If you asked one Michigan family physician how she spent her summer vacation last year, she would tell you she worked diligently toward expanding Medicaid for state residents.
Michigan Gov. Rick Snyder, center, at the bill-signing for Medicaid expansion with Michigan AFP members, from left, CEO Debra McGuire; President-elect Tina Tanner, M.D.; Vice President Kim Yu, M.D., Director of Government Affairs Christin Nohner; and Director of Communications and Membership Annie McIntosh
Tina Tanner, M.D., president-elect of the Michigan AFP (MAFP), cut her vacation short to give testimony on the issue before the Michigan Senate. She was enjoying time off with family when she took time out to travel to Lansing to testify. For more than a year, the MAFP and other state medical associations had been pushing for expansion of Medicaid in Michigan.
It wasn't Tanner's first foray into state politics. In late 2012, she recorded a video produced by a statewide Medicaid expansion coalition(www.youtube.com), where she made a compassionate plea for Medicaid expansion. In her three-minute segment, Tanner delivered a persuasive appeal to support Medicaid expansion on personal, not political, grounds. She talked about the needs of low-income families to gain access to care they otherwise could not afford.
"I never thought I'd be doing this," said Tanner in an interview with AAFP News. "I wanted to be the best rural physician I could be. Politics was not my thing." However, she soon realized that because of complications with insurance and state bureaucracy, she could not provide the kind of care her patients needed. So she decided to get involved in advocacy efforts.
- When Michigan senators expressed reluctance to approve an expansion of Medicaid in the state, medical associations statewide joined forces to advocate for change.
- The Michigan AFP was an active participant in efforts to effect a change, citing concerns for patients unable to afford health care.
- Intense lobbying efforts by the coalition led to the governor of Michigan signing the bill in September 2013.
Working as a Coalition
State groups, such as the Michigan Hospital Association and the MAFP, joined forces to pressure the Michigan Senate to vote on Medicaid expansion after months of delay. The hospital association was the leader of the coalition, but the MAFP lent significant support. All of the medical community's efforts bore fruit when Gov. Rick Snyder signed the bill into law in September 2013. The expansion of Medicaid for Michigan is scheduled to begin in April, and an estimated 470,000 individuals will be eligible for coverage when the law takes effect.
Christin Nohner, director of government affairs for the MAFP, said Tanner's video appearance was one of the highlights of the chapter's efforts. Other board members, including MAFP President Fred Van Alstine, M.D., M.B.A., and Vice President Kim Yu, M.D., met with their respective legislators.
"We were a small part of a very large coalition, but every little bit helps," Nohner said.
To get the bill passed, the MAFP took an active part in what was a statewide grassroots effort to expand Medicaid. MAFP officials sent out multiple electronic newsletters about the issue to members and used social media outlets to raise awareness. They sent letters and made phone calls to legislative offices. A handful of chapter members scheduled one-on-one meetings with their senators. Above all, they were helped by a governor who was committed to the issue.
"The governor showed remarkable leadership on this issue," Van Alstine said. "We were supporting cast members and would not have been able to do it on our own."
The MAFP helped by identifying five key senators who could be persuaded to change their minds about the issue and vote for Medicaid expansion. If one of the senators had a scheduled coffee meeting with constituents, the MAFP identified a member who could attend the event.
"We emphasized the human side of the debate," Nohner said. "It was about protecting the health of patients and expanding health care access to Michigan residents."
Facts About the Michigan AFP
Chapter CEO: Debra McGuire, M.B.A.
Number of chapter members: 3,790
Year chapter was chartered: 1948
Location of chapter headquarters: Okemos
2014 Annual Conference: July 17-19, Radisson Hotel, Lansing
Emphasizing the Human Element
Changing the nature of the debate was important, said Tanner, who believes the political infighting over health care reform has not served patients or anyone in the medical community well. "We need to get away from talk about Obamacare and labeling of the ACA (Patient Protection and Affordable Care Act)," she said. "Everyone agrees that the current system is broken. It may not be the best written bill, but the law is in place, and instead of fighting it, we can make it work for patients and physicians."
However, Michigan AFP members also noted that family physicians will need additional support at the state and federal level to handle the increased patient load. Tanner observed that national health reform efforts are being built on the backs of primary care providers, yet the value assigned to the care they provide is not returned in terms of payment rates or annual salaries.
Van Alstine emphasized that expansion of Medicaid will not alleviate the difficulties of managing a private practice in rural areas where Medicaid reimbursement rates for a single office visit are $30, far too low to support basic operations. The legislation is but one step in the long process toward health care coverage for all, he said. "As a (MAFP) board, we support the expansion, but expansion of Medicaid doesn't increase access to primary care."
For some patients, not having insurance means making fateful choices about their health. Van Alstine recalled a recent patient who worked a minimum wage job without health insurance. His throat became extremely sore, and, after delaying any kind of medical treatment, he went to the ER in his community, where the ER physician gave him penicillin. After two months without any noticeable improvement, the patient went to Van Alstine's office. From the time of the hospital visit, the man had lost 35 pounds and his lymph nodes were clearly swollen.
The patient was worried about costs because his visit to the ER had cost $500, which he could not pay. Sensing that the patient had lymphoma, Van Alstine insisted that the man's condition required more than simply prescribing more medication. He arranged for the patient to be seen again in the ER, but his condition had worsened to the point that it was too late to save him. Van Alstine said he read the man's obituary in the local newspaper a few weeks later.
"I'd rather a patient access the emergency room than have no access at all," he said.
Such personal stories motivated Van Alstine and Tanner to get active in the political arena to demonstrate to state leaders how gaps in health insurance are affecting people's lives.
"My patients know I advocate on issues so they will ask me how the local senator or representative voted on an issue," Tanner said.
With help from one of her patients she was able to bend the ear of Michigan State Sen. Geoff Hansen, who makes regular appearances at a local grocery store to bag groceries and talk with constituents. One of Tanner's patients approached Hansen in the store one day and asked him about his vote on the Medicaid expansion issue. The senator was impressed with Tanner's lobbying skills.
"He (Hansen) called me and said, 'A 91-year old man came over to me and started giving me the what for about Medicaid expansion,'" said Tanner. "I told him, 'There will be a lot more.'"
The senator, who initially opposed the measure, eventually voted for Medicaid expansion.
Using Resources Strategically
Other states are contending with heavy political opposition to health care reform and the uninsured, but they may believe they don't have the resources to mount an aggressive advocacy campaign. Not so, say members of the MAFP. The Michigan AFP has only a small staff of five, so they have had to be strategic about their use of resources. It's essential when dealing with such a major issue, that chapters find partners within the medical community.
According to Nohner, the MAFP developed an informal key contacts program whereby a member of the chapter's advocacy committee or a board member would be assigned to contact a particular legislator. In the end, taking advantage of all the "touch points" proved crucial. "Medicaid expansion had massive support among so many diverse groups," Nohner said. "Every big hitter in the health care community was behind it. There aren't many issues like that."