Maryland county idea offers access for uninsured

Washington -- A wealthy Maryland county is working on a plan to provide at least basic health care to most of its 15,000 uninsured adults -- a concept that could be reproduced in many counties around the United States, its proponents say.

The proposal, announced by Howard County leaders in October, would provide free primary, specialty and hospital care; personal care plans; and prescription drugs to enrollees. Individuals would pay monthly premiums ranging from $50 to $85, depending on income. These premiums would cover the bulk of the program's $2.8 million cost.

"We have the opportunity to make Howard County the model health community," said Howard County Executive Ken Ulman, the county's highest elected official.

A few states and even the combined city/county of San Francisco have expanded health insurance coverage or access to health care through comprehensive reforms. But Howard County might be the first county-only government to tackle health system reform in a significant way.

About 20,000 of the county's 275,000 residents are uninsured. That figure includes 5,000 children, the vast majority of whom are eligible for Maryland's State Children's Health Insurance Program. County leaders hope to enroll as many eligible kids in SCHIP as possible by alerting their parents in letters from Maryland's comptroller that their children qualify, said Howard County Health Officer Peter Beilenson, MD, MPH.

The county hopes to enroll up to 12,000 of the 15,000 uninsured adults in the proposed health access program, called Healthy Howard. Many of the remaining 3,000 uninsured adults are likely young and healthy and not interested in paying for health care, Dr. Beilenson said.

Healthy Howard participants would be eligible for up to seven free primary care visits a year at the Chase Brexton health center and free hospital care at Howard County General Hospital. County officials are negotiating contracts with specialist physicians, Dr. Beilenson said.

The heart of Healthy Howard is its health action plans -- an attempt to manage chronic diseases better and improve enrollees' general health. Enrollees would be given one of six priority levels based on their health, with more attention for those with more chronic diseases.

Each participant would see a team of health specialists, including a dietitian, a social worker and a health educator, with whom unhealthier enrollees would have more frequent contact. Those who don't make progress on their health action plan would lose their subsidized access to the hospital, specialty care and prescription drugs.

Healthy Howard has its limits. It's not health insurance and wouldn't help residents traveling outside of the county. It wouldn't cover noncitizens, and -- at least for its first year -- it would be limited to 2,000 residents earning 300% or less of the federal poverty level, Dr. Beilenson said. Also, applicants would have to be uninsured for one year.

"It's not the perfect solution. But it is a model for what national health care reform should include," Dr. Beilenson said. If adopted in the spring as part of Howard County's 2009 budget, the program would begin enrollment on July 1, 2008.

Physicians' early views

Earl V. Wilkinson, MD, an otolaryngologist and president of the Howard County Medical Society, wasn't familiar with the details of Healthy Howard. But Dr. Wilkinson, speaking on his own behalf, said he knows one thing for sure about this type of plan. "You have to pay the doctors, or they're not going to want to participate."

He expects local physicians to give Healthy Howard a wary reaction based on their experiences of caring for people in the state's Medicaid program.

But Dr. Beilenson, who is negotiating contracts with physician specialists, said he's received good feedback. "The physician community has been very positive."

MedChi, the Maryland State Medical Society, hasn't taken a position on the plan yet. Martin Wasserman, MD, the society's executive director, said he is enthusiastic about Healthy Howard. He said Dr. Beilenson, former Baltimore health commissioner, wouldn't back a program that financially straps physicians or increases their administrative work.

"He understands the situation and the problems that physicians are having," Dr. Wasserman said.

Doctors should be interested in Healthy Howard because it doesn't involve insurance companies, he said. Health plans reimburse Maryland physicians at lower-than-average rates, he said. Insurance companies pay doctors there an average of 100% of Medicare rates, compared with 120% for the rest of the nation, according to analyses by the Maryland Health Care Commission and the Medicare Payment Advisory Commission.

A gubernatorial task force recently began examining physician pay and has been asked to submit a final report by June 30, 2008.

Could other counties imitate?

Although Howard County's median household income of $80,904 in 2004 ranks third in the U.S., according to the Census Bureau, other counties could still reproduce a Healthy Howard-type of reform without bankrupting themselves, Dr. Beilenson said.

The county's wealth, in part, makes Healthy Howard possible. The county government plans to contribute $500,000 toward the $2.8 million, first-year budget. That $500,000 represents only 0.06% of the county's $813 million 2008 general fund budget.

But perhaps more important, Ulman -- whose brother is a three-time cancer survivor -- and other Howard county leaders support health care reform, when most county leaders don't see it as a county-level priority.

"It is the political will that is allowing us to go forward. It is not the funding," Dr. Beilenson said.

Many counties might not have some of the resources needed for a Healthy Howard-type plan. For example, the proposal anticipates $700,000 in private donations. More than $200,000 was pledged in the first two weeks after the county unveiled the plan, Dr. Beilenson said.

Dr. Wasserman said it's premature to talk about other counties adopting Healthy Howard. But he believes the plan will be successful because it must be. "If this program doesn't work, it's not a good omen for the future of medicine and health care."