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Access to Health Care - Lessons Learned

(Nancy Weber) -- As Howard County prepares to launch Healthy Howard, its innovative health care access plan, it is useful to review Maine's experience as a leader in health care reform. Maine's 2003 Dirigo Health Reform Act sought to make affordable health insurance coverage available to every Maine citizen by 2009, slow the growth of health care costs, and improve quality of care.  The word "Dirigo" comes from Maine’s motto in Latin and means "I direct".  Dirigo was the first health reform act in the nation since the early 1990's.

Dirigo Health focuses on two major coverage initiatives: 1) a subsidized health insurance program, initiated in January 2005, for eligible small businesses, self-employed workers, and individuals; and 2) an increase in the annual income eligibility level (from 150% to 200% of the federal poverty level (FPL) in the state's Medicaid program, MaineCare, for parents of dependent children under age 19.

Based on income eligibility, individuals, families and small business employees receive varying subsidies to offset a portion of their monthly insurance premiums.  The subsidies are financed through cost savings, including the reduction of uncompensated care.

The insurance program began in January 2005. By September 2006, it had an enrollment of approximately 16,000, about half of the 30,000 expected to enroll in the first year and about 12% of the total uninsured population of 136,000 people in Maine

The Dirigo Reform premise is that through reduction in the number of uninsured people (by offering a subsidized insurance product) and expansion of state Medicaid eligibility, hospitals and physicians will experience less bad debt and charity care. As a result, the program should reduce cost-shifting to the insured and self-funded market.

Maine has learned unanticipated lessons from the Dirigo experience. Health care cost savings are far below what was anticipated. Savings from reduction of uncompensated care are not sufficient to sustain the program. In addition smaller numbers of small businesses are participating than expected.

Maine will need to study other state health reform programs and adopt successful features from those programs to secure a long term solution to health access for all its citizens. One issue it will need to address is the need to develop a broad based funding mechanism to secure adequate, sustainable finances for the program.  

By contrast, Healthy Howard has a number of unique features that will hopefully sustain long term success.  The first is a broad base of financial support that includes monthly fees paid by participants and support by local government, state and private foundations and donors.  Healthy Howard is incorporated as a 501(c) 3 non-profit service provider and is therefore able to accept charitable funds.  It also has broad based support from the medical provider community with Howard County General Hospital and outpatient specialty providers providing care pro bono.

Healthy Howard's most innovative component is the requirement that participants will be responsible for personal Health Action Plans and must make progress toward their health goals.  Goals are set in three month increments.  Each participant will be partnered with a health coach who will help members overcome barriers to improving health and achieving goals.  Participants who fail to make progress with their plans will be placed on probation for three months with the possibility of losing their care subsidies.  Studies have shown that people who take responsibility for their health and make lifestyle improvements have better health outcomes.

Another feature is the restriction to 2,000 participants for the first year and the requirement for evaluation of the initiative.  This model reflects a comprehensive public – private partnership including the Howard County Health Department, Howard County General Hospital, Chase-Brexton Health Center, Johns Hopkins Health Care and Quest Diagnostics.

It will be interesting to watch Healthy Howard and its impact on Howard County when the program opens October 2008.