Health Reform Lessons

Howard County's Experience Shows Meager Subsidies Won't Help The Uninsured

August 16, 2009|By Ken Ulman and Dr. Peter Beilenson

The current debate on health care reform has primarily focused on two overarching goals: how to increase access to care by assuring that health coverage is available to all; and how to best control rapidly rising health care costs. Much of the discussion in Washington has been theoretical. Our experience is real-world. Every single day, we implement a universal health and wellness program that can inform both aspects of the debate.

The Healthy Howard health plan, launched in January of this year, is our health and wellness plan to cover the uninsured of Howard County - a jurisdiction of well over 270,000 people. In order to control costs, the plan is based on the "medical home" model of coordinated primary care delivery and includes hospital coverage and access to specialists. We use an evidence-based formula and help our participants take advantage of all existing pharmacy assistance programs that they would not otherwise know about, a proven method that has allowed our participants to drastically decrease their medication costs.

Every participant works with a health coach to develop and follow a health action plan that they have collaboratively developed by identifying key strengths as well as potential obstacles that might impede progress toward their goals. Our initial results are very promising - we are controlling prescription costs for both our members and the program, while significantly increasing our members' access to medications. Furthermore, our health coaching has demonstrated its initial effectiveness at increasing our members' healthy behaviors.

A full accounting of the cost-effectiveness of Healthy Howard - including anticipated decreases in unnecessary hospitalizations and emergency room visits - awaits the full-scale evaluation of our program now being conducted by the Johns Hopkins School of Public Health.

In the debate in Washington, one of the key mechanisms to obtain the goal of universal coverage is an individual mandate; in fact, it is included in all of the major Democratic proposals. Even though all of these plans include subsidies to help those with lower incomes to afford mandated coverage, they all require that the uninsured contribute up to 10 percent of their income to obtain coverage.

For a family of four making $60,000 a year (which is close to 300 percent of the federal poverty level) this means they would have to pay about $6,000 out of pocket for "affordable coverage" under most of the proposals.

Given the costs of housing, food and transportation alone, how can such a family be self-sufficient?

Our real-world experience seems to point out the folly of this approach. The yearly cost to our members (the eligibility criteria is 117 percent to 300 percent of the poverty level, or between $25,000 and $66,000 for a family of four) is between $600 and $900 per year, dependent on income. All of our participants have made their health and wellness a priority and have joined voluntarily. All have made the effort to apply, attend an orientation, provide required documents and met plan requirements.

And yet, despite all of these individual efforts, a sizeable number of our members (about 10 percent in each of the last couple of months) were in danger of being automatically disenrolled for failure to pay, either because of overdrawn bank accounts or declined credit cards - and all because they had trouble affording as little as $50 a month.

Yes, real people - not academic or political models - who simply can't make the $50 per month payment. Understanding that harsh reality, there is no way that even a modest number of working-class uninsured families making $50,000, $60,000 or $75,000 a year can possibly be expected to afford the monthly costs for health coverage now being proposed in Washington, particularly when many of them will feel that they are being coerced into participating. The result will be either large numbers of noncompliant families or more Americans placed in even greater financial jeopardy than they already are in.

Our health coaches see firsthand how financial insecurity directly impacts health. More than 40 percent of our members express concerns regarding finances and describe how the monthly struggle to survive financially greatly limits their ability to take charge of their health. Indeed, many of the health action plans developed have included goals directly related to improving members' financial well-being (i.e. debt counseling, budgeting skills, career counseling).

What is the solution? If we are truly serious about achieving health coverage for all - a goal shared by the vast majority of Americans - then health care reform must include the following: We must expand Medicaid eligibility up the income scale, without requiring onerous premiums; and, secondly, for those with incomes above Medicaid eligibility, more robust subsidies for working-class families are a must. Unless we make health coverage affordable, the president's goal of quality care for all Americans while controlling unnecessary costs will not be achieved.

Talk to us. We are anxious to share our real-world examples and experience.

Ken Ulman is the Howard County Executive. Dr. Peter Beilenson is the Howard County Health Officer. Their e-mail addresses are: kulman@howard countymd .gov and pbeilenson@howard countymd .gov.

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