With a far more contentious hearing than expected before the Supreme Court, President Barack Obama's Affordable Care Act (ACA) could be struck down by a sharply divided court when it rules in June. If that happens, insurance will continue to be priced beyond the means of many. It is therefore prudent to look at possible alternatives for these Americans.
Fortunately, a proven model exists today in Howard County: the Healthy Howard Health Plan. With some changes to its financing structure, it could emerge as a viable option for Americans who will not be able to afford to buy insurance should the ACA be struck down.
Initiated in October 2008, Healthy Howard provides comprehensive, affordable health care to working-class families and individuals who have incomes higher than the eligibility level for entitlement programs like Medicaid, but still too low to afford private health insurance. Based on the primary care "medical home" model, with an emphasis on wellness and preventive services, Healthy Howard uses a local, federally qualified health center as our primary care home, paying the health center a monthly capitated rate for each Healthy Howard member, funded by the modest premiums ($50 to $85 per month, depending on income) paid by each member. These premiums also pay for contracts for lab work and most imaging procedures.
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At the primary care home, a dedicated care coordinator acts as the point person for managing routine referrals and necessary follow-up for members recently discharged from the hospital. This latter service has been extremely important in Healthy Howard's success at reducing so-called "admission-readmission rates" (where recently hospitalized patients are readmitted, often due to lack of appropriate follow-up care). Additionally, our system of after-hours phone triage, combined with subsidized coverage of urgent care visits, has averted costly emergency room trips. Taken together, these facets of the Healthy Howard plan have resulted in a 50 percent reduction in hospitalization rates and a 35 percent reduction in emergency room visit rates among our members, compared to the same demographic group across the United States.
Another cost-effective service is our innovative model of health coaching. Each Healthy Howard member is offered a health coach who meets face-to-face with the member to develop a personalized health action plan. Using this collaborative approach, which fosters individual responsibility, members have shown significant improvement in their ability to positively affect their own health and increase their practice of healthy activities (according to a Johns Hopkins study of the program). By improving their health and avoiding development of expensive chronic conditions, like diabetes, further cost savings accrue.
Specialty services are provided by a network of specialists, with most specialist care given pro bono. Clearly, this is not a viable solution to take such a program to scale. One very promising alternative to provide funding for specialist care is the little-known "Community Benefit Dollars" system under which not-for-profit hospitals must provide funding for community benefit activities to maintain their IRS status as a nonprofit. In most states, these funds go to a scatter-shot range of projects, like sponsorship of charity walks and disease education classes. We propose that a set percentage of community benefit dollars be reserved to pay for specialty care benefits under a Healthy Howard-type plan.
Finally, for hospital coverage, a combination of funding sources could be employed, primarily member premiums and existing programs to subsidize the costs for the uninsured. Maryland has the "all payer system," whereby the cost of uncompensated care is borne by all payers to a given hospital through higher rates for insured patients at the same institution. In the rest of the country, charity hospitals providing uncompensated care are mostly reimbursed by Medicare. We argue that eligibility for hospital care provided without billing the patient be limited to those with incomes above Medicaid eligibility levels up to 300 percent of the federal poverty level (between $28,000 and $66,000 for a family of four, for example). Further subsidies could be provided by progressive county or state governments in the form of tax credits or the like.
Should the Supreme Court strike down the ACA, states and counties around the nation could, by building on the existing model of Healthy Howard, take on the role that our federal government should have assumed long ago: insuring access to health care for all.
Ken Ulman, the Howard County executive, and Dr. Peter Beilenson (email@example.com), the Howard County health officer, are founders of the Healthy Howard Health Plan.