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Healthy Howard Access Plan: A Closer Look

(Peter Beilenson, MD, MPH) -- Although Howard County is often perceived as a haven from some of the problems affecting the rest of the region, a substantial population in the county has significant social needs.  Primary among these is access to health care; approximately 20,000 Howard Countians are uninsured this year.  

The presence of the uninsured population is a serious issue for several major reasons.  The uninsured have virtually no access to primary and preventive care, and thus are much less likely than the insured to get screened for early identification of treatable conditions.  Uninsured folks also are much less likely to get care and be able to afford medications to manage chronic illnesses than those with health coverage.  

Lack of insurance affects the broader community. What few know about Maryland's health care system is that about $1,000 of the premiums paid by the typical Maryland family with health insurance goes directly to covering the cost of hospital and emergency room care of the uninsured.  That's right—those with insurance are currently paying a "hidden health tax" to provide late and expensive care to the uninsured.  Doesn't it make much more sense, from both a moral and financial standpoint, to assure that the uninsured get access to primary and preventive care?  To address this serious problem, we have developed the Healthy Howard Access Plan.

This plan is based on three basic tenets:  increasing access; overcoming barriers to healthy living; and improving health.  To participate in our program, individuals must meet two major eligibility criteria:  they must be legal residents of Howard County for at least one year; and they must have been uninsured for at least a year (the latter to avoid the problem of companies "dumping" their insured employees into this plan).  Participants in our program will gain access to primary care (through the Chase-Brexton practice), mental health and substance abuse services, steeply discounted prescription drugs, and specialty care for a variety of conditions, including heart disease and stroke, asthma, diabetes, and chronic obstructive pulmonary disease.  Those diagnosed with cancer will be enrolled in the Maryland Health Insurance Program—a state-based program for the medically uninsurable (Healthy Howard will pay the high deductible, to make the monthly premiums much more affordable for the individuals with the diagnosis).  Howard County General Hospital has agreed to forgive debt for our patients—a huge deal, because medical debt is the leading cause of personal bankruptcy and credit ruination.

While we strongly believe that health care is a basic human right, we also feel it is a responsibility, both financially and in terms of actions.  To that end, participants will be required to pay nominal monthly fees to join the program (between $50 and $85 per month, depending on income level) and they will be expected to work with a health coach and follow a health action plan developed specifically for them.

The health coach approach is intended to help the participant overcome barriers to healthy living.  By working with the coach and his/her primary care provider, the participant will develop a health action plan with measurable goals.  The health coach idea is not new. It has been used for several years in the management of certain chronic conditions. What is innovative in our plan is that all of our participants will work with coaches, and the action plan will be community focused.

How will this work?  Let's take a typical patient with one chronic condition—a 60 year old diabetic, who doesn't exercise and is a bit overweight.  His or her health action plan might include nutrition classes, participation in the Living Well program run by the Office on Aging, quarterly blood glucose tests and diabetic foot checks at his/her primary care doctor, and exercise three times a week.  Different members of our health coach team would take on different aspects of the plan: the nutritionist would deal with certain parts; our community benefit coordinator would work to get the patient into low cost exercise programs through the Columbia Association or the Department of Recreation and Parks.  Keeping with our philosophy of rights and responsibility, if the participant does not substantively comply with the action plan, he/she would eventually lose some of the array of services the program provides.

All of this is geared toward one overarching goal:  improving the health of our participants, and by extension, of the community as a whole.  To that end, we will be working with faculty from the Johns Hopkins School of Public Health to evaluate the impact of our program, by posing two major questions.  Does providing access to this array of services, combined with a health action plan make a difference in the health status of our participants?  And, cumulatively, does inappropriate utilization of emergency room services and potentially preventable hospital stays decrease?  If the answer to both those questions is yes, as we believe will be the case, then our program will not only improve the health of Howard Countians but may influence state and national health policy as well.