If you need health care in rural Michigan, and you don't have insurance or money, you can turn to a free clinic -- like the one University of Michigan medical students run each Saturday in the tiny town of Pinckney.
Fewer people need this kind of help these days, because of new insurance options made possible by the Affordable Care Act.
But hundreds of people still rely on free primary care from the students and the U-M doctors who volunteer with them, because they still lack health insurance.
Why so many? The students decided to find out. In a new paper, they report that the main barriers to coverage lie in perceived cost, and a knowledge gap about who is eligible for low-cost plans or programs to help pay for coverage.
The findings have already prompted several of the students to get certified to counsel patients about their insurance options under the ACA, in hope that personalized attention will help. They hope their research will prompt other safety net clinics to do the same, and overcome barriers to insurance so more people can get the coverage, tax credits and subsidies they're eligible for.
The students, and one of the Medical School professors who volunteers at the U-M Student-Run Free Clinic, have just published their findings from in-depth surveys of 80 patients treated this year in the Journal of Community Health. It's the first time this type of study has been done in a state that expanded Medicaid under the ACA; Michigan's program is called the Healthy Michigan Plan.
Eligible but not enrolled
"Almost everyone we see in our clinic should have an option for low- or reduced-cost insurance under the ACA," says Brian Desmond, the first author of the paper and a second-year medical student. "In all, 57 percent of the patients we surveyed were eligible for the Healthy Michigan Plan or Medicaid based on income, but only 35 percent of those eligible had actively applied in the last six months."
Most of those who hadn't applied said they thought they weren't eligible, or that it would cost too much. Though the Healthy Michigan Plan does include modest cost-sharing for participants above the poverty level, the program is free for most residents - including those who previously couldn't qualify for Medicaid.
Of the patients in the study whose incomes were too high for Medicaid or the Healthy Michigan Plan -- above 138 percent of the poverty level -- most said that the cost of private insurance was what kept them from getting insured. Many had actually shopped for such coverage on the Healthcare.gov marketplace, but had not bought it because of premium or deductible costs.
When the students looked at these patients' situations further, they found that all but one would have qualified for tax credits to help cut their monthly premium costs. This finding parallels a national survey by the Robert Wood Johnson Foundation that showed that many uninsured people are confused about, or have not heard of, federal tax credits to reduce premiums.
Eighty percent of the patients had jobs, and most were in their 40s and 50s. Only 18 percent had had health insurance within the last two years, and 40 percent had been uninsured for over 10 years. A quarter of respondents hadn't seen a doctor in more than a year before coming to the clinic for care, and 8 percent hadn't seen one in more than five years.
Most of those who said they were not actively seeking health insurance qualified for the Healthy Michigan Plan - suggesting that they had assumed no program was open to them. The students didn't ask about immigration status; some undocumented immigrants aren't eligible for ACA plans.
Turning research results into action
Starting this Saturday, the U-M Student Run Free Clinic will offer insurance counseling appointments every week, by students trained as Certified Application Counselors and fully versed in ACA insurance options and supports. Medical students Katherine He and Emily Arntson have led the clinic's drive to provide this service.
It's a timely new service. For those making more than 138 percent of the poverty level, an Open Enrollment period started November 1 for private ACA insurance plans, offering coverage that starts January 1, 2016.
As part of counseling, the students will help patients understand the tax credits available to them, and the tax penalty for being uninsured. Desmond notes that while many patients shopping on healthcare.gov look at the monthly premium costs or deductibles that private plans have, they may not realize that the tax penalty is growing year by year - nor that they can qualify for tax credits, and that certain preventive services are free under all plans.
For those who qualify for the Healthy Michigan Plan, enrollment is always open. More than 568,000 Michiganders are in it, including 5,000 in Livingston County, where the student clinic is.
"Despite the fact that the Healthy Michigan Plan has exceeded expectations for enrollment, our study shows there are people who still could qualify for it and benefit from it," says Desmond. "And because the equation for private plan costs, and the tax penalties for remaining uninsured, change every year, such plans are worth reinvestigating for those ineligible for other programs."
The professor who guided the research notes that it was entirely designed and carried out by students. "This provided a great opportunity for them to learn about the root causes of uninsurance under the ACA, and what can be done about it," says Brent Williams, M.D., MPH, senior author and an associate professor in the Division of General Medicine of the Department of Internal Medicine. "The challenges of getting patients good information -- and the complexities of eligibility, tax credits, and what is affordable in the context of patients' lives -- were evident to the students." Williams is a member of the U-M Institute for Healthcare Policy and Innovation.
University of Michigan Health System