By Lori Aratani
Washington Post Staff Writer
Tuesday, February 24, 2009
What if you build it and they don't come?
Officials in Howard County thought their low-cost health-care program would be an easy sell in a community where an estimated 15,000 adults are without coverage. But nearly four months later, they are struggling to get people to enroll.
Turns out, Howard is not unique. In Arkansas, a statewide program offering coverage through small businesses has enrolled 5,000 people, even though it can accommodate 10 times as many. And in Massachusetts, where health coverage is required by law, more than 167,000 individuals are losing tax benefits because they haven't signed up for insurance.
As the Obama administration and the Democratic-led Congress work to fulfill President Obama's campaign pledge to extend health coverage to more Americans, the experiences of those jurisdictions demonstrate a frustrating paradox: Even when low-cost health coverage is offered, many people fail to take advantage of it. People don't think they need coverage, don't know programs exist or don't have the money to afford even comparatively inexpensive, subsidized programs.
As a result, the programs have stepped up their marketing efforts. Howard officials plan to increase outreach efforts to local college students and small businesses. They are even resorting to cold cash -- offering some nonprofit community groups $20 for each person they help recruit for the program.
But the numbers alone show how daunting the job is.
In 2006, about 12 million non-elderly uninsured Americans -- about one in four -- were eligible for existing state or federal health programs but weren't enrolled, according to a recent study by the National Institute for Health Care Management, a D.C.-based nonprofit group underwritten partly by insurers. In all, 45 million people are without health coverage, a number expected to grow as the economy sheds jobs.
Still, even if more programs are offered, experts said, there is no guarantee that uninsured individuals will take advantage of them.
John Gruber, a Massachusetts Institute of Technology economics professor who studies health-care issues, said there is a long history of voluntary coverage programs that have failed because too few people enroll. The reasons run the gamut: People don't think they need coverage, don't know programs exist or don't have the money.
Julia Flynn, who lives in Howard and runs a marketing business with her sister, fits two of those three categories. She does everything she can to stay healthy -- everything, that is, but buy health insurance. She said she can't afford the premiums.
"It's always on my mind,'' said Flynn, who uses holistic treatments to keep healthy. She hasn't had any serious medical problems, but "when something does come up and I have to see the doctor, it's very upsetting."
There's a chance she could be eligible for coverage under Healthy Howard, which offers care for as little as $50 a month, but she wasn't aware of the program, the first of its kind in the Washington region and one of two of its type in the country.
Policymakers "can't take it for granted that people will come to them," said Linda Blumberg, an economist and senior fellow at the Urban Institute's health policy center who has studied enrollment trends in federal programs. States and counties that want to offer such programs must realize that they have to devote sizable resources to recruitment, especially now that the faltering economy will mean a growing number of people who have not dealt with the public system could be looking for help, she said.
In Arkansas, the need for coverage was obvious. The response was puzzling.
"We knew there was a lot of need," said Julie Munsell, communications director for the Arkansas Department of Human Services, which launched ARHealthNetworks in December 2007. But "one of the things a lot of us underestimated was the interest and desire [for health coverage]. A number of folks said, 'I'm not sick, and I don't need it.' "
The lack of enrollment should not be taken as a sign that such programs are not needed, experts said.
"It really comes down more to the financial issue -- pay rent or pay health insurance," said Barbara Lyons, vice president of the Kaiser Family Foundation. "It comes back to not being used to having coverage or not knowing where to get it."
Shayla-Rene Little, a 24-year-old Howard County Community College student, went without health coverage for about three years because she couldn't afford it.
"I would just pray, 'Please, don't let me get sick,' " she said. Then, she did. A serious ear infection landed her in the emergency room. One of her instructors told her about the county's program. She decided to bite the bullet and come up with the monthly fee to enroll.
In Massachusetts, those who aren't covered tend to be "young, healthy people who sometimes think they don't need health insurance because they're not going to use it,'' said JudyAnn Bigby, the state's secretary of health and human services.
Recently, Massachusetts officials have emphasized that there are financial penalties for not having coverage, which is having some effect. The number of uninsured adults has dropped by nearly half, and Bigby said that more are expected to sign up for coverage, because financial penalties increased this year. Those penalties are designed to not exceed half of what a person would have to pay for the cheapest coverage.
Now that more people are covered, the amount the state spends on uncompensated care has dropped dramatically.
In Howard, the early response to the Healthy Howard program was so promising that officials worried that they might have so many applicants they would be forced to hold a lottery for the 2,200 spots. Howard officials spread the word about the program through the news media, community groups and medical providers serving the uninsured population.
But as officials sorted through applicants, they discovered that many were eligible for other state or federal programs and directed them there instead. By the end of January, although more than 1,500 of the estimated 15,000 uninsured people in the county had coverage, only about 109 were receiving it through Healthy Howard.
Still, Peter Beilenson, the county's health officer, said the process has been successful because more people now have health care. He said officials will expand their outreach to community college students and small businesses. The county also recently changed the program requirements to allow the newly unemployed to enroll sooner than previously permitted. Beilenson said he expects enrollment to grow, given the state of the economy.
"There are now more than a thousand people getting care who didn't have it before,'' Beilenson said. "We've cut by 10 percent the number of uninsured people with very little added cost, so from that perspective, it's been a tremendous success."