Academic Publications

IHPI Member Publications on Medicaid Expansion in Michigan
 

Employment Status and Health Characteristics of Medicaid Expansion Enrollees

Patel, M.R., Clark, S.J., Beathard, E., Kirch, M., Box, N., Tipirneni, R., Ayanian, J.Z., Goold, S.D. (2025). Employment and health burden changes among Medicaid expansion enrollees. JAMA Health Forum, 6(10), e254639.

• Employment gains from 2016 to 2018 were observed across health burden levels: 18.9% to 32.2% for substantial, 43.1% to 54.1% for moderate, and 57.9% to 67.5% for minimal health burden.
• Beneficiaries with substantial or moderate health burden at baseline whose health improved at follow-up demonstrated the largest employment gains.

Tipirneni, R., Kieffer, E.C., Ayanian, J.Z., Patel, M.R., Kirch, M.A., Luster, J.E., Karmakar, M., Goold, S.D. (2022). Longitudinal trends in enrollees’ employment and student status after Medicaid expansion. BMC Health Services Research, 22.

• There was a significant increase in employment or student status among enrollees in Michigan’s Medicaid expansion program, from 54.5 percent in 2016 to 61.4 percent in 2018, including among those with a chronic condition or mental health/substance use disorder. 
• In contrast, the statewide proportion of low-income non-elderly adults who were employed or students did not change significantly.
• Medicaid expansion, absent a community engagement requirement, was associated with increased employment and related activities.

Tipirneni, R., Ayanian, J.Z., Patel, M.R., Kieffer, E.C., Kirch, M.A., Bryant, C., Kullgren, J.T, Clark, S.J., Lee, S., Solway, E., Chang, T., Haggins, A.N., Luster, J., Beathard, E., Goold, S.D. (2020). Association of Medicaid expansion with enrollee employment and student status in Michigan. JAMA Network Open, 3(1), e1920316.

• Employment or student status increased from 2016 to 2017 among Michigan Medicaid expansion enrollees. Non-Hispanic black enrollees had significantly larger gains in employment or student status compared with non-Hispanic white enrollees. Changes in employment or student status were not associated with improved health status.

Tipirneni, R., Patel, M.R., Goold, S.D., Kieffer, E.C., Ayanian, J.Z., Clark, S.J., Lee, S., Bryant, C., Kirch, M.A., Solway, E., Luster, J., Lewallen, M. Zivin, K. (2020). Association of expanded Medicaid coverage with health and job-related outcomes among enrollees with behavioral health disorders. Psychiatric Services, 71(1), 4-11.

• Enrollees with behavioral health diagnoses were less likely than enrollees without behavioral health diagnoses to be employed but significantly more likely to report improvements in health and ability to do a better job at work.

Tipirneni, R., Kullgren, J.T., Ayanian, J.Z., Kieffer, E. C., Rosland, A-M., Chang, T., Haggins, A.N., Clark, S.J., Lee, S., Solway, E., Kirch, M.A., Mrukowicz, C., Beathard, E., Sears, E., Goold, S.D. (2019). Changes in health and ability to work among Medicaid expansion enrollees: a mixed methods study. Journal of General Internal Medicine, 34(2), 272-280.  

• Many HMP enrollees reported improved health, ability to work, and job seeking after health insurance through Medicaid expansion. However, some enrollees faced persistent barriers to employment such as poor health, disability, caregiving responsibilities, and older age.

Tipirneni, R., Goold, S.D., Ayanian, J.Z. (2018). Employment status and health characteristics of adults with expanded Medicaid coverage in Michigan. JAMA Internal Medicine, 178(4), 564-567.

• Nearly half of enrollees in the Healthy Michigan Plan reported being employed or self-employed full or part-time.
• About one in four enrollees said they were out of work. About one in ten enrollees said they were unable to work. Most of those unable to work reported significant barriers to employment. such as poor health, chronic conditions, older age, or functional limitations.

Impact of Medicaid Expansion on Health

Su-En Lee, M., Beathard, E., Kirch, M., Solway, E., Lewallen, M., Tipirneni, R., Patel, M., Rowe, Z., Goold, S.D. (2021). Self-reported health status improved for racial and ethnic minority groups after Michigan Medicaid expansion. Health Affairs, 40(10), 1637-1643.

• More than 90 percent of respondents of all racial and ethnic groups reported having a regular source of care after HMP enrollment compared with 74.4 percent before enrollment. Respondents who identified as non-Hispanic White, African American, and Hispanic reported improvements in health status after HMP enrollment.

Kieffer, E.C., Goold, S.D., Buchmueller, T., Nalliah, R., Beathard, E., Kirch, M.A., Solway, E., Tipirneni, R., Clark, S.J., Haggins, A.N., Patel, M.R., Ayanian, J.Z. (2021). Beneficiaries' perspectives on improved oral health and its mediators after Medicaid expansion in Michigan: a mixed methods study. Journal of Public Health Dentistry, 1-11.

• Three in five surveyed enrollees had at least one dental visit and two in five surveyed enrollees reported improved oral health since enrolling in HMP. Enrollees reporting improved oral health were more likely to report improved job seeking and job performance due to HMP. 
• Interviewees described previously unmet oral health needs and treatments that improved oral health, functioning, appearance, confidence, and employability.

Patel, M.R., Tipirneni, R., Kieffer, E.C., Kullgren, J.T., Ayanian, J.Z., Chang, T., Solway, E., Beathard, E., Kirch, M., Lee, S., Clark, S., Skillicorn, J., Rowe, Z., Goold, S.D. (2020). Examination of changes in health status among Michigan Medicaid expansion enrollees from 2016 to 2017. JAMA Network Open, 3(7), e208776.

• Reports of fair or poor health and days of poor physical health decreased over time among enrollees, especially among non-Hispanic black enrollees and those with very low incomes. There were no statistically significant differences in the number of days of poor mental health or the number of days of usual activities missed owing to poor physical or mental health over time.

Goold, S.D., Tipirneni, R., Chang T., Kirch, M.A., Bryant, C., Rowe, Z., Beathard, E., Solway, E., Lee, S., Clark, S.J., Skillicorn, J., Ayanian, J.Z., Kullgren, J.T. (2020). Primary care, health promotion, and disease prevention with Michigan Medicaid expansion. Journal of General Internal Medicine, 35(3), 800-807.

• After enrolling in Michigan’s Medicaid expansion program, beneficiaries reported less forgone care and improved access to primary care and prevention services.

Rosland, A-M., Kieffer, E.C., Tipirneni, R., Kullgren, J.T., Kirch, M., Arntson, E.K., Clark, S.J., Lee, S., Solway, E., Beathard, E., Ayanian, J.Z., Goold, S.J. (2019). Diagnosis and care of chronic health conditions among Medicaid expansion enrollees: A mixed-methods observational study. Journal of General Internal Medicine, 34(11), 2549-2558.

• Enrollees with expanded Medicaid coverage commonly reported detection of previously undiagnosed chronic conditions. Perceived health status and access improved more often among enrollees with chronic health conditions. Improved access was associated with improved physical and mental health.

Utilization and Experiences of Telehealth Among Medicaid Expansion Enrollees

Liu, T., Box, N., Kirch, M., Anthony, D., Ayanian, J.Z., Patel, M.R., Clark, S.J., Goold, S.D. (2025). Utilization and patient experiences of telehealth among Medicaid expansion enrollees. Health Affairs Scholar, 3(5), qxaf060.

• Approximately one in three enrollees reported a telehealth visit within the past year. Individuals reporting barriers to primary care were more likely to have had a telehealth visit compared with those reporting no barriers to primary care.
• Among those who had a telehealth visit, most individuals reported that telehealth provided care they could not or would not otherwise receive (63.3%) and were satisfied with telehealth adequately addressing their health concerns (92.1%).

Experiences with Health Risk Assessments

Zhang, E., Tipirneni, R., Beathard, E., Lee, S., Kirch, M.A., Salman, C., Solway, E., Clark, S. J., Haggins, A.N., Kieffer, E.C., Ayanian, J.Z., Goold, S.D. (2020). Health Risk Assessments in Michigan's Medicaid expansion: Early experiences in primary care. American Journal of Preventive Medicine, 58(3), e79-e86.   

• Early in program implementation, health risk assessment (HRA) completion rates by primary care providers were low and awareness of financial incentives limited. Most primary care providers perceived HRAs to be very or somewhat useful in identifying health risks, and about half viewed HRAs as very or somewhat useful in helping patients to change health behaviors.

Kelley, A.T., Goold, S.D., Ayanian, J.Z., Patel, M., Zhang, E., Beathard, E., Chang, T., Solway, E., Tipirneni, R. (2020). Engagement with Health Risk Assessments and commitment to healthy behaviors in Michigan’s Medicaid expansion program. Journal of General Internal Medicine, 35(2), 514-522.

• Primary care providers appeared influential in enrollee’s completion of HRAs and healthy behavior engagement, though knowledge of financial incentives was limited.

Cost-Sharing Among Medicaid Expansion Enrollees

Cliff, B.Q., Hirth, R.A., Ayanian, J.Z. (2022). Enrollee Premiums in Medicaid — Insights from Michigan. New England Journal of Medicine, 386(25), 2352-2354.

Cliff, B.Q., Miller, S., Kullgren, J.T., Ayanian, J.Z., Hirth, R. (2022). Adverse selection in Medicaid: Evidence from discontinuous program rules. American Journal of Health Economics, 8(1), 127-150.

Cliff, B.Q., Miller, S., Kullgren, J.T., Ayanian, J.Z., Hirth, R. (2021). Adverse selection in Medicaid: Evidence from discontinuous program rules. NBER Working Paper No. 28762.

• Disenrollment increased by 2.3 percentage points among enrollees with household incomes over the federal poverty level. Increased disenrollment occurred among enrollees with fewer documented medical needs at baseline but not among those with greater medical needs.

Hirth, R.A., Cliff, B.Q., Kullgren, J.T., Ayanian, J.Z. (2021). Cost-sharing with Medicaid expansion in Michigan: Obligations and propensity to pay. Medical Care, 59(9), 785-788.

• About half of enrollees with cost-sharing obligations made at least partial payments, with payments more likely among those >100% FPL. Payment of the full obligation was highest in the initial 6 months.

Economic Effects of Medicaid Expansion in Michigan

Becker, N.V., Levy, H., Hirth, R.A., Clark, S.J., Tipirneni, R., Ayanian, J.Z. (2026). Financial outcomes among Medicaid expansion enrollees. JAMA Network Open, 9(4), e269328. 

• Medicaid expansion enrollees in Michigan experienced significant reductions in medical debt in collections and rates of subprime credit score after enrollment.

Levy, H., Ayanian, J.Z., Buchmueller, T.C., Grimes, D.R., Ehrlich, G. (2020). Macroeconomic feedback effects of Medicaid expansion: Evidence from Michigan. Journal of Health Politics, Policy and Law, 45(1), 5-48.

• Medicaid expansion in Michigan yields clear fiscal benefits for the state, in the form of savings on other non-Medicaid health programs and increases in revenue from provider taxes and broad-based sales and income taxes through at least 2021. These benefits exceed the state's costs in every year.

Miller, S., Hu, L., Kaestner, R., Mazumder, B., Wong, A. (2018). The ACA Medicaid expansion in Michigan and financial health. NBER Working Paper No. 25053.

• Enrollment in the Healthy Michigan Plan was associated with large improvements in several measures of financial health, including reductions in unpaid bills, medical bills, over limit credit card spending, delinquencies, and public records (such as evictions, judgments, and bankruptcies). These benefits were apparent across several subgroups, although individuals with greater medical need, such as those with chronic illnesses, experience the largest improvements.

Ayanian, J.Z., Ehrlich, G.M., Grimes, D.R., Levy, H. (2017). Economic effects of Medicaid expansion in Michigan. New England Journal of Medicine, 376(5), 407-410.

• Additional employment associated with federal Medicaid expansion spending peaked at over 39,000 jobs in 2016 and is projected to support approximately 30,000 jobs in 2021.
• Increased personal income associated with new employment in Michigan is expected to be relatively stable, at $2.2 billion to 2.4 billion per year.
• Added economic activity is projected to yield $145-$153 million/year in new state tax revenue.

Primary Care Provider Views and Experiences

Tipirneni, R., Kieffer, E.C., Ayanian, J.Z., Campbell, E.G., Salman, C., Clark, S.J., Chang, T., Haggins, A.N., Solway, E., Kirch, M.A., Goold, S.D. (2019). Factors influencing primary care providers’ decisions to accept new Medicaid patients under Michigan’s Medicaid expansion. American Journal of Managed Care, 25(3), 294-301.

• A majority of PCPs surveyed reported accepting additional Medicaid patients after Medicaid expansion in Michigan. Factors considered important in the decision to accept new Medicaid patients included practice capacity to accept any new patients, availability of specialists for Medicaid patients, reimbursement, psychosocial needs of Medicaid patients, and illness burden of Medicaid patients.

Tipirneni, R., Patel, M.R., Kirch, M.A., Goold., S.D. (2018). Cost conversations between primary care providers and patients with expanded Medicaid coverage. Journal of General Internal Medicine, 33(11), 1845-1847.

• One in five PCPs reported conversations about out-of-pocket medical costs with low-income Medicaid patients. Half of PCPs who had cost conversations reported a resulting change in management, attesting to the value of such conversations for patient-centered care for patients with Medicaid.

Goold, S.D., Tipirneni, R., Kieffer, E., Haggins, A., Salman, C., Solway, E., Szymecko, L., Chang, T., Rowe, Z., Clark, S., Lee, S., Campbell, E.G., Ayanian, J.Z. (2018). Primary care clinicians’ views about the impact of Medicaid expansion in Michigan: A mixed methods study. Journal of General Internal Medicine, 33(8), 1307-1316.

• PCPs reported improved patient access to care, medication adherence, chronic condition management, and detection of serious illness. Established patients' access did not diminish, possibly due to reported practice changes.

Medicaid Acceptance and Appointment Availability in Primary Care Practices

Tipirneni, R., Rhodes, K.V., Hayward, R.A., Lichtenstein, R.L., Choi, H., Arntson, E.K., Landgraf, J.M., Davis, M.M. (2018). Geographic variation in Medicaid acceptance across Michigan primary care practices in the era of the Affordable Care Act. Medical Care Research and Review, 75(5), 633–650.

• Geographic regions with lower baseline (<50%) Medicaid acceptance had significant increases in Medicaid acceptance at 4 and 8 months post-expansion, while regions with higher baseline (≥50%) Medicaid acceptance did not experience significant changes in Medicaid acceptance.

Tipirneni, R., Rhodes, K.V., Hayward, R.A., Lichtenstein, R.L., Choi, H., Reamer, E.N., Davis, M.M. (2016). Primary care appointment availability, wait times, and the importance of non-physician providers during the first year of Medicaid expansion under the Affordable Care Act. American Journal of Managed Care, 22(6), 427-431.

• Medicaid appointment availability that had increased at 4 months remained increased 1 year after expansion.
• More appointments were scheduled with non-physician providers over time.

Tipirneni, R., Rhodes, K.V., Hayward, R.A., Lichtenstein, R.L., Reamer, E.N., Davis, M.M. (2015). Primary care appointment availability for new Medicaid patients increased after Medicaid expansion in Michigan. Health Affairs, 34(8), 1399-1406.

• Appointment availability increased 6 percentage points for new Medicaid patients and decreased 2 percentage points for new privately insured patients following Medicaid expansion.
• Wait times remained stable at 1–2 weeks for both groups.

Changes in Insurance Coverage Among Hospitalized Non-Elderly Adults

Davis, M.M., Gebremariam, A., Ayanian, J.Z. (2016). Changes in insurance coverage among hospitalized non-elderly adults after Medicaid expansion in Michigan. Journal of the American Medical Association, 315(23), 2617-2618.

• With implementation of the Healthy Michigan Plan, the proportion of hospitalized non-elderly adult patients who were uninsured decreased 4 percentage points and the proportion with Medicaid coverage increased 6 percentage points.

Impact of Medicaid Expansion on Access to Family Planning Services

Moniz, M., Kirch, M.A., Solway, E., Goold, S., Ayanian, J.Z., Kieffer, E.C., Clark, S.J., Tipirneni, R., Kullgren, J.T., Chang, T. (2018). Association of access to family planning services with Medicaid expansion among female enrollees in Michigan. JAMA Network Open, 1(4), e181627.

• One-third of women of reproductive age reported better ability to access birth control and family planning services through HMP compared with before enrollment. This suggests that Medicaid expansion is associated with improved access to family planning services, which may enable low-income women to maintain optimal reproductive health.

Impact of Medicaid Expansion on Cardiac Surgery Volume and Outcomes

Likosky, D.S., Sukul, D., Seth, M., He, C., Gurm, H.S., Prager, R.L. (2018). Association between Medicaid expansion and cardiovascular interventions in Michigan. Journal of the American College of Cardiology, 71(9), 1050-1051.

• Medicaid expansion in Michigan was associated with increased access (volume of services) and equivalent quality for patients receiving cardiovascular revascularization.

Charles, E.J., Johnston, L.E., Herbert, M.A., Mehaffey, J.H., Yount, K.W., Likosky, D.S., Theurer, P.F., Fonner, C.E., Rich, J.B., Speir, A.M., Ailawadi, G., Prager, R.L., Kron, I.L. (2017). Impact of Medicaid expansion on cardiac surgery volume and outcomes. Annals of Thoracic Surgery, 104(4), 1251-1258.

• Medicaid expansion in Michigan as compared to Virginia, a nonexpansion state, was associated with fewer uninsured cardiac surgery patients and improved predicted risk scores and morbidity rates.

Michigan’s Approach to Medicaid Expansion and Reform

Ayanian, J.Z., Clark, S.J., Tipirneni, R. (2014). Launching the Healthy Michigan Plan – The first 100 days. New England Journal of Medicine, 371(17), 1573-1575.

• The Healthy Michigan Plan launched on April 1, 2014 and reached its projected enrollment for 2014 within the first 100 days. Several factors contributed to rapid early enrollment.
• Outlines policy questions that Michigan is addressing that may also be relevant to other states that have expanded Medicaid or are considering doing so.

Ayanian, J.Z., (2013). Michigan’s approach to Medicaid expansion and reform. New England Journal of Medicine, 369(19), 1773-1775.

• By linking Michigan’s Medicaid expansion to market-oriented changes to the program, the governor and legislature created a pragmatic path to link Republican and Democratic health care priorities.
• Outlines five core principles in Michigan’s approach to expand Medicaid under the ACA, including: 1) the state must achieve sufficient savings to offset its contributions for the Medicaid expansion when federal funding drops; 2) financial incentives for program enrollees to control their use of health care services and maintain healthy behaviors; 3) use of Medicaid managed care plans rather than fee-for-service; 4) requirement that enrollees have access to primary care and preventive services; and 5) opportunities to enhance the state’s capacity to monitor the costs and quality of health care.

IHPI Member Publications on Medicaid Expansion Nationally

Christine, P.J., Tipirneni, R. (2020). Substance use disorder treatment availability among states considering Medicaid work requirements. Journal of General Internal Medicine.

Buchmueller, T.C., Levy, H.G., Valletta, R.G. (2019). Medicaid expansion and the unemployed. NBER Working Paper No. 26553.

Miller, S., Altekruse, S., Johnson, N., Wherry, L. (2019). Medicaid and mortality: New evidence from linked survey and administrative data. NBER Working Paper No. 26081.

Mahmoud, E., Cohen, A., Buxbaum, J., Richardson, C.R., Tarraf, W. (2018). Gaining Medicaid coverage during ACA implementation: Effects on access to care and preventive services. Journal of Health Care for the Poor and Underserved, 29(4), 1472-1487.

Levine, D.A., Burke, J.F., Shannon, C.F., Reale, B.K., Chen, L.M. (2018). Association of medication nonadherence among adult survivors of stroke after implementation of the US Affordable Care Act. JAMA Neurology, 75(12), 1538-1541. 

Ayanian, J.Z., Tipirneni, R., Goold, S.D. (2018). Mitigating the risks of Medicaid work requirements. New England Journal of Medicine, 379(9), 803-805.

Miller, S., Wherry, L.R. (2017). Health and access to care during the first 2 years of the ACA Medicaid expansions. New England Journal of Medicine, 376(10), 947-956.

Nikpay, S., Freedman, S., Levy, H., Buchmueller, T. (2017). Effect of the Affordable Care Act Medicaid expansion on emergency department visits: Evidence from state-level emergency department databases. Annals of Emergency Medicine, 70(2), 215-225.

Desmond, B.S., Laux, M.A., Levin, C.C., Huang, J., Williams, B.C. (2016). Reasons why individuals remain uninsured under the Affordable Care Act: Experiences of patients at a student-run free clinic in Michigan, a Medicaid expansion state. Journal of Community Health, 41(2), 417-423.

Hu, L., Kaestner, R., Mazumder, B., Miller, S., Wong, A. (2016). The effect of the Patient Protection and Affordable Care Act Medicaid expansions on financial well-being. NBER Working Paper No. 22170.

Kullgren, J. T. (2016). Injecting facts into the heated debates over Medicaid expansion. Annals of Internal Medicine, 164(12), 848-849.

Lipton, B. J., Wherry, L.R., Miller, S., Kenney, G.M., Decker, S. (2016). Previous Medicaid expansion may have had lasting positive effects on oral health of non-Hispanic black children. Health Affairs, 35(12), 2249-2258.

Nikpay, S., Buchmueller, T., Levy, H.G. (2016). Affordable care act Medicaid expansion reduced uninsured hospital stays in 2014. Health Affairs, 35(1), 106-110.

Wherry, L.R., Miller, S. (2016). Early coverage, access, utilization, and health effects associated with the Affordable Care Act Medicaid expansions. Annals of Internal Medicine, 164(12), 795-803.

Giladi, A.M., Aliu, O., Chung, K.C. (2015). The effect of Medicaid expansion on delivery of finger and thumb replantation care to Medicaid beneficiaries and the uninsured. Plastic and Reconstructive Surgery, 138(5), 640e-647e.

Giladi, A.M., Chung, K.C., Aliu, O. (2015). Changes in use of autologous and prosthetic postmastectomy reconstruction after Medicaid expansion in New York State. Plastic and Reconstructive Surgery, 135(1), 53-62.

Nikpay, S., Buchmueller, T., Levy, H. (2015). Early Medicaid expansion in Connecticut stemmed the growth in hospital uncompensated care. Health Affairs, 34(7), 1170-1179.

Aliu, O., Auger, K.A., Sun, G.H., Burke, J.F., Cooke, C.R., Chung, K.C., Hayward, R. A. (2014). The effect of pre-Affordable Care Act (ACA) Medicaid eligibility expansion in New York State on access to specialty surgical care. Medical Care, 52(9), 790-795.

Giladi, A.M., Aliu, O., Chung, K.C. (2014). The effect of Medicaid expansion in new york state on use of subspecialty surgical procedures by Medicaid beneficiaries and the uninsured. Journal of the American College of Surgeons, 218(5), 889-897.

Jones, D.K., Singer, P.M., Ayanian, J.Z. (2014). The changing landscape of Medicaid practical and political considerations for expansion. Journal of the American Medical Association, 311(19), 1964-1966.

Waits, S.A., Reames, B.N., Sheetz, K.H., Englesbe, M.J., Campbell, D.A. (2014). Anticipating the effects of Medicaid expansion on surgery care. JAMA Surgery, 149(7), 745-747.

Lyon, S.M., Douglas, I.S., Cooke, C.R. (2014). Medicaid expansion under the affordable care act: Implications for insurance-related disparities in pulmonary, critical care, and sleep. Annals of the American Thoracic Society, 11(4), 661-667.

Chang, T., Davis, M.M. (2013). Potential adult Medicaid beneficiaries under the patient protection and Affordable Care Act compared with current adult Medicaid beneficiaries. Annals of Family Medicine, 11(5), 406-411.