From NPR News, this is ALL THINGS CONSIDERED. I'm Robert Siegel.


And I'm Michele Norris.

This week we're reporting on how the challenges of health care play out in one suburban county: Howard County, Maryland. It's a prosperous place not far from Baltimore - population 275,000. Robert went there to speak with all sorts of people involved in the issue. And it's a place we will return to as the national debate on health care progresses. Today, Howard County's plan for the uninsured.

SIEGEL: Howard County figured that 20,000 people who lived there legally, doesn't include illegal immigrants, 20,000 people had no health insurance. So last fall, the county launched a special program to provide the uninsured with access to health care. It's called the Healthy Howard Access Plan. It's still very new, but it offers lessons that could be applied nationwide. The Howard County Health Commissioner, the man in charge of Healthy Howard is Dr. Peter Beilenson.

Dr. PETER BEILENSON (Howard County Health Commissioner): Our Healthy Howard plan for a very, very modest fee of 50 to $80 per person per month, so between 600 and $900 per person per year, you get the following: You get six or seven visits, depending if you're a man or woman, to our primary care center. You get the hospital and emergency room costs waived. You have pro bono specialty services in about 17 different specialties, including mental health and substance abuse parity, in and outpatient. And dental is included, as well.

We have prescription medication subsidies for those that we're not able to get for people for free. We are leveraging existing pharmacy assistance programs that Big Pharma has out there, that almost no one who's uninsured knows about. And very importantly, every single person in our plan gets a personal health coach who doesn't call them, but rather, meets with them face-to-face and develops a health action plan.

SIEGEL: That is what Van Wensil was doing one recent morning in Rockburn Park in Elkridge, Maryland.

Ms. MAUREEN PIKE (Health Coach): Now, is this level of heat and humidity, is that hard on your breathing?

Ms. VAN WENSIL: It is. It's tough.

(Soundbite of wheezing and coughing)

SIEGEL: Van has COPD: chronic obstructive pulmonary disease. She lost her health insurance after her divorce several years ago. She is now unemployed in her mid-50s. Van Wensil was in the park to meet with her health coach, Maureen Pike. This was their second meeting, face-to-face in an informal setting on neutral ground. No office. No waiting room. No white lab coat. The emphasis of the action plan is on a healthful lifestyle, on taking responsibility for oneself.

Ms. PIKE: I'm going to grab out your action plan. I know last time we talked we made a couple adjustments. We had talked about maybe getting different shoes to walk in, if that was necessary. Is that something you still...

Ms. WENSIL: Yes, that's still a necessity. So...

SIEGEL: This is a wellness program. The point is to keep people healthy and out of the hospital emergency room. Van gets seven appointments a year with primary care physicians. And what she's most pleased with - Healthy Howard negotiates great bargains on her drug prescriptions.

Ms. WENSIL: I have four a month. And one was, alone, was $98 per, and now I get all four for 28, amazingly. I was stunned.

SIEGEL: Howard County Health Commissioner Peter Beilenson is both proud of the Healthy Howard program and mindful of the cautionary lessons he's learned in its first few months.

Lesson number one: the ranks of the uninsured include lots of people who are actually entitled to existing public coverage. Of those 20,000 uninsured in Howard County, 5,000 were children and about 25 percent of them were enrolled in short order in the existing Children's Health Insurance Program, CHIP.

Of the 15,000 adults under 65, about one-third of them also turned out to be eligible for some existing state or federal health plan, even though they didn't know it or hadn't bothered to enroll. Dr. Beilenson said that confirms what people think about the uninsured, nationally.

Dr. BEILENSON: In all the studies that we've seen nationally, show that between 25 and 30 percent of the uninsured in the country are eligible for existing entitlement programs, and either don't know it or don't sign up. That is an important lesson to be learned. Because of the 48 to 50 million uninsured Americans, you could say, even to be conservative about it, 10, 12, 14 million of them, you don't have to have any new program whatsoever. You just have to do better outreach and better targeting of people to get them enrolled in those programs.

SIEGEL: But words like outreach and targeting turn out to be much easier said than done, which brings us to the next lesson. Of the 10,000 uninsured adults who are eligible for Healthy Howard, people whose incomes are no more than three times the poverty level, how many have signed up for the program that was designed specifically for them?

Dr. BEILENSON: Two hundred are in the program fully enrolled and about 390 more are in the queue. They have passed screened eligible and are in the process of providing documentation to get enrolled.

SIEGEL: That is not quite 600 people, less than six percent of the 10,000 who are eligible. And it's been seven months. Dr. Beilenson admits that if the program had been deluged with thousands of applicants from day one, it would have been overwhelmed. But if health coverage is the huge concern that we think it is, and Healthy Howard is about as cheap as you can get it, why so few people?

Dr. BEILENSON: Clearly there are some, the young invincibles, the 22 to 25 to 35-year-olds, 40-year-olds who think...

SIEGEL: They're going to live forever.

Dr. BEILENSON: ... they're going to live forever. The costs are somewhat problematic, even though it's very reasonable, 50 to $85 per person per month, far less than insurance, it nonetheless is something. And for a lot of people who are having trouble holding jobs during this recession or have lost their jobs, economics plays some part of it.

SIEGEL: Even the cheapest health care program will strike some low-income working families as too costly.

Dr. Beilenson and others I asked about Healthy Howard cite another reason for the low enrollment - there just isn't adequate public awareness, they say. So the county has now added a marketing budget to get the word out. But the paltry enrollment figures have also confirmed Peter Beilenson's belief in the need for a reform that's not even on the Obama administration's agenda.

Dr. BEILENSON: I am 100 percent convinced that if we're going to have comprehensive affordable quality coverage for all and spread the risk amongst the entire population, you have to have individual mandates.

SIEGEL: That means people would be required by law to have health insurance, and that is something President Obama campaigned against.

Here's another question posed by Healthy Howard. The average American adult spends almost $8,000 per year on health care. The Howard County program charges no more than 10 percent of that. But it makes ends meet, in part, by getting specialist care donated pro bono. With just a few hundred potential patients, that's handled easily enough. But if the program were better subscribed, specialists would probably not donate that much service free of charge. And if they were reimbursed, the cost of the program would obviously mount. And then the question is, who pays?

Dr. Beilenson is a medical and public health professional, but he also knows a few things about politics. He grew up the son of a California Democratic congressman. He was health commissioner of the city of Baltimore and ran second in a Democratic congressional primary there. Can Washington cut through the Gordian knot this time? Or could it make some small incremental improvements? He says he thinks big reform is possible

Dr. BEILENSON: This is one of the rare instances, certainly in a generation, where at least most of the stars are coming together at the right time. My experience has been overwhelmingly, here in Maryland particularly, that if you make incremental changes, that's it for the entire term, the entire session.

You know, people will say that's health care reform for the year, or for two years, or for four years. That's what you'll hear. And with incremental change during the Clinton years, we actually have 12 to 14 million more uninsured now than at the beginning of the Clinton term. So I'm very much not an incrementalist.

The cut of the Gordian knot, I think, are twofold: if the federal government has an individual mandate plus subsidizes the cost to help those who couldn't otherwise afford to get it, I think that is the only way we are going to get to universal coverage.

SIEGEL: Dr. Peter Beilenson's aims may sound a lot more palatable in a wealthy county, in a liberal Democratic state, than they do elsewhere in the country. But they do reflect his experience of Healthy Howard. The incentives are impressively crafted, but so far they haven't gotten the county's uninsured to sign up in significant numbers.

NORRIS: And you can find a link to the Healthy Howard program and how the county's demographics compare with the national averages. That's at

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