COACHING GOOD HEALTH

The Baltimore Sun

In an initiative likely to be closely watched in Maryland and across the nation, Howard County is preparing to launch a program aimed at providing low-cost access to care to an estimated 20,000 county residents who are uninsured.

County officials say their plan might be a model for other communities seeking to provide a health care safety net to low-income residents at a time of significant national concern about the availability of affordable health care.

The plan is to begin operating July 1, with a goal of enrolling around 2,000 adults. The county also hopes to enroll up to 4,000 eligible, but uninsured, children in the State Children's Health Insurance program, a federally funded, state-administered program that provides insurance for children from families with incomes up to 300 percent of the federal povertly level.

County Executive Ken Ulman and Dr. Peter Beilenson, the county health officer, have stressed that the Healthy Howard Plan is not insurance, and that only American citizens who have been county residents for one year and uninsured for one year will be eligible. The care is also not portable.

Participants will pay fees of $50 to $115 a month, depending on income and family size, and the county will use the Chase-Brexton clinic in Columbia and Howard County General Hospital as prime service providers. Ulman said he would include $500,000 in the county budget for the next fiscal year to help pay the estimated $2.8 million first-year costs. Patient fees will provide another $1.6 million and the remainder is to be donations from individuals and organizations.

The program contains a strong element of preventive care, since health counselors will work with every patient to help craft a plan to promote their overall good health, guide them to existing programs they may be eligible for, and, it is hoped, reduce the need for medical treatment over time.

Beilenson, who was formerly Baltimore's health commissioner, has long advocated making quality health care more widely available. He agreed last week to answer some questions about the Howard County plan and the broader challenges of health care. What happens if only a handful of Howard County's 12,000 uninsured adults decides to sign up for the new program?

I think there's very little possibility of this. When Kaiser [Permanente] offered low-cost insurance for 175 Howard families, the county got over 650 [applicants] - almost four times the people we had slots for. ... We've been getting lots of response on our help line eight months in advance. ... We've planned a lot of outreach to business owners, labor pools and areas where we'll likely reach people who are not insured, like through clergy and community leaders. We're pretty confident we'll have a sizable number of individuals apply. What if you are deluged with more applicants than you expected?

That could be a tad of a problem. It's certainly conceivable with our plan not being insurance. Again, the interest that's been generated is pretty sizable. We're opening the program to interested parties before July 1. If by June we have 4,000 people interested, we will clearly have to do a lottery. A deadline date, and then a lottery. My strong suspicion is we'll get 2,000 people the first year, but probably not too many above that. Like Mchip [the Maryland Children's Health Insurance Program], not everyone eligible will apply. I think we'll come in around that comfortable medium. You say that health coaches will work with participants to craft an individual-care plan and that people who refuse to follow the plan could be put on probation after three months and lose health care after six. Specifically, what kinds of failure would lead to the loss of coverage?

One of the luxuries we have by announcing this eight months in advance is we're still refining it. This is where the town hall meetings [Nov. 6, 13 and 14] come into play. We want to hear from what people think about this issue. I don't think we'll get tons of changes on services, but we will get comments on the health coach. What constitutes substantive compliance? We clearly want input from the community on that. It may be somewhat subjective. We don't have one specific definition fully fleshed out yet.

We've got to have some relatively firm definitions [so standards don't vary greatly from one health coach to another]. What's the importance of this health coach?

Honestly, it's a combination of two things - access and helping people overcome barriers to health - that are going to get us to improving health. Just giving people access alone doesn't guarantee better outcomes. The coaches will help people overcome barriers and help facilitate compliance with the action plans. They will work with people. For example, take a 40-year-old person who is overweight and diabetic. The goal is to increase exercise to three times a week, but this person has three children and doesn't have day care. The community benefits coordinator will help them find a hour of free day care. Those are the kinds of things we can do. What if participants can't find time for the exercises called for or can't afford recommended diets?

I don't buy that people don't have time. The president of the United States still can exercise an hour every day. I'm not a big fan of this president, but I would argue the presidency requires a lot of time. But there are barriers [to exercise or diet]. That's where the coach comes in. They will help people overcome those. There are very few legitimate barriers to doing most components of the action plans. Dental care is considered important to overall health, yet the Healthy Howard Plan doesn't cover dental. Why not?

We are working with the Howard County Dental Association for more pro-bono care. We'll also be talking with the University of Maryland School of Dentistry. We also have our own [Howard County Health Department] dental clinic. That is clearly a deficit in our plan. We'll be working over the next eight months to provide some. What if people (or their employers) decide to drop private insurance with the expectation that they will become eligible for the county plan after a year?

That's the reason we did a full year [without insurance], which is more than most programs. Two years is kind of hard. We think a year is sufficient to avoid the dumping issue. One reason to phase it in with 2,000 people the first year is also to see things like: Does the one-year residency requirement defeat the residency concern, and is one year anti-dumping adequate? We really need to rely on the market here. The market will work against employers who offer employees an incentive to drop their insurance for a year to enroll in the county plan. My strong suspicion is that those employees will not stay with that employer. What do you think of Governor O'Malley's new state health insurance proposal? What effect on Howard's plan will O'Malley's proposed expansion of the state's Medicaid program have? What if it doesn't happen? What if the state is forced to cut local county budgets instead?

I think it's great to expand Medicaid to poor adults. For the wealthiest state in the country, the level of income eligibility for adults [in Maryland] is abysmally low. Increasing it to 116 percent of poverty and covering 100,000 more people is great. Any increase in Medicaid coverage will only help the Howard plan because it will mean less people without health insurance. It's totally in concert.

If the plan fails in the General Assembly, it doesn't hurt us. We're in the same position we're in now.

But if the federal SCHIP [State Children's Health Insurance Program] does not get enough added funding and people fall off, then our plan has to take on kids. If the president and Congress don't get a significant [funding] compromise, there will be kids dumped [from the state program for children]. That will be an extra burden [on the county plan].

If there are big state budget cuts, the most likely cut would be in Medicaid. It will increase the number of uninsured in the county and increase the burden on our program. Some critics say the Howard health insurance plan won't be easily replicated elsewhere because of the county's relatively small proportion of low-income, uninsured workers. Do you agree?

I don't agree. It's clear that we have a bit easier row to hoe than Baltimore City, but I think it's quite replicable, and portions are replicable in poorer jurisdictions. The amount of dollars the county is putting in is really quite modest [$500,000 the first year]. What is different about Howard is that the county executive has made this a major priority. It's really county political will rather than county dollars. It's not that this is a wealthy county.

It is true, per capita, there are a bit fewer uninsured people [in Howard] than elsewhere, but other [jurisdictions] in the state are closer to Howard County. Across the country - from California to Wisconsin - efforts by states to step up and provide some form of universal health coverage appear to be stumbling into battles between unions and other advocates of broader and deeper coverage and critics who say the public coverage plans are undermining existing private insurance programs. How do you get past this conflict?

That conflict is not really here. Our plan, again, which is not insurance, is innovative in that it combines a significant increase in access to care and a health action plan that has been attracting attention and is replicable in national and state efforts in the future. The reason that so much political controversy occurs is based on our historical way of covering health insurance through employers - because of that constant tension between unions, workers and management. The beauty of our plan is that it's not employer-based. It could be a model at the national or state level. The only way we're going to have health care for all is to move away from the employer base. The main reason the number of uninsured has gone up is that a smaller percentage of small businesses are offering coverage. Surveys show many Americans are not convinced that being uninsured is a problem. How can advocates of universal insurance get past this obstacle?

If you look at national polls, health care is the No. 1 issue domestically for Democrats and No. 2 for Republicans. I think most people feel health care is a big issue. The average American realizes they are one paycheck or economic downturn away from being uninsured. What they don't realize is the immense burden on the average American for the uninsured. More than $1,000 of [each family's annual] premium goes not one iota for their own health coverage. It subsidizes hospital emergency-room care. I believe very strongly that health care is a human right, but there is self interest for people and financial self-interest that covering the uninsured [with inflated insurance premiums] is already a hidden tax. Growing numbers of families with employer-provided insurance are finding that their shares of the premium and/or co-pays have grown to make getting good health care a serious financial burden. Is it possible to find a way to ensure that private insurance will provide reasonably comprehensive coverage at an affordable price?

Honestly, I am not convinced after working on this issue for 15 years, that health care and access to it can be completely market-based. I'm not an economist, but there are so many aspects of the health care arena that don't necessarily translate into being done by the market.

People should have the ability to choose, the argument goes. Here's an example: Let's say you're going to have elective but important surgery. Honestly, it's a lot different than going to find the best wide-screen TV. I don't think health care translates into that. Judging the quality of a medical provider is much harder than defining the quality of a TV. The success rate of a physician depends on where they practice, who their patients are, who the insurance company is. Unlike TV sets, a lot of medical care is illness, injury or life and death. The combination of all thse issues does not lend itself to market forces. Really, I think there needs to be involvement of government, though not as the provider. What can you do to make insurance affordable for middle-income families with serious health care issues?

Although I understand the political heat that one takes when supporting a single-payer system, I strongly support a single-payer system with private providers and hospitals. That would be the most equitable, cost-effective and highest-quality health system. That's the only way we can get control of costs.

larry.carson@baltsun.com

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