Gov. Rick Snyder of Michigan does not fit the current ideological Republican stereotype. He threw his support behind the development of a health insurance exchange because it will make the health insurance market work better.
This and other views related to health care and state government's role in Michigan mirrors the national debate.
"Even if the act of establishing a health insurance exchange were not mandated by the Affordable Care Act, I would still be in favor of utilizing technology to create a better customer service experience for Michiganders," the governor said in a special healthcare message last fall.
Despite Snyder's support, Michigan did not enact the legislation it needs to move forward to establish the online marketplace. While it passed in the Michigan Senate, Republicans stalled it in the House.
While Republicans have control of Michigan government, more state House members are up for re-election than in the Senate. "The challenge was to vote on something that a lot of people don't understand," said Marianne Udow-Phillips, director of the Center for Healthcare Research and Transformation at the University of Michigan.
State lawmakers say, perhaps shortsightedly, that there will be plenty of time after the Supreme Court rules on the constitutionality of the Patient Protection and Affordable Care Act (ACA) to get serious about the health insurance exchange.
Adding fuel to the fire, the Republican presidential contenders vying in the Michigan primary Feb. 28 each vow in contentious language to repeal the health reform law, which calls for the health insurance marketplaces to be operational in 2014.
Despite the insurance exchange logjam, the Health and Human Services Department recently awarded Michigan a second tranche of exchange funds, this one for establishing an exchange. HHS has said the lack of exchange legislation is not a barrier to receiving funds.
In addition to the exchange, Snyder has identified population health priorities that affect the state's health picture and economy, including trying to reduce the high rate of obesity. As part of obesity goals, Snyder proposed having pediatricians reporting on children's body mass index (BMI), and that became very controversial.
"The legislature doesn't think that that is the role of government. But the governor thinks we have to do something about obesity," she said.
Last fall, Snyder outlined a vision for a healthier Michigan because "wellness and economics are linked," such as the fact that treatment for coronary heart disease, which is largely preventable, accounts for $1 in every $6 spent by Michigan for health care.
He included in that vision "ready access to an affordable, patient-centered and community-based system of care." Snyder also highlighted the benefits of establishing the statewide Michigan Health Information Network (MHIN) so that providers can share patient data and use electronic health records in a meaningful way.
Like all states, Michigan has experienced a significant increase in individuals who are covered by Medicaid. About 1 in 5, or 20 percent, of the state's population are covered by Medicaid.
From surveys done at her center, Udow-Phillips said that those with Medicaid coverage experience more difficulty in getting appointments with their primary care providers than those who have private health insurance, even though the vast majority of Medicaid enrollees are in managed care.
That's very connected to the fact that Michigan Medicaid is a very low payer, amounting to about 70 percent of the cost of hospital services. Michigan ranks as the 44th lowest paying state, she said, adding that "it's not so surprising then that providers are not so keen on covering the Medicaid population."
That challenge will be significantly magnified with the expansion in 2014 of Medicaid under health reform.
The focus has been on expanding safety net clinics, which already serve the Medicaid population. "We had hoped to get more support from federally qualified health centers, but a lot of those funds ended up getting cut in the debt ceiling debates," she said.
In her county, Udow-Phillips is trying to get more support from the two academic medical centers to make sure individuals who have Medicaid coverage are seen and treated.
"We're trying a variety of strategies and we'd like to see the funds for federally qualified health centers restored," she said.
For more of our primaries coverage, visit Political Malpractice: Healthcare in the 2012 Election.