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The
Brooklyn Borough President's Northern Brooklyn Health Consortium
Brooklyn,
NY
April
2000
§ Background
Many of the
consortium members have been engaged for several years in building
comprehensive and cohesive neighborhood healthcare alliance and
examining community healthcare needs. One very special effort is
the Brooklyn Health Connection. This alliance is made up of more
than 130 community organizations. Brookdale University Hospital
and Medical Center with the assistance of The Brooklyn Hospital Center
spearheads this effort. The community needs assessment work
undertaken through the Brooklyn Health Connection will serve as the
springboard for expansion into this larger target area.
The Brooklyn
Health Consortium is another partnership of community-based
organizations, neighborhood groups and local businesses including SUNY
Health Science Center in Brooklyn, Kings County Medical Center and
Brooklyn College Center for Health Promotion of the City University of
New York. Projects and programs have been developed with the New
York State Department of Health, the City Department of Health and the
Centers for Disease Control and Prevention.
The Brooklyn
Borough President's consortium members include:
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The Brooklyn
Chamber of Commerce
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The Brooklyn
College Center for Health Promotion
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The
Community District Planning Boards for the seven community
districts representing Brooklyn
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The
free-standing primary care centers located throughout the region
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The faith
organizations, social service groups, and healthcare advocacy
groups
Until the very
recent passage of statewide legislation, there was no organized
insurance coverage for uninsured adults. In 1994, the state
underwrote demonstration programs for the children that in 1996 were
written into law. The Child Health Plus Program provides a
health benefit package to all children under the age of nineteen who
are uninsured and do not qualify for Medicaid. Participation is below
expectations, with a total enrollment of over 292,000 statewide,
152,400 are enrolled in New York City. In Brooklyn, 69,000 are
enrolled.
In January 2000,
the state passed new legislation to finance a similar program for
adults that exists for children, called Family Health Plus. This
fully insured direct subsidy is to be targeted to families up to 150
percent of the Federal Poverty Level who meet Federal Medicaid
residency requirements. Federal approval is anticipated during
2000 with implementation to begin January 2001.
Historically,
New York State has a longstanding commitment to funding healthcare
services for the uninsured. Among its various approaches is the
bad debt and charity tax on commercial carriers that in 1998 generated
$786 million in revenue, this is expected to grow to nearly $900
million in 2000. Bad debt and charity care providers who treat
the uninsured to compensate for previous levels of charity care.
With regard to
small businesses, other state legislated insurance subsidies exist in
the form of vouchers and small business partnerships. In January
2000, the state legislature reconfigured its approach and added a stop
loss fund for individuals and small group purchases of insurance to
cover the cost of catastrophic care. The availability of this
pool will lower the cost of premiums and risk among insurance carriers
to underwrite insurance products in this market.
While
community-rated programs have increased access to small businesses,
those most able to afford coverage have income above 200-250% of the
FPL. Therefore, despite New York's efforts to expand affordable
insurance to the uninsured, significant gaps still exist in the
affordability of health benefits for persons/families with income at
or below the 200% of the Federal Poverty Level.
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§ Guiding
Principles
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Typical
of the small business insurance market, cost effiecieny is extremely
attractive. We will seek to tailor the benefits package and the
delivery system to the needs of our targeted population. We believe
that price will be central to the successful design of our approach.
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The
uninsured population we seek to target will most likely to be found in the
so-called small business group market. Our product will likely utilize
a similar healthcare benefit design as in prevalent in this market.
This design may exclude some of the benefits available under Medicaid
fee-for-service and the Medicaid benefit design may prove to be too costly
for this demonstration to succeed in the early years.
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Conceptually,
we will seek participation from our provider network with discounted fee
schedules designed as part of this benefit package and a modest co-payment
from the uninsured person using an agreed upon sliding scale approach.
The issue of participant contribution to the cost of the premium will also
be examined. Contributory plans are difficult to market and often
confused by network design and choice features that require higher
premiums. Often these products are unaffordable for the lower income
uninsured working families and individuals.
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We
will examine supplemental benefits, such as social services.
Prescription drug riders in today's marketplace are becoming quickly
affordable for even the middle class. Nevertheless, feasibility will
be explored, as will all other aspects of a comprehensive health benefit
package.
The
above aspects of the benefit design will require concentrated analysis, market
research and focus group studies. This is also an area where the office of
the Borough President will be utilized through its community development
efforts, particularly among small businesses in the Borough.
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§ Initial
Project Objectives
The
Brooklyn Borough President is leading an alliance of healthcare providers,
academic institutions and community organizations to form the Brooklyn Borough
President's Northern Brooklyn Health Consortium (NBHC). The development of
an insurance product for the uninsured product for the uninsured is a natural
progression of the consortium's objectives. Foremost among its objectives
is the development of a financially sound and accessible healthcare delivery
system for the uninsured that will have value to healthier uninsured
individuals. At the same time, it will be affordable to those with greater
healthcare needs.
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Financing
& Outreach Strategy
Financing
Strategy
How an insurance
product is underwritten is a significant issue for the consortium.
This requires the establishment of a dedicated fund or long-term
funding approach for the uninsured. The nature and form of a
dedicated revenue stream will include, among others, using premiums,
co-pays, and deductibles; accessing existing revenues to providers for
bad debt and charity care; seeking waivers from insurer taxes that
underwrite bad debt pools; and subsidies based on ability to pay.
Through the work
of its technical committees, consortium members will be exposed to the
factors that of into developing an insurance product.
Underwriting, risk factors and other insurance issues that will
require resolution during the planning grant year.
As part of the
Brooklyn Borough President's Northern Health Consortium's approach to
building a community-based healthcare program for the uninsured, the
consortium will apply for funding from these sources once we have
developed the appropriate program and funding vehicle.
The consortium
will actively pursue other funding sources and contracts with New York
State such as through state sponsored health insurance partnerships
and its grant funding mechanisms. Once the product is designed,
priced and readied for the marketplace we will seek formal recognition
of it in our state legislature, the State Insurance Department and
Health Department, the Federal Public Health Service, HCFA and other
federal agencies that have a stake in finding permanent solutions for
the uninsured.
Outreach
Strategy
Based on their
community assessments, the consortium will participate in the work of
the Brooklyn Borough President's Northern Brooklyn Consortium
regarding community assessment and consensus building processes, and
the development of education, outreach, and marketing strategies in
their respective communities.
Delivery
System
Much work has
been accomplished with regard to the network development and community
needs assessments. This network includes not only the hospitals,
but also many of the social service agencies and community-based
providers within our target area.
As managed care
principles play such an important role in the healthcare delivery
system, the consortium hospitals have been engaged in care management
practices, network development and management information systems
improvements for many years. They sponsor Medicaid managed care
plans, physician practice plans and engage in risk contracting.
Venturing into the development of an uninsured health plan and
delivery system is a logical and natural progression.
With regard to
participation in the service delivery network, financial feasibility
will be a major factor. The health benefit package for the
uninsured must be affordable. A decision by providers to accept
discounted fee schedules is a matter of choice. Pricing
decisions will be a matter of consortium involvement and
agreement. Effective medical management policies and low
administrative costs will also enhance our network service delivery.
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Challenges
Affordability of
healthcare coverage plays a significant part in the number of
uninsured New Yorkers. The portion of the poor and working poor
in our Northern Brooklyn targeted communities make it difficult if not
impossible for our residents to either afford healthcare premiums or
to contribute to employer sponsored programs. We believe one of
the more difficult challenges will be to determine the nature and
extent to which uninsured persons can or will contribute to the cost
of care, be it a co-payment, a deductible, and/or premium
contribution.
Evaluations of
the New York State's Child Health Plus Program show that complicated
enrollment applications and lack of comprehensive marketing strategies
have hampered the success of this program in reaching its target
population. We believe that our consortium's outreach
efforts are informed (and will benefit from) the problems experienced
elsewhere. As a strategic approach the consortium will explore
the most sensible and direct ways to reach its audience more
effectively through community-based organizations, faith organizations
and through the Brooklyn Chamber of Commerce.
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§
Demographics
The communities
that make up the Northern Brooklyn area are characterized by either
their poverty or near poverty profile. Our targeted communities
reflect a population of considerable economic, cultural and ethnic
diversity. Significant inequities in health status accompany
this diversity. Within Northern Brooklyn resides a substantial
number of working poor. Typically, they are employed in part
time jobs, in small businesses, self-employed, non-unionized and in
service industries, all of which are characterized by lack of
insurance coverage.
The need for
insurance products for the uninsured is indicated by the structure of
business entities in our targeted area. It is characterized by a
preponderance of small businesses with fewer than four
employees. Nearly 11,500 businesses are located in our targeted
area, constituting one-third of all establishments in Brooklyn.
Of that number 9,900 small businesses, or 86 percent, have fewer than
20 employees.
Nationally, less
than half of firms with fewer than ten workers offered health benefits
in 1998. As part of a comprehensive survey of small businesses,
over two-thirds cited that "premiums" were too
expensive. the seven communities that constitute our proposed
targeted area are Williamsburg/Greenpoint, Fort Greene, Bedford
Stuyvesant, and Ocean Hill, Bushwick, Crown Heights, Brownsville, and
East New York. the population of the targeted area is 835,000.
While the
precise number of uninsured persons residing and/or working in
Northern Brooklyn is unknown, we can estimated possible ranges based
on socio-demographic characteristics. Among New York City
residents, an estimated 27.8 percent are without health
insurance. Applying this 27.8 percent to the total population of
our targeted area yield an estimated 235,000 uninsured persons.
Children under the age of 19 would be channeled into Child Health Plus
Program, several of which are operational in the Borough. With a
focus on adults between the ages of 19 and 64, we project 200,000
uninsured persons would qualify for this demonstration project.
Once fully operational, our goal would be to reach 25 percent of these
individuals in year one, 35 percent in year two and 40 percent in year
three.
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§
Contact
Us
Nancy
Gaeta, M.S.
Principal/Consultant
Program
Planners, Inc
230
West 41st Street
New
York, NY 10019
Phone:
212-840-2600
Fax:
212-769-4094
E-mail:
ppi@bway.net
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