Journal of General Internal Medicine

, Volume 33, Issue 8, pp 1307–1316 | Cite as

Primary Care Clinicians’ Views About the Impact of Medicaid Expansion in Michigan: A Mixed Methods Study

  • Susan Dorr GooldEmail author
  • Renuka Tipirneni
  • Edith Kieffer
  • Adrianne Haggins
  • Cengiz Salman
  • Erica Solway
  • Lisa Szymecko
  • Tammy Chang
  • Zachary Rowe
  • Sarah Clark
  • Sunghee Lee
  • Eric G. Campbell
  • John Z. Ayanian
Original Research



Michigan’s approach to Medicaid expansion, the Healthy Michigan Plan (HMP), emphasizes primary care, prevention, and incentives for patients and primary care practitioners (PCPs).


Assess PCPs’ perspectives about the impact of HMP on their patients and practices.


In 2014–2015, we conducted semi-structured interviews then a statewide survey of PCPs.


Interviewees came from varied types of practices in five Michigan regions selected for racial/ethnic diversity and a mix of rural and urban settings. Surveys were sent via mail.


Interviewees were physician (n = 16) and non-physician practitioners (n = 3). All Michigan PCPs caring for ≥ 12 HMP enrollees were surveyed (response rate 55.5%, N = 2104).


PCPs’ experiences with HMP patients and recent changes in their practices.


Interviews include examples of the impact of Medicaid expansion on patients and practices. A majority of surveyed PCPs reported recent increases in new patients (52.3%) and patients who had not seen a PCP in many years (56.2%). For previously uninsured patients, PCPs reported positive impact on control of chronic conditions (74.4%), early detection of serious illness (71.1%), medication adherence (69.1%), health behaviors (56.5%), emotional well-being (57.0%), and the ability to work, attend school, or live independently (41.5%). HMP patients reportedly still had more difficulty than privately insured patients accessing some services. Most PCPs reported that their practices had, in the past year, hired clinicians (53.2%) and/or staff (57.5%); 15.4% had colocated mental health care. Few (15.8%) reported established patients’ access to urgent appointments worsened.


PCP reports of patient experiences may not be accurate. Results reflect the experiences of PCPs with ≥ 12 Medicaid patients. Differences between respondents and non-respondents present the possibility for response bias.


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


Compliance with ethical standards

Conflict of interest

The authors declare that they do not have a conflict of interest.

Supplementary material

11606_2018_4487_MOESM1_ESM.docx (107 kb)
ESM 1 (DOCX 106 kb)
11606_2018_4487_MOESM2_ESM.docx (16 kb)
ESM 2 (DOCX 16.1 kb)
11606_2018_4487_MOESM3_ESM.docx (25 kb)
ESM 3 (DOCX 24.8 kb)
11606_2018_4487_MOESM4_ESM.docx (16 kb)
ESM 4 (DOCX 16.2 kb)
11606_2018_4487_MOESM5_ESM.docx (93 kb)
ESM 5 (DOCX 93.0 kb)


  1. 1.
    Ayanian JZ. Michigan’s approach to Medicaid expansion and reform. N Engl J Med 2013;369:1773–1775.CrossRefPubMedGoogle Scholar
  2. 2.
    Healthy Michigan Plan. Michigan Department of Health and Human Services. 2017. Accessed at,5885,7-339-71547_2943_66797---,00.html on 3 March 2018.
  3. 3.
    Friedberg MW, Chen PG, Van Busum KR, Aunon F, Pham C, Caloyeras J, et al. Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. Santa Monica, CA: RAND Corporation, 2013. Report No.: RR-439-AMA.Google Scholar
  4. 4.
    U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. National Ambulatory Medical Care Survey 2014 Panel. 2014. Accessed at on 30 March 2018.
  5. 5.
    Newman SE, Udow-Phillips M, and Anderson KC. 2012 Michigan Physician Survey. Ann Arbor, MI: Center for Healthcare Research and Transformation, 2010.Google Scholar
  6. 6.
    SteelFisher GK, Blendon RJ, Sussman T, Connolly JM, Benson JM, Herrmann MJ. Physicians’ views of the Massachusetts health care reform law—a poll. N Engl J Med 2009; 361:e39.CrossRefPubMedGoogle Scholar
  7. 7.
    The Commonwealth Fund. 2012 International Survey of Primary Care Doctors. 2012. Accessed at on March 30, 2018.
  8. 8.
    Patton MQ. How to use qualitative methods in evaluation. Newbury Park, CA: Sage, 1987.Google Scholar
  9. 9.
    Strauss A and Corbin J. Basics of qualitative research: grounded theory procedures and techniques. 3rd ed. Newbury Park, CA: Sage, 2008.Google Scholar
  10. 10.
    Sommers BD, Blendon RJ, Orav EJ, Epstein AM. Changes in utilization and health among low-income adults after Medicaid expansion or expanded private insurance. JAMA Intern Med 2016; 176:1501–1509.CrossRefPubMedGoogle Scholar
  11. 11.
    Kaufman H, Chen Z, Fonseca V, McPhaul MJ. Surge in newly identified diabetes among Medicaid patients in 2014 within expansion states under the Affordable Care Act. Diabetes Care 2015; 38:833.CrossRefPubMedGoogle Scholar
  12. 12.
    Baicker K, Taubman SL, Allen HL, et al. The Oregon Experiment—effects of Medicaid on clinical outcomes. N Engl J Med 2013; 368:1713–1722.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Sommers B, Blendon R, Orav EJ. Both the ‘private option’ and traditional Medicaid expansions improved access to care for low-income adults. Health Aff 2016; 35:96–105.CrossRefGoogle Scholar
  14. 14.
    Wherry LR, Miller S. Early coverage, access, utilization, and health effects associated with the Affordable Care Act Medicaid expansions. JAMA Intern Med 2016; 164:795–803.Google Scholar
  15. 15.
    Miller S, Wherry LR. Health and access to care during the first 2 years of the ACA Medicaid expansions. New Engl J Med 2017; 376:947–956.CrossRefPubMedGoogle Scholar
  16. 16.
    Simon K, Soni A, Cawley J. The impact of health insurance on preventive care and health behaviors: evidence from the first two years of the ACA Medicaid expansions. J Pol Anal Manag 2017; 36:390–417.CrossRefGoogle Scholar
  17. 17.
    Christopher AS, McCormick D, Woolhandler S, Himmelstein DU, Bor DH, Wilper AP. Access to care and chronic disease outcomes among medicaid-insured persons versus the uninsured. Am J Public Health 2016; 106:63–69.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Decker SL, Kostova D, Kenney GM, Long SK. Health status, risk factors, and medical conditions among persons enrolled in Medicaid vs uninsured low-income adults potentially eligible for Medicaid under the Affordable Care Act. JAMA 2013; 309:2579–2586.CrossRefPubMedGoogle Scholar
  19. 19.
    Piette JD, Wagner TH, Potter MB, Schillinger D. Health insurance status, cost-related medication underuse, and outcomes among diabetes patients in three systems of care. Med Care 2004; 42:102–109.CrossRefPubMedGoogle Scholar
  20. 20.
    Gray J, Sung I, Richardson S. Observations on the Affordable Care Act: 2014. athenaResearch and Robert Wood Johnson Foundation ACA View Report. 2015 Feb 25. Accessed at on March 30, 2018.
  21. 21.
    Gray J, Zink A, Drevfus T. Effects of the Affordable Care Act through 2015. athenaResearch and Robert Wood Johnson Foundation ACA View Report. 2016 March 1. Accessed at on March 30, 2018.
  22. 22.
    Tipirneni R, Rhodes KV, Hayward RA, Lichtenstein RL, Reamer EN, Davis MM. Primary care appointment availability for new Medicaid patients increased after Medicaid expansion in Michigan. Health Aff 2015; 34:10–377.CrossRefGoogle Scholar
  23. 23.
    Tipirneni R, Rhodes KV, Hayward RA, et al. Primary care appointment availability and nonphysician providers one year after Medicaid expansion. Am J Manag Care 2016; 22:427–431.PubMedGoogle Scholar
  24. 24.
    Polsky D, Richards M, Basseyn S, et al. Appointment availability after increases in Medicaid payments for primary care. N Engl J Med 2015; 372:537–545.CrossRefPubMedGoogle Scholar
  25. 25.
    Polsky D, Candon M, Saloner B et al. Changes in primary care access between 2012 and 2016 for new patients with Medicaid and private coverage. JAMA Intern Med 2017; 177:588–590.CrossRefPubMedGoogle Scholar
  26. 26.
    Experiences and attitudes of primary care providers under the first year of ACA coverage expansion. Henry J. Kaiser Family Foundation. 2016 June 18. Accessed at on March 30, 2018.
  27. 27.
    The Colorado Trust. Medicaid in Colorado: how enrollees access and use health care. Colorado Health Access Survey (CHAS) Issue Brief. 2011 Data Series: 5.Google Scholar
  28. 28.
    Asplin BR, Rhodes KV, Levy H, Lurie N, Crain AL, Carlin BP, Kellermann AL. Insurance status and access to urgent ambulatory care follow-up appointments. JAMA 2005; 294:1248–1254.CrossRefPubMedGoogle Scholar
  29. 29.
    Facilitating access to mental health services: a look at Medicaid, private insurance, and the uninsured. The Henry J. Kaiser Family Foundation. 2017 Nov. 27. Accessed at on March 30, 2018.
  30. 30.
    Cook NL, Hicks LS, O’Malley AJ, Keegan T, Guadagnoli E, Landon BE. Access to specialty care and medical services in community health centers. Health Aff 2007; 26:1459–1468.CrossRefGoogle Scholar
  31. 31.
    Atiga S, Rudowitz R, Tolbert J, Paradise J, Majerol M. Findings from the field: Medicaid delivery systems and access to care in four states in year three of the ACA. The Henry J. Kaiser Family Foundation. 2016 Sept. 20. Accessed at on March 30, 2018.
  32. 32.
    Antonisse L, Garfield R, Rudowitz R, Artiga S. The effects of Medicaid expansion under the ACA: findings from a literature review. The Henry J. Kaiser Family Foundation. 2016 June 20. Accessed at on March 30, 2018.
  33. 33.
    Cohen RA, Martinez ME, Zammitti EP. Health insurance coverage: early release of estimates from the National Health Interview Survey, 2015. Hyattsville, MD: National Center for Health Statistics. 2017 May. Accessed at on March. 30, 2018.
  34. 34.
    Slevin ML, Plant H, Lynch DA, Drinkwater J, Gregory WM. Who should measure quality of life, the doctor or the patient? Br J Cancer 1988;57:109–112.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Osborn R, Moulds D, Schneider EC, Doty MM, Squires D, Sarnak DO. Primary care physicians in ten countries report challenges caring for patients with complex health needs. Health Aff 2015; 34:2104–2112.CrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2018

Authors and Affiliations

  • Susan Dorr Goold
    • 1
    • 2
    • 3
    Email author
  • Renuka Tipirneni
    • 1
    • 2
  • Edith Kieffer
    • 2
    • 4
  • Adrianne Haggins
    • 2
    • 5
  • Cengiz Salman
    • 2
    • 6
  • Erica Solway
    • 2
  • Lisa Szymecko
    • 7
  • Tammy Chang
    • 2
    • 8
  • Zachary Rowe
    • 9
  • Sarah Clark
    • 2
    • 10
  • Sunghee Lee
    • 11
  • Eric G. Campbell
    • 12
  • John Z. Ayanian
    • 1
    • 2
    • 3
    • 13
  1. 1.Department of Internal Medicine, Medical School University of MichiganAnn ArborUSA
  2. 2.Institute for Healthcare Policy and InnovationUniversity of MichiganAnn ArborUSA
  3. 3.Department of Health Management and Policy, School of Public HealthUniversity of MichiganAnn ArborUSA
  4. 4.School of Social Work and the Institute for Healthcare Policy and InnovationUniversity of MichiganAnn ArborUSA
  5. 5.Emergency Medicine and the Institute for Healthcare Policy and InnovationUniversity of MichiganAnn ArborUSA
  6. 6.Center for Bioethics and Social Sciences in MedicineUniversity of MichiganAnn ArborUSA
  7. 7.Department of Community PsychologyMichigan State UniversityEast LansingUSA
  8. 8.Family MedicineUniversity of MichiganAnn ArborUSA
  9. 9.Friends of ParksideDetroitUSA
  10. 10.Department of PediatricsUniversity of MichiganAnn ArborUSA
  11. 11.The Institute for Social ResearchUniversity of MichiganAnn ArborUSA
  12. 12.CU Center for Bioethics and HumanitiesUniversity of ColoradoDenverUSA
  13. 13.Gerald R. Ford School of Public PolicyUniversity of MichiganAnn ArborUSA

Personalised recommendations