Healthy Howard takes lead in county approach to federal health-care reform

Josh Curtis and Liddy Garcia-Bunuel, Healthy Howard's  deputy director and executive director, respectively, look over the nonprofit's 2012 budget.

It's been a local political football and a national cause célèbre, criticized for having a high cost-per-beneficiary using county dollars and lauded as saving lives.

Since its inception in 2008, the nonprofit organization Healthy Howard Inc., best known for its subsidized health-care plan for uninsured county residents, has left its mark on county politics and health policy. It has also lifted Howard County out of national health-care mediocrity — as a top-performing county, but in a middle-of-the-pack state, according to one recent study — and placed it at the forefront of the national health-care conversation.


Now, county officials are looking at the organization as the ace up their sleeves in dealing with what will be a massive roll-out of federal health-care reform in coming years.

It is the same reform for which Healthy Howard Inc. — which was "only created to fill a void left by inaction at the federal level," according to County Executive Ken Ulman — was once considered a substitution.


According to Dr. Peter Beilenson, head of the county Health Department, Healthy Howard is the department's most agile resource for interacting with residents looking for health coverage, a role that will become increasingly important as federal officials begin implementing the Patient Protection and Affordable Care Act, passed last year.

The law, if it survives a lawsuit challenging its constitutionality likely to be taken up by the U.S. Supreme Court next year, will require all residents to buy health insurance or face fines in taxes starting in January 2014. That requirement is expected to cause an influx of confused residents at local health offices upon implementation, officials said.

Healthy Howard, which was once assumed to have an expiration date that aligned with the implementation of the federal law, will instead play a continuing and prominent role in dealing with that influx through its Door to Health Care program, they said.

Opposition fades

It's an evolution of roles for the organization that has swayed some of its most outspoken critics, including County Council member Greg Fox, a Fulton Republican.

This May marked the first time Fox did not challenge the organization's funding during the county budget process. After years of opposition, Fox noted that his issues with Healthy Howard had diminished.

"I'm better with the new direction," he said at the time.

As it exists today, Healthy Howard is a multifaceted organization handling not only its well known health plan, but also "community wellness" programs and the "Door to Health Care," a program opened in January as a veritable clearinghouse for residents who are unsure of which, if any, existing health programs they are eligible for enrollment in, including Healthy Howard's plan, the Maryland Children's Health Insurance Program (MCHIP), Medical Assistance for Families, Pregnant Women and Children, and the Primary Adult Care Program (PAC).


The "Door," as it is referred to by Healthy Howard staffers, uses software the organization is piloting for the state to help residents complete an electronic application that not only determines potential program eligibility, but also collates needed documentation for enrollment. At times, pieces of that documentation are pulled directly from existing medical databases, including the Medicaid Management Information System, and the Client Automated Resources and Eligibility System.

Before the Door's launch, Beilenson shifted department staffers who work with program applicants into office space adjacent to that of Healthy Howard, furthering direct collaboration between them and streamlining the county's response to residents looking for coverage, he said. The result has been dramatic.

The program has caused a rapid increase in the number of residents whom Healthy Howard serves on a daily basis, partially cutting down criticism that it isn't a cost-effective use of the $500,000-a-year funding it has received from the county since its start.

Between Jan. 18 and Oct. 6, a total of 5,504 residents used the service, an average of 30 per workday, according to Lena Hershkovitz, Healthy Howard's enrollment manager. Many have found some sort of coverage through the process, she said. That, combined with the 750 or so clients enrolled in the organization's health plan, amounts to a large increase in impact, officials said, and that impact has changed minds.

Last year, County Council member Courtney Watson, an Ellicott City Democrat, joined Fox in an unsuccessful attempt to amend the county budget to cut funding to Healthy Howard in half, largely because she felt it wasn't serving enough people, she said.

"I felt that we weren't getting enough bang for our buck," Watson said.


This year, because of the increased service through the Door and increased enrollment in the health plan, Watson voted to approve full funding to the organization.

"Healthy Howard has evolved and taken on a new dimension with Door to Health Care," Watson said. "They're more relevant to a larger number of people than they were before."

Fox said that while he remains opposed to using county tax dollars to fund initiatives like health coaching, which is one of the plan's components, he is less critical of the Door because of its emphasis on connecting residents with existing programs.

Filling gaps

One such connection was made on a Wednesday morning this spring for Belen Fernan, 63, who moved with her husband from Cebu City in the Philippines to her daughter's home in Long Reach in June 2010. Three months later, while looking for jobs, her husband had a heart attack and died, leaving Fernan shaken and even more concerned about her own lack of health coverage, she said.

"We are old already," she said. "Anytime, we can get sick."


Though she said she was embarrassed asking for help from a government agency, Fernan met directly with Wendy Flores, a client assistant with the Door, to fill out an electronic application. As Fernan is just below retirement age and a permanent resident but not a citizen, her case was a difficult one. The application results showed she wasn't eligible for any state programs, only for Healthy Howard's plan, which Flores told Fernan would likely cost $50 a month. Fernan said she couldn't afford that, but agreed to have a meeting with Healthy Howard staffers the following week.

When the meeting took place, Hershkovitz said, the cost was still prohibitive for Fernan. But staffers suggested she apply instead for the Kaiser Permanente Bridge Program, which provides coverage to people in situations similar to Fernan's starting at $20 a month. Fernan is now enrolled in the program.

Moving forward, Healthy Howard Executive Director Liddy Garcia-Bunuel said the Door will increasingly become the organization's most active program, serving not only low-income residents eligible to enroll in state or federal health programs but also middle-class residents looking to enroll in federal health-care exchanges in 2014.

Shifting gears

That growth will come just as Healthy Howard's signature health plan becomes obsolete, Garcia-Bunuel said. Because it is not health insurance and would not meet the new federal requirement, Healthy Howard intends to discontinue the plan starting in the summer of 2013, with an emphasis on transitioning clients into federal exchanges.

As the plan "shrinks away to nothing," and the Door becomes "very robust," Beilenson said, Healthy Howard will take a new, leaner form that will "clearly need less than the $500,000" per year in county funding to maintain.


Ulman said that having the Door in place has put the county "leaps and bounds over folks around the country" in terms of preparation for the federal reform. Still, he and Beilenson said they are concerned that the federal government has not done adequate preparation.

Federal officials are "tragically naive" about the law's roll-out, Beilenson said. They are full of "pie-in-the-sky thoughts," Ulman said, and think they'll be able to "wave a magic wand" to settle confusion among thousands of residents.

Beilenson said he expects there will be "a deluge of people, and possibly an ongoing one," who show up confused at his department's offices after being warned of the federal law by mail, making the Door an invaluable asset.

"There's got to be real, live people helping people with this system, and it's not going to happen at the state level. It's going to happen at the local level," he said.

In providing that help, the Door will remain a strong program, he said.

But it's not the only Healthy Howard program he and others hope will continue beyond 2014.


Another one is the health-coaching component of the health plan, which pairs clients with coaches who help them set health goals and assess risk factors in their lives. The program could be getting new wind in its sails in the run-up to 2014. It just won a national Healthy Living Innovation Award from the U.S. Department of Health and Human Services, and recently received a grant to study ways to monetize itself by attracting paying customers — whose fees would subsidize the coaching of nonpaying customers, Beilenson said.

Such funding could be necessary once the health plan itself is discontinued.

Fostering wellness

Also likely to continue beyond 2014, officials said, is Healthy Howard's "community wellness" program, which was transferred to the organization from the county Health Department in October 2010. The program identifies and rewards schools, businesses and restaurants for pursuing health-oriented programs or innovations, said Robin McClave, Healthy Howard's outreach and community partnerships manager.

Rather than preparing for a 2014 end date, McClave said she is now working on expanding the program to include faith communities, individual family homes and recreation communities.

"We've made our society very convenient for all the things we have to do, and unfortunately, health hasn't been on that list," McClave said. "We want to change people's thinking."


One success story that was recognized by Healthy Howard occurred at Hollifield Station Elementary School in 2008, when administrators there made the decision to hold recess before lunch, instead of after. The result was that more students completed their lunches, and were more alert and engaged in the afternoon, said Patti Caplan, a schools spokeswoman. Schools throughout the county are being encouraged to follow a similar recess schedule.

Overall, Garcia-Bunuel said she has given no thought to closing up shop at Healthy Howard, only to fine-tuning programs, attracting more outside funding, ramping up the Door, and finding the best way to transition clients out of the health plan and into federal exchanges when the time comes, she said.

Josh Curtis, the organization's young deputy director, who started at the organization as an intern and now serves as Garcia-Bunuel's right-hand man, echoed those thoughts.

"It's about addressing fundamental issues that are a barrier to your health," said Curtis, a 2008 graduate of University of Maryland, Baltimore County.