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Keeping Howard Healthy

Can an experimental program in the richest county in one of the richest states influence the nation’s health care reform agenda?

By Jonathan Bor

Eighteen months ago, Elizabeth McCarthy lost her auto sales job and the health insurance that went along with it. She and her husband, Jay, realized that if they got sick they’d have to reach into their own pockets or forgo care altogether. As it turned out, they did a little of both. Jay spent nearly $500 on medications to quell spring allergies that may have been exacerbated by the chemicals he uses in his furniture refinishing business. Elizabeth decided against seeing a doctor for a new prescription of the anti-anxiety drug she’d been taking for several years. And after slipping and cracking her elbow on her icy front stoop, she toughed out months of pain rather than pay for X-rays and treatment.

“I just hoped we wouldn’t get in a wreck or something,” says Jay, 57, who lives with his wife and 9-year-old daughter, Jillian, in a comfortable house in Ellicott City, Md.

The McCarthys are among the estimated 48 million people across the country without medical insurance. The problem was growing at a rapid clip even before the recent meltdown of the national economy, increasing by almost 8 million people between 2000 and 2008. Now, as the unemployment rate rises, health economists worry that the uninsured could swell by millions more.

The repercussions are well-documented: delayed care, large out-of-pocket expenses and over $40 billion nationally in uncompensated care that forces up premiums for those with insurance. An uninsured American receives less preventive care, gets diagnosed later and, once diagnosed, has a greater chance of dying than someone with insurance.

For the McCarthys, this was a reprise. They first lost coverage in the early part of the decade, when Elizabeth, now 50, lost her job selling homes in new developments. Not long after, she spent three days in the hospital where she incurred a $5,000 debt that still dogs the couple today.

Losing health insurance for a second time brought a new round of anxiety. But last fall, they were surprised to learn they were eligible for a new program called the Healthy Howard Access Plan. For a low monthly premium, the plan provides an array of primary care and specialty services along with subsidies for prescription drugs. Among the first residents to enroll in the program, the McCarthys are now part of an experiment to see if—in the absence of comprehensive national reform—a county going its own way can ease the health insurance crisis within its borders.

The richest county in one of the nation’s richest states—with a median household income of $101,000 and a 7 percent uninsured rate that’s less than half the national average—Howard may be more primed for success than most jurisdictions. County Health Officer Peter Beilenson, MD, MPH ’90, who during his 13-year stint as Baltimore health commissioner founded a universal coverage movement called Maryland Health Care for All, went to work on Healthy Howard soon after assuming his new post in February 2007. He says he’s first concerned with the “parochial” goal of bringing relief to thousands of uninsured Howard residents. But he hopes that success will ultimately have the broader effect of prodding state and even national leaders into action.

“Frankly, the reason we did this in Howard is that we’re tired of waiting for things to happen,” says Beilenson, who testified on the issue before a U.S. Senate committee in February. “We didn’t need anyone else’s approval to do this. But on the grander scale, our goal is to influence what comes out of Washington.”

David Holtgrave, chair of the Bloomberg School’s Department of Health, Behavior and Society (HBS), calls Healthy Howard “a proof of concept.” Says Holtgrave, PhD, who will be evaluating the program, “If this works in Howard County, an interesting next study would be to see if there are another five to 10 counties across the country that have wider ranges of income and challenges. They could serve as demonstration projects.”

The McCarthys were the sort of family that county leaders had in mind when they went about crafting their Healthy Howard Access Plan. Started in October 2008, it provides services to uninsured residents who earn too much to qualify for Medicaid but not enough to afford the high cost of individual coverage. To qualify, people must earn somewhere between 116 percent and 300 percent of federal poverty (or $25,000 to $66,000 for a family of four), and pay $50 to $85 a month depending where in the spectrum they fall. Jay and Elizabeth McCarthy pay a combined $115 for dual coverage. (A staff member also helped them enroll their daughter in the state and federally funded Maryland Children’s Health Program, for which they had no idea she was qualified.)

Healthy Howard isn’t exactly health insurance, but a network of services that includes up to six primary care visits per year at the not-for-profit Chase Brexton Health Services clinic in Columbia, Md., and pro bono services from a bank of 200 specialists in 17 fields. With permission from a state regulatory commission, Howard County General Hospital has agreed to provide free hospitalization to members, forgoing the usual procedure under Maryland’s all-payer system of pursuing collection from uninsured patients. Johns Hopkins Hospital and the Maryland Shock Trauma Center have stepped up too, agreeing to see patients who need care unavailable at Howard County General. The program transfers members requiring very costly treatment to the more inclusive Maryland Health Insurance Program (MHIP) by paying down the required $4,500 deductible. Then they are left to pay the somewhat higher MHIP premium.

There are notable limitations: Healthy Howard provides no coverage outside the area, so members who get sick or injured while traveling are out of luck. Also, it doesn’t cover the county’s undocumented immigrants, who may number in the thousands. But it may be the only public program in the nation to require that enrollees meet periodically with health coaches, who help them set and meet goals such as losing weight or lowering blood sugar through diet and exercise. In this way, the Howard plan is partly an experiment in prevention—an effort to see if the county can offset costs by helping residents forestall ailments that are expensive to treat. “The philosophy is that health care is a human right but also a responsibility, both financially and behaviorally for participants,” says Beilenson.

Beilenson has sown seeds of reform since the late 1990s when he founded the Maryland Health Care for All Coalition, a small collection of doctors and health policy experts who agitated for statewide universal health coverage at a time when the momentum nationally seemed to have stalled out (see related story).

That work caught the eye of Howard County Executive Ken Ulman. Two years ago, he tapped Beilenson to become his chief health officer and transform the county into a model public health community. Beilenson’s central challenge: Craft a health care plan for some of the estimated 20,000 residents without insurance.

Its architects drew ideas—if not the precise details—from San Francisco, which covers people making less than 400 percent of poverty but relies on an existing network of public clinics and hospitals. They also looked to Muskegon, Mich., which offers a health access plan that covers a limited number of clinic visits and is funded in equal shares by employers, members and the city.

The Howard County reformers ended up with a homegrown plan that taps the altruism of community specialists and makes use of a clinic, Chase Brexton, with long experience delivering care to uninsured and marginally insured patients. And it requires nothing of local businesses.

“We’re not obligating businesses that for the most part are doing the right thing, and we didn’t want to compete with those already offering health insurance to their employees,” says Elizabeth Edsall Kromm, PhD ’08, an adjunct professor in HBS at the Bloomberg School, who directs Howard County’s Bureau of Healthy Community Development.

Also, neither the San Francisco program nor the Muskegon program required health coaching, a concept that some insurers have applied to members with chronic illnesses. But Howard County is betting that coaching for everyone, regardless of health status, will pay dividends in the
long run.

“Good health coaching is rooted in the development of a trusting, caring relationship between patient and coach and allowing patients to drive the agenda to a large extent,” says Glenn Schneider, director of health planning and policy for Beilenson. “Long term, our coaching process will hopefully result in healthier patients—ones that have better health outcomes and avoid costly hospital stays.”

According to Holtgrave, there really is no model for what Healthy Howard is doing, so the county may provide the first data of whether coaching saves costs in the long run. In theory, coaches can hold members accountable for complying with mutually agreed-upon plans and can terminate members for nonadherence. But Maureen Pike, a registered nurse who is one of four coaches with the plan, says she and her colleagues expect to function more as guides than enforcers, and don’t expect to cut many patients loose.

“We’re not telling people what to do,” she says. “The goal is to sit down with people and get to know them. What is it about their health they’d like to work on?” Ultimately, they will look for signs that people are trying, whether or not they achieve hard results.

So far, coaches have met with Howard County residents who struggle to gain or lose weight and members so overwhelmed by family stresses they can’t begin to think about their health. They have linked patients to social service agencies that can help them pay bills, arrange for the care of an elderly parent, and find cheaper gym memberships.

Not everyone supports the new initiative. Although Howard County Councilman Greg Fox has derided many elements of the plan (including premiums that he says may cost the average healthy resident more than simply paying out of pocket for care), he reserves his harshest criticism for health coaching. Fox, who as the council’s lone Republican cast the only dissenting vote, said he could hardly believe his eyes when he read a handout describing suggestions a health coach could make. “Meet with a dietitian to prepare at least four healthy dinners? Join a gym? You’ve got to be kidding!” Such advice, he says, strikes him as mere common sense, hardly worth the salaries paid to the coaches.

But Elizabeth McCarthy says she could really use a helping hand in meeting personal health goals such as controlling anxiety and losing weight. “I’m having trouble on my own implementing a diet that the whole family can get on board with,” she says. “I don’t think doctors always have time to explain, to help you implement things into a plan.”

When Howard held enrollment sessions in libraries and other venues last fall, about 1,100 people showed up to apply. This was half the first-year goal of 2,200 people, and the health department quickly discovered that most of them qualified for Medicaid and other programs they didn’t know they were eligible for. By early June, the county had enrolled more than 200 people in Healthy Howard and had helped 2,400 others sign up with federal or state programs for which they hadn’t known they were eligible.

Fox cites the relatively small number of people enrolled in Healthy Howard as evidence that the program isn’t worth the $500,000 the county is spending on it in the first year. (The Horizon Foundation has kicked in an additional $500,000 toward the program’s annual budget of about $1.5 million, with remaining revenues expected to come from patient fees.)

But Beilenson argues the county is merely doing the right thing by linking residents to insurance that doesn’t cost the county anything. “It’s really an indictment of the current system,” he says, noting that American health care is so “fragmented” that many people don’t know how it works.

In evaluating the program, Holtgrave will be asking many questions: What are its costs? What health problems do its members have upon entry? Are they receptive to their coaches? What, for instance, has happened to important markers such as blood pressure or body mass index since people entered the program? Healthy Howard isn’t large enough for a randomized trial comparing people inside and outside the program, so he plans a smaller descriptive study of a few dozen patients.

“This is really a pretty interesting proof of concept in Howard County,” Holtgrave says. “It’s an affluent county, and it’s a good test to see if you’re able to construct this provider of last resort. As we look at other counties, the size of the population may be larger and the health needs greater, but it’s good to see if you can prove the concept and then go forward.”

The McCarthys are optimistic that Healthy Howard will work for them. Already, Elizabeth has made an appointment for physical therapy that she hopes will help ease the pain of her arthritic back, and she expects also to see a podiatrist about a foot problem. Her primary care doctor is requesting prior medical records so he can decide how best to treat her anxiety. Jay has learned that his blood pressure and cholesterol levels are normal, and has talked to his doctor about additional tests that could determine if he’s suffered kidney or liver damage from the fumes he inhales at work. And both look forward to their first coaching appointments.

“Knowing that we have a health plan in effect means that if I get hurt, I can go get treated,” says Jay. “It’s peace of mind.”