Eric Scuderi needs surgery on his ankle, which he injured in an accident on his motorcycle, and a crown on a tooth that had a root canal.
But his job as a dance and gymnastics teacher comes with low pay and no health insurance, so the 27-year-old Howard County resident has put off getting the procedures done because he can't afford them.
"Considering I ride a motorcycle a lot and I've had one accident already, I definitely need health insurance," Scuderi said. "I've done without it for a long time."
Scuderi plans to be among the first to sign up today for Howard County's new program to provide health care access to the more than 20,000 uninsured residents in the county. After more than a year of planning, the first phase of Healthy Howard Inc. gets under way in earnest as the county begins enrolling participants on a first-come basis at the East Columbia Library.
"I think I'm a good candidate for it," said Scuderi, who lives in the Howard portion of Mount Airy.
The program will be watched closely by many in public health care circles, particularly as widespread economic distress threatens any major federal reforms.
"Health reform is on everybody's wish list, but it's moved to the back burner," said Jonathan Weiner, a professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health. "Howard County has kept it on the front burner."
The program is not insurance, but instead uses health "coaches" and individual lifestyle plans to improve a patient's health and reduce emergency room visits.
"It really tries to ensure access to essential care by using existing resources and emphasizing a theme of shared responsibility - including patients," said Karen Davis, president of Commonwealth Fund, a New York-based private foundation that supports research on health care issues.
The early stage of such a venture can be critical, said Tangerine Brigham, director of Healthy San Francisco, a similar program begun last year that now serves 30,000 people. She offered advice to Howard officials.
"Dive straight in," she said. "Learn from your first two months."
Brigham predicted that the program will be well received because patients will have a personal connection to one care provider.
Not everyone is cheering, though. County Council member Greg Fox said he remains worried about the future contributions of county funding as state and local revenues slow.
"If there's not enough money, how is that prioritization [of services] going to be done?" the Republican councilman asked.
County Health Officer Dr. Peter L. Beilenson said he's got a "shut-down plan" that would close the program in an orderly way if certain negative financial "triggers" are tripped. But he said he doesn't expect that.
The $2.8 million budget for the first year includes $500,000 from the county government, $500,000 from the Columbia-based Horizon Foundation, $728,574 from projected patient fees and some added donations. But those make up only about 69 percent of the budget.
Healthy Howard has applied for another $1 million in grants from 12 nonprofits, but has no final word yet on those requests, officials said. Expenses may be less than budgeted because of delays in hiring and uncertainty about the level of medical needs.
Still, the program is starting none too soon, said Victor A. Broccolino, president and CEO of Howard County General Hospital, because thousands of county residents are being forced to search for new primary care doctors as more physicians move to smaller fee-for-membership practices.
Beilenson considers the first year's operation a test run - a time to gauge public response, begin using the network of services and financing, and gather information that could be used to replicate the program elsewhere.
The first enrollees will not likely see a doctor until January, unless they have an existing medical problem that needs prompt attention, Beilenson said. The first few months will be used to screen and enroll people, collect their first monthly fee, and assign each to a health coach who will help divide patients according to the urgency of their needs and then craft a health program for each.
Though all of the pieces are not yet in place, several specialists have signed on, Beilenson said. Chase Brexton Clinic in Columbia will provide up to six doctor's visits per year for primary care. Also available are a range of discounted medicines, dental, mental health and other specialty care.
Fees will range from $50 to $115 a month, depending on income and family size. People are eligible if they are legal county residents who have been without health insurance for six months and have incomes less than three times the federal poverty level - $62,000 for a family of four. The income limit for a single person like Scuderi is $30,620 annually.
The county is using an electronic enrollment program that will allow access to the program from computers at various county facilities, including libraries, Howard Community College and the North Laurel Multi-Purpose Center.
County officials hope today's enrollment kicks off a new era in health care.
"The bottom line is: Thousands of people who do not have a doctor and don't get the care they need are going to get that," County Executive Ken Ulman said.
THE HEALTHY HOWARD PLAN
* $50 to $85 for one person earning up to 300 percent of the federal poverty level; A couple would pay up to $115 a month
* $100 fee for noncrisis emergency room visit
* $50 fee for urgent care center visit
Features of the plan
* Free or discounted prescription drugs
* Free immunizations, health screenings and inpatient hospital treatment
* Up to six doctor visits per year for men, seven for women
* Discounted dental services for an additional $19.80 per person per year (no vision services)
For the fiscal year ending June 30, 2009, the program would cost $2.8 million; the money is coming from several sources:
* $728,574 from participation fees
* $660,600 in donations
* $500,000 in county funding
* $75,000 in Health Department funds
* $1 million in grants applied for but not yet awarded
Source: Howard County Health Department