Developments in Michigan
The legislature in Michigan is exploring some avenues, within the constraints of the ACA, that may reduce medical costs, administrative costs, and provide more options for patients.
Michigan
Senate Bill 460 , sponsored by Senator Pat Colbeck, would be the first step toward setting up an infrastructure that would allow individuals to contract directly with primary caregivers (no insurance company forms/paperwork/etc) for Direct Primary Care Services (DPCS). These arrangements are increasingly popular in the private sector--pay a doctor/practice a fixed fee monthy/annually, go in as often as you need to. For specialized/more expensive issues, the patient uses a high-deductible insurance plan (HDIP) (purchased within an HSA--with all the tax advantages). The federal subsidies etc would still be in place, but the subsidy checks are used by participants to buy their DPCS contracts and their HDIP, and to pay co-pays, etc. All of this is independent of the "exchanges," I suppose Michiganders could still buy from the exchanges if they want. Michigan also hopes to use the same mechanism to cover their Medicaid patients, with the money coming from the same sources (federal/state) that now pay for the program.
A rather obscure portion of the ACA (Section 10104 (3) ) authorizes what they call "Qualified Direct Primary Care Home Plans", so waivers might not be required for implementing some portions of the Michigan proposal.
The bill has been voted out of committee and will now be considered on the floor of the Michigan Senate.
The states are supposed to be the laboratories. If Michigan implements this and it works, I suppose it might spread to other states.