, really important from the political side that we recognize that some of the elements baked into these programs aren't bad things.  The health risk assessments wonderful things.  Actually helping people to become an even greater part of their own health care team, looking to have a little bit if you will personal responsibility.  I think it's critical for the success of the program, one, but also the political success of the program that we be able to advocate support and tout the victories that we are seeing and will be seeing in people completing those health risks assessments becoming a part of their own team and if you will for our Republican conservative friends and colleagues enjoying some of the results of that personal responsibility.  

In terms of the [inaudible], I can't speak to that personally.  I don't really see that as our health center personal responsibility, but I do think that we need to be able to speak in terms of successes across the board in order to try to create a political environment to be able to keep this operational.  

We have people coming to care, medical care, dental care, mental health and substance use services that have not received those services historically.  We can't help but ultimately see the fruit of all of our labor in healthier communities but that takes time and we don't save money right out of the box.

In closing what I want to say is, that I believe that if we really are going to impact the tripling quality costs and personal experience, we need to have the vast majority of our public covered.  We cannot take a state with 13 to 15% uninsured into a project like the statewide innovations model, plan implementation, SIM, and expect that we are going to start to really create change until we literally have a covered, one covered population, which we're getting awful darn close.  [Inaudible] around 93%?  I haven't, Matt is nodding his head, so I'm going to say 93% covered.  

It's not just the coverage it's the data that coverage allows us to start to have access to and only with accessible data that can be turned to information to help to drive change.  Will we see success in a massive undertaking like SIM?  Seventy million dollars to be expended over 4 years to help to move Michigan to the triple lane [phonetic].  I really think that we have got the additional piece, the [inaudible] and personal responsibility not to mention health.  I think we need to say that it's critical that we continue on this pathway in order to affect truly meaningful change in quality costs, patient experience, economic health for communities and a healthier state.  So, I'm writing it down for Senator Shirkey.  Thank you.  

[ Applause ]

>> Thank you to all of our speakers for their very insightful remarks and now we'll open it up to our students in Masters in Public Policy, Ruth McDonald and Megan Freedman to introduce the questions that we have from the audience.  

>> Thank you.  I'm Ruth McDonald, and I'm a student here at the Ford School of Public Policy and also a student at the School of Public Health getting a Master's in Public Health.  Thanks for being here.  Our first question is for those [inaudible] what has been your experience communicating with consumers about the cost sharing and health behavior and financial [inaudible]?  Are there any concerns about affordability for the patients?  We'll start with Kim for additional comments.  Thank you.

>> Yeah, my answer will be very brief.  Health centers provide health coverage.  No, health centers create access for folks without insurance by offering the possibility to do a financial review and get a sliding fee scale.  We had naively assumed that in an expanded coverage world our sliding fee scale would shift to the folks who are uninsured as we have [inaudible] directly.  What we are finding is a large number of folks who are under insured and as a result thanks to [inaudible] in the Department of Health and Human Services they have approved that we can utilize our sliding fee scale for those folks who are insured but cannot, can't cover their own financial participation.  To me that's a sign that we have affordability issues.

>> One of the things that frustrated me greatly during the entire debate about Healthy Michigan was everybody kept throwing up Arkansas and Arkansas is great, we love Arkansas.  Well, I worked on Medicaid Managed Care when John [inaudible] decided we were going to do it in 1996.  So, when Arkansas started thinking, well, we'll use major care it's been 17 years since we started it, and we had had co-pays and deductibles for most of that time.  We have a $50 first day, in-patient deductible and I would say that for the most part hospitals just don't collect it.  It's not collectible.  So it's basically a rate change for us, but I understand why those people, these are people who don't have anything especially at the population before we got to expansion.  

>> Excuse me just a couple of points.  During the first open enrollment period I published January, maybe early February of 2014, we had Enroll America shifted our message because we realized folks were taking the opportunity to enroll.  Again this is the Marketplace because they didn't understand the financial assistance was available.  These are all of our talking points was about financial assistance, you know, the conclusion of the second open enrollment period you know the 88% of those enrollees received some form of financial assistance and 68% of those folks got it for $100 or less; so a plan for $100 or less.

Sometimes the media talk about well that's the cost of my cell phone bill, but in reality it's still $100 it's still at times unaffordable for folks and so there's that point to make.  There's also the point that we're seeing after whether it's Healthy Michigan or 2 Marketplace enrollments consumers didn't understand what they purchased and they didn't read through the fine print to see that they had things such as co-pays or deductibles and that was a surprise to them.  

So we're trying to do better as folks renew next year to make sure that they understand what they're signing on to and a second point to that is this time around we saw substantially this is focused on the Marketplace but silver of the plans were no longer the most popular.  Well, I'm sorry that's misleading.  Silver plans we were getting feedback from those that were enrolling even with financial assistance were determined to be affordable for them and so they were opting to go with bronze plans that, you know, had $6,000 deductibles and up and so we have to work with folks to understand what the consequences could be to the choices that they're making they're trying to balance their monthly what's coming in now.  

>> Thank you.  My name is Megan Foster-Freedman.  I'm a first year's Masters of Public Policy student here at the Ford School and [inaudible] prevention [inaudible] wonderful insights.  This is a question from the audience talking about just, you know, the remarkable enrollment in Healthy Michigan as everyone has said it's really [inaudible] expectations.  Why was it so successful beyond predictions that were originally, you know, are we capturing most of the hard to reach population?  If so, [inaudible] and now do we ensure that people don't fall through cracks?  If Erin would like to get started?  

>> At the risk of sounding very negative I don't think it's great that we have 600,000 people that could qualify.  I mean we now have 25 of our population qualifies for Medicaid that's how many people are that low of an income.  When I talked earlier about we essentially doubled the number of people on Medicaid in roughly 10 years during the years of the 2000s, we made no changes to eligibility; that was all people just getting poorer and so to have, where are we compared to Marketplace about, are we at expected level of Marketplace enrollment or below?

>> Below.

>> Basically we thought people were going to belong in the Marketplace and they belong in Medicaid.  So, I think that's part of the reason.  I'm really glad we have.  I'm absolutely am glad we have it.  I'm kind of disappointed we don't have it a little more balanced.  I don't know if you guys wanted to say anything about that?

>> Well, I agree I don't, I described earlier I felt like this was the commercial where we just launched a website and they're watching, they get their first hit and another one and then it looks really great and then all of a sudden it's like, whoa, that's out of control.  I felt that way a little bit about Healthy Michigan and 605,000 is the number I think as of today.  And really I feel, you know, I feel its success as it relates to enrollment but like Laura I'm not sure that speaks well of the state and our economy.  Honestly my sense is the economy is getting better from where I sit we're certainly healing but I think it speaks to a lot of people who sort of dropped out of the economy all together and this is a way to measure that and it's not, that's not good news necessarily on some fronts.  

>> Sorry.  Okay, for those who supported the passage of the Healthy Michigan plan for cost reasons, we think that was one of the reasons of the support, what is your plan if the evaluation of the Healthy Michigan does not, evaluation binds that Healthy Michigan do not [inaudible] the cost curve and sort of on [inaudible] note.  As we heard the state is authorized to [inaudible] Medicaid Expansion 2017 if cost savings for the expansion can be found . Do you think the legislation will actually rescind at this point or what do you think is the real [inaudible]?  

>> If we can start with Ken for the state perspective?

>> [Inaudible] anywhere.  [Laughter]

>> Yes, one of the, I think selling points here in Michigan was that we're going to save money over time and it's sort of baked into the statute, you know, they're going to do these calculations and if that's not true then we pull the plug.  I'm not sure that's what will happen for a couple of reasons.  One is once you start something and it sort of gets ingrained in government it's hard to reverse course.  I mean I think that's been my experience.  
Now that doesn't mean that the people that put that in there are well intentioned and that it is certainly possible.  I think over time it's more likely that they will want to make changes to this.  I mean just, you know, this happened a year ago or 2 years ago and maybe it's not going to work. What do I mean by that?  Well, maybe the co-pays and the premium sharing from recipients I think the theory is that will help them take ownership and they'll get healthy because they don't want to spend the co-pay to go in the hospital or whatever and that'll be an incentive to, you know, for healthy behaviors.  Well, maybe it won't be.  So maybe there's a different way to structure Medicaid that will become apparent in 3 years and they'll want to make some changes.  So, I for one am somewhat circumspect about whether or not the lack of measurable cost savings to the Michigan taxpayer will mean the plug gets pulled over time when they will want to maybe make some other changes and maybe that will be the reaction.  Maybe they'll say, well, if we make changes X, Y and Z there will be cost savings.  

So I'm a little bit like I said circumspect whether that trigger would end the program.  I'm a little bit more certain that federal government and I'm going to say recalcitrants, you know, not approving the second waiver would have a better, bigger impact on having the program end, but that's just my opinion.  

>> Yeah, I, maybe a slightly different perspective.  I did a lot of arm twisting of Republicans during this debate and we tried very hard to stay on message.  This is about cost saving not to the state, it's not who I represent but to insurance premium payers in our state, the cost of health care again manifest itself as premiums for us and I feel will I'm very much out on a limb and I feel like I've taken some policymakers with me out on that limb and we've taken a policy bet that this will manifest itself as cost savings, bending the cost curve.  I'm not so naive to think it's really going to notch down but in a measureable way showing that instead of going on this trajectory it is lower.  

I think if that doesn't manifest then there will be some policymakers who are the champions from the conservative side who will rethink their position.  So, I think absolutely it's very difficult to take away a benefit that's been given but let me tell you, you hear all of this, this took on all the arguments of a welfare debate ending in 48 months having some skin in the game, personal responsibility, all those are arguments about welfare.  And so this really became to a lot of conservatives one of the basket of welfare things we provide to citizens.  

I get that; I actually tend to agree with that, that if it becomes too comfortable to not work, it becomes incentives to not do so.  I wouldn't start with health care, however, if I were going to pull back some sort of public benefits.  The access to health care actually becomes the nexus for a lot of other ability to make it to work and take care of your kids and that sort of thing.  So this isn't the place I would concentrate if I were going to try to pull back a little bit, but I think this is the most recent thing on the table and, therefore, it's vulnerable to being pulled back.  

>> We have time for 1 or 2 more questions.

>> Excellent.  All right.  I think we are going to pull on some Twitter here [inaudible] our friends on the Internet.  This one Twitter user wants to talk about as many of you have mentioned expanding coverage doesn't mean making people healthier.  So expanding coverage isn't always enough.  How do we accomplish improved practice patterns, reduce over utilization [inaudible] and I think I [inaudible] a tag on that too how do we encourage healthy behaviors and prevention in the populations that we're serving?

>> Nothing about world peace?

[ Laughter ]
You know there are perhaps within the health care community and Dr. Davis may want to speak about this.  For example, we are I would say partners on the over use of opioids and we have another, this is a collaborative that our hospitals will do the work [inaudible] will convene to work on over subscribing or, you know, to basically weed out the wrong practices around using opioids as part of an in-patient stay and after surgery.  

That is I don't know what number of collaborative we worked on improving care in the ICU eliminating urinary tract infections, safer surgeries, saver and better OB, you know, getting people, everybody to term, all kinds of stuff that we've been doing, but there's a lot of fatigue out there among the caregivers.  There are 900 measures, collaborators from the MHA, collaborators from or [inaudible], Blue Cross has their things.  As Dr. Joyce Lee [phonetic], who is from the University of Michigan said last week during the Detroit Chamber, you know, nobody got up and said I want to be a doctor so I can do really poor, sloppy care and maybe people won't feel so good at the end of it.  So nobody has got that goal but certainly, you know, bad things are happening to good people in our system and we're really working to improve that.

One thing that I commend to everybody because I read it every time I do one of these things is the busted health care myths from the Spring 2008 findings of the School of Public Health [inaudible].  You know a lot of the things that we want to do to improve care, you know, they're not going to really answer I think what Rob said earlier we need people to be in a better place and being, your inner section [phonetic] with the health care system is usually very brief, I hope it is.  I hope you only see your doc a couple of times a year for simple things like a flu shot and a physical maybe.  Even that's [inaudible].  But the other 363 days you're on your own and that's where the rubber really hits the road in terms of having a healthy population.  So, yeah, we've got a long way to go on preventable harm absolutely among all of those other things that were mentioned, but being healthy goes way beyond whether or not, you're not going to get healthy by being, we can cure people in an in-patient setting, but we can't keep them healthy because you're [inaudible].

>> Thank you.  Our final question and, Kim, I think you might be the first one to talk about this.  [Inaudible] clarify that Medicaid expansion also [inaudible] transitional way to care for transgender residents?  What will it take for Michigan to overcome this policy deficit for such a [inaudible] population in the state?

>> Would you just read that one more time, please?

>> Sure.  Several states have clarified that Medicaid also covers transition related care for transgender residents.  What will it take for Michigan [inaudible]?  

>> I got nothing.  I'm going to give this to Sikkema.  

[ Laughter ]

>> [Inaudible] I don't know what our policy is on that.

>> Well, right, and I mean it's going to be a wonderful, wonderful debate because it's my sense that the governor has staked himself out to not, to not sign a Religious Freedom Bill unless there is LGBT language within, and I always [inaudible] those bills --

>> -- Elliott Larson.

>> Elliott Larson, thank you.  At which point I think Mr. Shirkey, Senator, excuse me, Shirkey, has said he's going to [inaudible] forward.  So it's going to be a wonderful [inaudible].  I have no strong sense of how it will wrap up, but what I'll say is I do not take Senator Shirkey lightly.  I do not.  I have not seen will like his since Governor Angler and I pulled all the [inaudible] because he knew what he wanted and he would get it.  So I'm not sure that's an answer to that question but fundamentally speaking it will be dealt with I think politically before it gets dealt with in terms of coverage and care.

>> If I could offer just an observer's answer to the question when will Michigan do this?  I would say no time soon.  Again, if you look at the political makeup of our legislature that is just not on the drawing board in any significant way.  I would say Kim has rightly said that, you know, the Indiana religious freedom effort and Michigan's expansion Delegate Larson coming together isn't going to happen any time soon either.  I just think the political environment right now will suggest that doesn't get done.  

>> Well, but there's another, there's another issue there because as I understand the question it's using taxpayer dollars, Medicaid, to fund that transition, if I understood the question.  And regardless of how the Elliott Larson debate plays out or how the Religious Freedom Restoration Act debate plays out, I can't imagine this legislature or any legislature in the foreseeable future making the decision to use taxpayer money to fund that procedure because that's what you're asked about and you could add --

>> -- so they fund Viagra [phonetic]?

>> Exactly.

>> Well, I don't want to get in a debate with you.  I'm giving you a political --

>> -- I'm just wondering --

>> -- a political judgment about.  I mean you could add LGBT rights to the Elliott Larson's Civil Rights Act, you cannot pass Religious Freedom Restoration Act, but you still have that remaining issue.  So, that's why I agree with Rob.  I think it's important to put that, that's a wrinkle in that question that needs to be on the table that people need to understand I think.

>> Well, as we wrap up our policy talk for today, I first want to invite all of you to the reception the Ford School is hosting right in the great hall outside the hall here where we're meeting and we'll be in right after our session today.  I want to thank Dean Collins and Dr. Davis and [inaudible] Martin in the back for hosting us and organizing today's event here at the Ford School.  I want to thank our student questioners, Ruth and Megan, for moderating our discussion, and most of all I want to thank our 5 guests from across the state for sharing very thoughtful insights into the future of the Healthy Michigan plan here.  Thank you.

[ Applause ]