Healthy Howard coverage expansion could inform future reforms

Howard County, Maryland is set to launch an ambitious universal health coverage, and the county’s top health officials says the effort will provide valuable lessons for future reformers.Fastfacts

Starting next month, 2,200 of Howard County’s 20,000
uninsured residents can enroll in the Healthy Howard Plan,
which will provide them access to primary, specialty and hospital care, and
prescriptions drugs for $85 or less a month.

Dr. Peter Beilenson, Howard County health commissioner and former Baltimore City health commissioner who ran for Congress in 2006, said this is the most ambitious local effort at universal coverage since San Francisco launched a universal coverage plan in April 2007.

Like Healthy San Francisco, Healthy Howard is not portable health insurance but rather health coverage for local treatment. Instead of levying a "pay or play" tax on businesses like San Francisco, however, Healthy Howard’s funding comes from individual premiums, county general fund dollars and substantial amounts of charity. (The Golden gate Restaurant Association is battling San Francisco in court over its tax.)

Beyond the grand ambition to provide universal health coverage, what Beilenson says  distinguishes Healthy Howard is its emphasis on personal responsibility, mandatory health coaching and a forthcoming rigorous evaluation.

Healthy Howard is built on the philosophy that health care is a right and a responsibility. Thus, each enrollee has to complete a health assessment and is assigned a health coach, who helps them reach the goals set in their "health action plan."

If participants are not "substantively compliant" (yet to be defined) with their action plan, they can be dropped from the program. But the coach’s job is to make it as easy as possible comply, Beilenson said.

For example, if a woman’s action plan requires her to exercise three times a week, but she says she can’t because she lacks day care, the health coach will help her find an affordable exercise option with day care, he said.

The health coaching is based on the strategy of telephone health coaches that many insurance plans offer, but Howard County’s will be local, hands-on coaches to increase relationship building and accountability. The decision to make it mandatory was hotly debated, Beilenson said, but ultimately it reinforces their philosophy of personal responsibility.

Meanwhile, all the participants’ activities and health care use will be tracked electronically. Researchers at Johns Hopkins School of Public Health will use that data to track health status changes, specialist, hospital and emergency room utilization. This will be one of the most rigorous analysis of its kind, Beilenson said.

In 1998, Beilenson founded Maryland’s Health Care For All movement. Despite, his history with health care bureaucracy, politics and unsuccessful reform efforts, Beilenson said working through the "nitty gritty details" of the Healthy Howard plan has been the most convincing evidence that a single-payer system is the most sensible reform option."The most equitable and fair system would be a single-payer system because it removes so many of the barriers and fragmentations of the current health care system," he said. "That being said, it’s not going to happen anytime soon so we’re doing the best we can in the county."

Healthy Howard relies on charity care from the local hospital, deeply discounted drugs from pharmaceutical companies and pro bono work from specialists. Beilenson knows the financing is unsustainable and doesn’t pretend otherwise. But he doesn’t think that makes the effort futile.

As long as national health care politics remain paralyzed, local and state governments will experiment with reform and coverage expansion plans. Evaluations of Healthy Howard and other regional efforts can offer valuable lessons about what does and doesn’t work to lower costs, keep providers and patients happy and improve health.

And in the meantime, thousands of Howard County residents will have affordable access to a doctor, prescription drugs and a personal coach to help them reach their health goals.

For local governments thinking about launching a health coverage expansion, Beilenson offered this advice:

1. Support from the county executive is critical. The political capital raised from a supportive county executive or another elected official makes an ambitious effort like this possible.

2. A health department willing to work hard to make such an ambitious plan possible. "This has been an immense amount of work," Beilenson said. "I would estimate that as a health officer well over half my time is spent on this, and two of the top three people in the health department spend two-thirds of their time on this."

3. Learn from Healthy Howard’s successes and mistakes. An initial evaluation should be ready within six to 12 months to highlight what aspects of the program are working well and not so well.

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  3. Health coaching is a quality way to institute behavior modification. As an individual health coach and health behavior corporate consultant, I have seen great results due to the individual attention, but there are no “profits” to be won from coaching: only healthier individuals who stay out of hospitals longer and/or more useful to work, community and family.
    Coaching doesn’t seem to be a business model for companies who sell drugs, fast junk food, or placebo pharma, nor for hospitals that want profit for its shareholders. However, there are countries in Europe which believe that health care is a right– and profits are downplayed in favor of health for its people. The return on investment for health coaches (and for passing on valuable health lessons within a family or business structure) is sky-high — however, if ROI is based on high profit instead of break-even or light profit, this health intervention won’t “work”.
    Yet, does public payment for unhealthy poor or middle-class Americans help the economy? No. Do other profit-based solutions based on profits work for the betterment of society as a whole? No. Do health-insurance scams work, either for the individual or the community? No. The USA healthcare system is based on making money from treatment, (or pharmaceuticals), not prevention, and even that system doesn’t work.
    Only behavior intervention can help those conditions which are directly related to behavior (not disease or orthopedics). If the citizens cannot make changes on their own, they need help to get them there.
    SOMEONE has to step to the plate and create a health system based on health, not profit. Who will have the guts to do that? Howard County, step on up; you’re on deck.

  4. “Beilenson knows the financing is unsustainable and doesn’t pretend otherwise.”
    Good luck to Howard but I doubt any universal plan can survive without the larger tax base of the federal government – along with price/cost controls. I wonder how many single-pay counties have to institute
    “mandatory health coaching”? Not one I bet. Easier just to tax fast food and give proceeds to healthcare.