Diagnosis and Care of Chronic Health Conditions Among Medicaid Expansion Enrollees: a Mixed-Methods Observational Study

  • Ann-Marie RoslandEmail author
  • Edith C. Kieffer
  • Renuka Tipirneni
  • Jeffrey T. Kullgren
  • Matthias Kirch
  • Emily K. Arntson
  • Sarah J. Clark
  • Sunghee Lee
  • Erica Solway
  • Erin Beathard
  • John Z. Ayanian
  • Susan D. Goold
Original Research



It is uncertain how Medicaid expansion under the Affordable Care Act influences the diagnosis of chronic health conditions, and the care and health of enrollees with chronic conditions.


Describe the prevalence of new and pre-existing chronic health conditions among Medicaid expansion enrollees. Examine whether perceived changes in specific types of access and self-rated health status differed between enrollees with chronic conditions and those without. Examine how gaining Medicaid coverage affected chronic disease management and well-being.


Mixed-methods study including a telephone survey and semi-structured interviews.


Michigan’s Medicaid expansion, the “Healthy Michigan Plan” (HMP).


4090 survey respondents (response rate 54%) with ≥ 12 months HMP enrollment and 67 interviewees with ≥ 6 months enrollment.

Main Measures

Self-reported chronic condition diagnoses, changes in physical/mental health, and healthcare access. Descriptive survey data were adjusted for survey design and nonresponse. Semi-structured interview questions about how gaining HMP coverage led to changes in health status.

Key Results

Among enrollees, 68% had a self-reported diagnosis of a chronic health condition; 42% of those were newly diagnosed since HMP enrollment. In multivariable models, enrollees with chronic conditions were significantly more likely to report improved physical (adjusted odds ratio (aOR) 1.70, 95% CI (1.40, 2.07)) and mental health (aOR 1.75, (1.43, 2.15)) since HMP enrollment than enrollees without chronic conditions. Among enrollees with chronic conditions, the strongest predictors of improvements in health were having seen a primary care physician, improved mental health care access, and improved medication access. Interviewees with chronic conditions described how increased access to health care led to improvements in both physical and mental health.


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 among this vulnerable group.



The University of Michigan Institute for Healthcare Policy and Innovation (IHPI) is conducting an evaluation of the Healthy Michigan Plan (HMP), as required by the Centers for Medicare & Medicaid Services (CMS), under contract with the Michigan Department of Health and Human Services (MDHHS).

This study was conducted while Dr. Rosland was a faculty member with the University of Michigan Institute for Healthcare Policy and Innovation.

The authors would like to acknowledge the valuable insights provided by Tammy Chang, Adrianne Haggins, Zachary Rowe from Friends of Parkside and the members of the Healthy Michigan Voices Steering Committee: Karen Calhoun, Michigan Institute for Clinical and Health Research and City Connect Detroit; Adnan Hammad, Global Health Research, Management and Solutions; Lynnette LaHahnn, AuSable Valley Community Mental Health Authority; Charo Ledón, Acción Buenos Vecinos; Raymond Neff, Spectrum Health; Jennifer Raymond, Mid Michigan Community Action; George Sedlacek, Marquette County YMCA; and Ashley Tuomi, American Indian Health and Family Services.

Funding Information

This study was funded by MDHHS and CMS but does not represent the official views of either agency. Support was also provided by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service. Dr. Kullgren is a VA HSR&D Career Development awardee.

Compliance with Ethical Standards

Conflict of Interest

Dr. Kullgren has received consulting fees from See Change Health and Health Mine, and a speaking honorarium from AbilTo, Inc. All remaining authors declare that they do not have a conflict of interest.


The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

Supplementary material

11606_2019_5323_MOESM1_ESM.docx (33 kb)
ESM 1 (DOCX 33 kb)


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Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  • Ann-Marie Rosland
    • 1
    • 2
    Email author
  • Edith C. Kieffer
    • 3
    • 4
  • Renuka Tipirneni
    • 4
    • 5
  • Jeffrey T. Kullgren
    • 4
    • 5
    • 6
  • Matthias Kirch
    • 4
  • Emily K. Arntson
    • 7
  • Sarah J. Clark
    • 4
    • 8
  • Sunghee Lee
    • 4
    • 9
  • Erica Solway
    • 4
  • Erin Beathard
    • 5
  • John Z. Ayanian
    • 4
    • 5
    • 7
    • 10
  • Susan D. Goold
    • 4
    • 5
    • 7
  1. 1.Department of Medicine University of Pittsburgh School of MedicinePittsburghUSA
  2. 2.VA Pittsburgh Center for Health Equity Research and PromotionPittsburghUSA
  3. 3.University of Michigan School of Social WorkAnn ArborUSA
  4. 4.Institute for Healthcare Policy and Innovation (IHPI)University of MichiganAnn ArborUSA
  5. 5.Division of General MedicineUniversity of Michigan School of MedicineAnn ArborUSA
  6. 6.VA Ann Arbor Center for Clinical Management ResearchAnn ArborUSA
  7. 7.Department of Health Management and PolicyUniversity of Michigan School of Public HealthAnn ArborUSA
  8. 8.Child Health Evaluation and Research CenterUniversity of MichiganAnn ArborUSA
  9. 9.Institute for Social ResearchUniversity of MichiganAnn ArborUSA
  10. 10.Gerald R. Ford School of Public PolicyUniversity of MichiganAnn ArborUSA

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