Even if lawmakers can agree on how to overhaul the nation's health care system, the hope of universal coverage could crumble if individuals can't afford their share.
Take Howard County. Less than five months into an innovative program to give low-income people access to medical care for as little as $50 a month, nearly one in 10 participants is at risk of being cut off because they can no longer afford the cost.
Howard officials say their fledgling program, called the Healthy Howard Access Plan, provides a cautionary lesson for federal policymakers battling over how to re-imagine the nation's health care system and extend insurance to some 47 million Americans. While the major congressional proposals would require that nearly everyone have insurance or pay a penalty, low-income people could qualify for subsidies to help cover the cost of premiums. But lawmakers are wrangling over who would get financial help - and how much.
If the subsidies fall short, millions of Americans could continue to struggle without health insurance, say advocates for the uninsured. Besides, if people in Howard County - among the richest localities in the nation - can't manage $50 a month, how could those struggling elsewhere afford the plans under consideration in Washington that would require a much higher out-of-pocket cost?
Dr. Peter Beilenson, Howard County's health officer, said higher government subsidies are crucial to making health care affordable to all. "I'm totally for universal health care, but these are working people who are asking themselves, 'How in the world can I afford this?' The bottom line is there will be insurance reform and, I think, a modest expansion. But unless the subsidies are significantly ramped up to deal with real-life families, it's not going to be even close to universal coverage."
Today, as premiums skyrocket, many uninsured people say they would be unable to purchase coverage without substantial subsidies.
Jean Barnett tried pricing insurance, but threw up her hands when she discovered the cost: $186 a month. The 47-year-old from Baltimore has been uninsured since being laid off from her job at an addiction counseling center in February, where she made about $400 a week.
Barnett pays $90 for 30 pills to manage her high blood pressure, but can no longer afford the Lipitor she took for years to keep her cholesterol in check. She is eyeing proposals in Congress closely with hopes that she may one day be able to afford insurance.
"I understand that taxpayers that have nice salaries shouldn't have to cushion the impact for lower-income people," she said. "But if President Obama is going to institute this plan for health care, then it should at least be a plan where you won't forget about the low-income people such as myself."
Healthy Howard offers access to doctors at low cost to county residents in Barnett's predicament. It isn't insurance, but rather a network of services, designed in the absence of federal reform for those who earn too much to qualify for Medicaid but not enough to afford private coverage. For $50 to $85 a month, depending on income, enrollees receive primary care, access to specialty doctors, subsidies for prescription drugs, and a personal health coach.
The architects of the program aimed for monthly costs to be no more than 4 percent to 6 percent of a member's income. In Congress, however, the percentages being tossed around are much higher - between 10 percent and 12 percent.
Federal subsidies would kick in on a sliding scale. One proposal makes subsidies available for people earning up to 300 percent of the poverty level, or $66,150 for a family of four. Meanwhile, two other bills say up to 400 percent of the poverty level, or $88,200 for a family of four. Lawmakers are also negotiating limits on out-of-pocket costs and exemptions for financial hardship.
Even the most heavily subsidized proposals in Congress are twice the cost of Healthy Howard. Some cost six times as much, Beilenson said.
"What you're going to have is people either not complying with individual mandates and getting a penalty, or they will ... end up going bankrupt to pay for their health care," he said. "If they are noncompliant, they still are uninsured and will continue to go to the emergency room and run up costs."
Healthy Howard administrators at times have worked with people in jeopardy of losing benefits to keep them on the plan, with phone call reminders and in some cases, a few extra days to send in payments. The program's small size - just 325 members - made it possible to offer second chances an insurance company with millions of policy holders wouldn't, said Liddy Garcia-Bunuel, Healthy Howard's executive director.
Alan Sager, a professor of health policy at Boston University, said that subsidies - which act as a bridge for families who earn too little to afford the most expensive health care in the world - are at the heart of the effort to provide universal coverage.
"A premium is $15,000 per family or $12,000 per family, regardless of income," he said. "The subsidies are a big issue, first, because so many people can't afford insurance because it's a bigger percentage of their income. And second, because U.S. health care costs are twice as great as the average wealthy country."
But Sager cautioned against Beilenson's doomsday scenario. For starters, Healthy Howard is not the same as comprehensive health insurance, which covers everything from primary care and surgeries to medical equipment and mental health services, so it makes little sense to compare the two, he said.
In addition, the federal subsidies being proposed are similar to those offered in Massachusetts, where a health care makeover in 2006 mandated insurance for all state residents and has managed to expand insurance to an estimated 400,000 people, bringing down the state's uninsured rate from 10 percent to about 3 percent, Sager said.
"It's affordable enough," he said. "People have enrolled and maintained coverage."
Massachusetts also offers lessons for a nation grappling with how to pay for health care reform. That state did not devise any cost controls when it mandated universal coverage. Now, with tax revenue down and high subsidies, the state is struggling financially, said Sager.
Sager agreed that substantial subsidies will be necessary for the federal plans to keep insurance affordable, but lawmakers face a delicate balancing act.
"There will only be so much available to subsidize insurance premiums," he said. "There will be trade-offs: bigger subsidies for fewer people or smaller subsidies to stretch the finite new federal dollars to try to cover as many of the 50 million uninsured" as possible.
Trimming Medicare payments to hospitals and other providers, adding new taxes and reducing expensive procedures are among the many ideas for cutting costs and raising money to pay for health care reform. But Sager said it's unclear if proposed reforms will achieve major cost savings.
Advocates for the uninsured have suggested other taxes, including an alcohol tax, to raise money, said Vincent DeMarco, president of Maryland Citizens Health Initiative. He notes that while subsidies will be important, federal reformers also propose expanding Medicaid, which would offer coverage to millions of low-income people - including as many as 200,000 Marylanders.
Still, interest groups such as AARP fear that many of its members may not qualify for subsidies or federal programs.
Nora Super, chief health lobbyist with AARP, said the organization is worried about people 50 years old to 64 years old, about 13 percent of whom (7 million) are uninsured and too young to be covered by Medicare. She said only 1.2 million people in that group earn between 300 percent and 400 percent of the poverty level, the two thresholds for subsidies being negotiated by lawmakers.
"That would be a lot of people who wouldn't be covered," Super said. "These are the folks we think could really lose out."
