A good piece from Kaiser Health News and USA Today this week about Michigan’s Medicaid expansion plan offers some pointers for reporters covering healthcare reform in their states—but more than that, it offers a small lesson in the importance of independent outside sources when covering any new government policy
The article, by Phil Galewitz, focused on Michigan’s approach to expanding Medicaid: the state is taking federal funds to expand the program for low-income people, but it is requiring co-pays, along with premiums for residents above the federal poverty line—and then offering financial incentives to people who agree to an annual wellness assessment with their doctor and pledge to take steps to improve their health. The model brings together a couple fashionable features pushed by health policy wonks, designed to control costs while improving health: “skin in the game” and “personal responsibility.”
The problem is that it’s not entirely clear that requirements for skin in the game and personal responsibility work as they’re supposed to. Galewitz gets at that here:
Joan Alker, executive director of the Georgetown University Center for Children and Families, credits the state for using the “carrot approach over the stick approach,” but said there’s little evidence such incentives improve enrollees’ health.
“We know from the employer world, this is very hard to do,” she said.
She said the complexity will also make it harder for the state to implement the plan. “The legislation adds a lot of red tape,” she said.
It’s a small but useful bit of skepticism—and it was missing from a Detroit Free Press article on the Michigan’s Medicaid model that ran back in March, just before the expansion launched. That piece, by Robin Erb, was much more boosterish: “Michigan’s expanded Medicaid could be a model for other states,” read the headline. The gist was that while Medicaid expansion is a huge political fight in many states, Michigan had found an approach that could get bipartisan support while making poor people healthier and also keeping costs down—a win-win-win.
Maybe it will work out that way, but it’s notable that all the quotes supporting this hopeful story came from official stakeholders like the head of the state Department of Community Health (“The goal is simple… ‘Keep people out of the emergency room’”) and a regional official from the federal Centers for Medicare & Medicaid Services (“If other states decide to expand, they’ll be able to look at Michigan as a really good example of the way it can done”). There were no skeptical or independent voices to be found. (I don’t mean to pick too much on the Free Press, whose coverage of the Medicaid expansion was the most detailed I found among Michigan outlets in a web search, but it was no surprise state lawmakers liked the piece.)
The federal Medicaid official quoted by the Freep also said something about mirroring other health plans’ wellness programs. That would have been a good opportunity for follow-up, which would have revealed that the evidence about those programs is mixed. The California Health Benefits Review Program, which advises that state’s legislature about health mandates, reviewed the research in April 2013 and found that while workplace programs were helpful for quitting smoking and drinking less, “The preponderance of evidence from [randomized controlled trials] suggests that participating in work-based wellness programs does not lower the following risk factors for disease: blood pressure, blood sugar, or cholesterol.” The authors of a 2013 RAND Corp. study also found evidence of some improved behaviors and saw reasons to be optimistic that wellness programs could control costs, but did “not detect statistically significant decreases in cost and use of emergency department and hospital care”—the big-ticket services Medicaid directors would like to trim. Motivation seems to be key to success, and just how states plan to keep Medicaid recipients motivated to participate and follow through on those pledges is something reporters might probe.
Incentive programs and higher levels of cost-sharing are becoming more common throughout the healthcare system, of course—not just in Medicaid—which means that they’re important to cover. More and more data will be showing up about how effective they actually are. Not every reporter has the time to dig into that research, but there are plenty of independent experts who do. Bringing their voices into the mix, and offering some skepticism of official pronouncements, is important.
The broader point: Too often, a string of quotes from government officials touting how great a new program is substitutes for reporting that takes a closer look. When an official tells you how great something is, check it out.