```

[Senate Hearing 111-356]
[From the U.S. Government Publishing Office]

                                                        S. Hrg. 111-356
 
           HEALTHY HOWARD: IMPROVING CARE THROUGH INNOVATION

=======================================================================

                             FIELD HEARING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                     ONE HUNDRED ELEVENTH CONGRESS

                             FIRST SESSION

                                   ON

 EXAMINING HEALTHCARE IN HOWARD COUNTY, MD, FOCUSING ON IMPROVING CARE 
                           THROUGH INNOVATION

                               __________

                    FEBRUARY 17, 2009 (COLUMBIA, MD)

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions

  Available via the World Wide Web: http://www.gpoaccess.gov/congress/
                                 senate

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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

               EDWARD M. KENNEDY, Massachusetts, Chairman

CHRISTOPHER J. DODD, Connecticut     MICHAEL B. ENZI, Wyoming
TOM HARKIN, Iowa                     JUDD GREGG, New Hampshire
BARBARA A. MIKULSKI, Maryland        LAMAR ALEXANDER, Tennessee
JEFF BINGAMAN, New Mexico            RICHARD BURR, North Carolina
PATTY MURRAY, Washington             JOHNNY ISAKSON, Georgia
JACK REED, Rhode Island              JOHN McCAIN, Arizona
BERNARD SANDERS (I), Vermont         ORRIN G. HATCH, Utah
SHERROD BROWN, Ohio                  LISA MURKOWSKI, Alaska
ROBERT P. CASEY, JR., Pennsylvania   TOM COBURN, M.D., Oklahoma
KAY R. HAGAN, North Carolina         PAT ROBERTS, Kansas
JEFF MERKLEY, Oregon

           J. Michael Myers, Staff Director and Chief Counsel

     Frank Macchiarola, Republican Staff Director and Chief Counsel

                                  (ii)

  
?

                            C O N T E N T S

                               __________

                               STATEMENTS

                       TUESDAY, FEBRUARY 17, 2009

                                                                   Page
Mikulski, Hon. Barbara A., a U.S. Senator from the State of 
  Maryland, opening statement....................................     1
Sarbanes, Hon. John, a U.S. Representative from the State of 
  Maryland, opening statement....................................     2
Ulman, Ken, Howard County Executive, Howard County Government, 
  Ellicott City, MD..............................................     3
    Prepared statement...........................................     6
Beilenson, Peter, M.D., MPH, Howard County Health Officer, Howard 
  County Health Department, Ellicott City, MD....................     7
    Prepared statement...........................................     9
Page, Claudia, Director, One-e-App, Oakland, CA..................    10
    Prepared statement...........................................    12
Wensil, Van Lynn, Resident, Hanover, MD..........................    16
Tucci-Farley, Frances, Resident, Ellicott City, MD...............    18
    Prepared statement...........................................    21

                                 (iii)

  

           HEALTHY HOWARD: IMPROVING CARE THROUGH INNOVATION

                              ----------                              

                       TUESDAY, FEBRUARY 17, 2009

                                       U.S. Senate,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 11:45 a.m. in 
Howard County Community College, Business Training Center 
Gateway Building, Room 5, 6751 Columbia Gateway Drive, 
Columbia, MD, Hon. Barbara Mikulski, presiding.
    Present: Senator Mikulski.

                 Opening Statement of Senator Mikulski

    Senator Mikulski. Good morning, everybody. This is an 
official hearing of the Health, Education, Labor, and Pensions 
Committee, which I now officially call to order.
    As part of our responsibility for doing health reform for 
the United States of America, Senator Kennedy's committee, 
which is the Health, Education, Labor, and Pensions Committee, 
of which I am a member, has established three working groups, 
one on coverage, one on prevention, and I chair the working 
group on quality. But, at the end of the day, all three of 
those issues are artificial silos for purposes of investigation 
about what our policy should be.
    Part of my approach to combining all of these is to ask, 
``How can we deal with the issues of the uninsured in our 
country, or the underinsured? ''--where, even if you have 
insurance, sometimes it's so little or so Spartan, it doesn't 
meet compelling needs of the family. At the same time it's not 
only about access, but it's also about, How do we improve the 
health of both individuals and also families and How do we have 
the greatest impact?
    Today, what I'm kicking off, for me, is my innovation tour. 
I want to travel the State of Maryland to see what are the best 
ideas that we can take back to Washington. Like our President, 
I am an old-fashioned, grassroots community organizer. We 
believe that the best ideas and the best direction comes from 
the people and also comes from those who are most impacted.
    I chose Howard County to kick this off because of the bold 
vision of our county executive, Ken Ulman, and his very able 
and intrepid, unflinching and unflagging health commissioner, 
Dr. Peter Beilenson.
    In October a year ago, both Mr. Ulman and Dr. Beilenson 
shared with us the Howard County dream, which was to make sure 
that everyone in Howard County who did not have adequate 
healthcare would have it. That's pretty bold. They've embarked 
upon, really, this bold initiative. We wanted to come here 
today to hear more about it. About lessons they learned from it 
that we can take back to Washington so that, when we're talking 
about our issues, we really make sure that what we do makes a 
difference.
    Too often in Washington, the topic is on macroeconomics. 
They talk about the big picture, and they forget the little 
people. They forget the people who have to implement the 
program, the people who have to pay for the program, and the 
people who should benefit from the program. I'm a macaroni-and-
cheese economist. I believe----
    [Laughter.]
    Senator Mikulski [continuing]. That you start with the 
basics, well made, as long as it has a salad.
    [Laughter.]
    But, really more the grassroots approach. So, this is why 
we're here today, to listen and to learn.
    Invited to join me is Congressman John Sarbanes, a mentor 
and a member of the Energy and Commerce Committee, who brings, 
one, a great deal of background, himself--before he was a 
congressman--as a lawyer, heading up the health practice at one 
of our most distinguished law firms. But, on the Energy and 
Commerce Committee, it will have major responsibility for the 
national legislation, and we're going to be part of your 
Maryland team. I'm going to ask him to say a few words before 
we turn it over.
    I want to thank Mr. Ulman for his initiative and for being 
bold enough to do it, and the people of Howard County who are 
willing to support this. This is no small undertaking.
    Dr. Beilenson, who, along with his own great ideas, 
harvested the great ideas of many people, and now we're testing 
them out, whether the ideas really work for people.
    We want to thank Ms. Page, who's come here to tell us how 
to smooth the path of eligibility often challenged.
    But, most of all, at the end of the day, we want to hear 
from the people. Why did you come to this program? Did it help 
you? And if you could sit down to talk with Members of 
Congress, what would you tell us about what we needed to keep? 
What's your must-do list and what you would work on improving?
    So, that's why we're here, and we're really eager to listen 
to everybody.
    But, I'd like to turn, for a few opening comments, to my 
colleague John Sarbanes.

   STATEMENT OF HON. JOHN SARBANES, U.S. REPRESENTATIVE FOR 
               MARYLAND'S 3D DISTRICT, TOWSON, MD

    Mr. Sarbanes. I appreciate it, Senator. It's a treat to be 
here. This is exactly where we should be: in the field, 
listening to the real-life experiences of people that are 
trying to tackle this problem of healthcare reform across the 
country.
    I am thrilled that Senator Mikulski has been given this 
portfolio on healthcare quality by Senator Kennedy. As she 
indicated, that has a broad reach; and it should, because 
that's the underpinning of the healthcare system that works. 
Quality is what makes the difference. And quality is what's 
being pioneered here by the Healthy Howard Initiative.
    I want to congratulate County Executive Ulman and 
Commissioner Beilenson on their work. I was privileged to be at 
the kickoff when we had great hopes for where this might lead 
us and the lessons that we could learn from it. We've just 
heard, before this meeting, on some of the advances that have 
been made. That's part of the hearing today, to understand the 
lessons that you all are seeing, and how they can be made 
applicable, more broadly.
    I think there's a number of principles that many of us have 
come to agree on as we move forward with healthcare reform. No. 
1, is universal coverage, No. 2, is universal access, and No. 
3, is quality. We're going to have to take those principles and 
shape them into an approach that allow for real healthcare 
reform. And now is the moment. Many think that we should wait, 
but the economic security of so many Americans is dependent on 
their healthcare situation. So, if we want to address that 
situation, we have to keep moving on healthcare reform.
    Hearings like this are a wonderful way for us to gather up 
information. So, Senator, thank you for convening it today.
    Senator Mikulski. Now we're going to turn to our witnesses. 
And the reason I said this is an official hearing is that we 
actually have the resources of the committee to take an 
official record and testimony. You're now going to go, quite 
frankly, into the history books. What you say here today will 
be incorporated in all of the information and testimony we're 
taking as we're fashioning our health reform initiative.
    I'm going to ask each and every one of you to introduce 
yourselves as you do testify. But, I'm going to turn it over to 
Ken, who's already writing quite a history for Howard County.
    Mr. Ulman.

STATEMENT BY KEN ULMAN, HOWARD COUNTY EXECUTIVE, HOWARD COUNTY 
                 GOVERNMENT, ELLICOTT CITY, MD

    Mr. Ulman. Well, thank you, Senator. It's truly a great 
honor for me to start your healthcare innovation tour in Howard 
County, and I really appreciate your leadership on these 
issues. It's been great to meet with you every few months over 
the last couple of years as we've hatched this idea, and I just 
can't thank you enough for your leadership and support of all 
the things we're doing in Howard County. I echo those 
sentiments for Congressman Sarbanes; it's been a wonderful 
partnership, and I thank you for your leadership on these 
issues, as well.
    You know, this is truly an exciting time for healthcare 
innovation in our country. I was glad to see the recent 
stimulus package include dollars for healthcare, especially 
health IT infrastructure and research. And again, the citizens 
of Howard County appreciate your strong leadership and 
partnership in these efforts.
    We believe, here in Howard County, that healthcare is both 
a right and a responsibility. And toward that end, last year we 
announced the Healthy Howard Access Plan, becoming one of only 
two jurisdictions in the Nation with a plan to provide 
affordable access to healthcare and comprehensive wellness, 
prevention, and health coaching for all uninsured individuals, 
and the only to do it without any mandates on businesses.
    I believe that most businesses who do not offer health 
insurance to their employees want to, but simply can't afford 
the ever-escalating cost of healthcare. We must remember that, 
of the approximately 20,000 of our neighbors here in Howard 
County who do not have health insurance--of course, we've 
whittled down that number since--85 percent are from working 
families, people just like the Ellicott City woman who sent me 
the following e-mail after we announced our plans for Healthy 
Howard. It read,

          ``Mr. Ulman, You've made my day today, watching 
        Channel 13 news this morning before work. I am 45 years 
        old and have lived in Howard County the majority of my 
        life. I have two children and I have raised them in 
        Howard County from day one. I don't have health 
        insurance offered to me at my work, and it seems you're 
        doing something about it. Recently, I had problems and 
        needed a doctor. I have ruined my credit and can never 
        buy anything, because I had to go to the emergency 
        room. Every day, my cell phone rings with bill 
        collectors from the emergency room visits. Pretty soon, 
        I guess my pay will be garnished and I'll be at the 
        food bank trying to feed my kids. Finally, someone is 
        trying to do something.''

    Unfortunately, this woman's story is an all-too-common one. 
In a moment, you'll hear from two of our neighbors here in 
Howard County who have similar experiences.
    Fortunately, through Healthy Howard's partnership, we were 
able to help the woman I just referenced enroll in the Kaiser 
Bridge Program. This is 2 years' worth of full health insurance 
subsidized by Kaiser Permanente, one of our private-sector 
partners.
    As you well know, our healthcare system is broken; however, 
we've begun to put it back together here in Howard County. By 
bringing together existing healthcare resources, such as Howard 
County General Hospital, Johns Hopkins Hospital, Chase Brexton, 
and specialty medical practices across the county, we are 
leveraging our existing healthcare community.
    Most critical to this effort is our partnership with Howard 
County General Hospital. We have a unique partnership which 
allows the hospital to provide care to our Healthy Howard 
participants, free of charge. I'm glad to see the recent 
attention placed on our system for uncompensated care. And I'd 
like to just briefly discuss this area.
    Actually, you know what? I'm probably going to skip over 
some of this and just----
    Senator Mikulski. No, that's OK. We want to hear----
    Mr. Ulman. OK.
    Senator Mikulski [continuing]. Everything you've got to 
say.
    Mr. Ulman. When--just to recap----
    Senator Mikulski. Believe me, we're--compared to what we 
hear every day----
    [Laughter.]
    Senator Mikulski [continuing]. Your speech is pretty short, 
so you're doing fine.
    Mr. Ulman. Well, good. I was glad that there was a recent 
series in the Sun about this topic of uncompensated care, and 
some initiatives.
    Just to recap, when an uninsured person goes to a hospital 
and cannot afford to pay, the hospital spends time and effort 
trying to collect, and then, after not collecting, refers the 
matter to a collection agency and typically ruins the patient's 
credit. Then, in many cases, the patient files for personal 
bankruptcy, as medical bills are the single-biggest cause of 
personal bankruptcy in this country.
    After all that, the hospital then writes it off to what's 
called uncompensated care, but the truth is, it's not 
uncompensated care; the hospital is compensated by the rest of 
us. Maryland is the only State in the United States with an 
all-payor hospital system, meaning that every hospital is 
required to treat every patient who comes through their doors, 
no matter whether they have insurance or not. The State sets 
the rate that the hospital can charge for every procedure a 
little bit higher, and that extra premium is set aside in a 
fund so the hospital can cover the cost of care for the 
uninsured patient who cannot pay. Every Maryland family with 
health insurance pays approximately $1,070 per year in this 
hidden healthcare tax.
    We believe that, through our Healthy Howard Access Plan, we 
can, and are, driving down this cost by getting folks the care 
they need, when they need it, by providing access to primary 
and preventative care, specialist care, prescription drugs, as 
well as personalized health coaching. Every Access Plan member 
is matched with a health coach to help them formulate a Health 
Action Plan and take steps toward achieving their health goals. 
This will lead, and is leading, to improved quality of life and 
decreasing the risk of future disease development.
    Our goal is that a significant number of participants will 
never need to set foot in the hospital emergency room, not only 
saving us all money, but freeing up the resources of the 
hospital for true emergencies. Of course, our program is still 
quite young, but we're well on our way. We opened enrollment 
last October. Today, we have 109 individuals enrolled in the 
Healthy Howard Access Plan, and another 143 in the process of 
enrolling. And through the Health-e-Link Web-based system, 
which you'll hear more about in a moment, we've connected over 
1,200 individuals with other State, Federal, and private 
healthcare programs for which they did not realize they were 
eligible. Through this enrollment effort and prior efforts to 
identify uninsured individuals in Howard County, such as a 
letter from the comptroller's office which went out last year, 
approximately 2,500 individuals who were uninsured just a few 
months ago now have access to affordable healthcare. This means 
that over 10 percent of the uninsured in Howard County now have 
coverage.
    Today, you will hear personal testimony from two Howard 
County residents. Both came to open enrollment in October, 
thinking they were eligible for Healthy Howard, both were 
connected to healthcare through the Health-e-Link system, one 
is now a member of the Healthy Howard Access Plan, one is 
enrolled in Medical Assistance for Families, an expansion of 
the State's Medicaid Program. In addition, you will hear more 
about Health-e-Link from Claudia Page, the director of the 
Center to Promote Healthcare Access, and then from our county's 
health officer, Dr. Beilenson, who you've aptly described a few 
moments ago.
    I thank you sincerely for your interest in Howard County's 
progress and for your tireless advocacy on healthcare issues at 
the Federal level. And again, I thank you for your leadership 
and for starting your tour here in Howard County.
    [The prepared statement of Mr. Ulman follows:]

                    Prepared Statement of Ken Ulman

    Good morning. Senator Mikulski, Congressman Sarbanes, and to all of 
you, thank you for being here. It is an honor, Senator, to have you 
hold this hearing in Howard County and an honor to be able to speak to 
you today about Howard County's efforts to increase access to 
affordable health care.
    Last year, we announced the Healthy Howard Access Plan, becoming 
one of only two jurisdictions in the Nation with a plan to provide 
affordable access to health care for all uninsured individuals, and the 
only to do it without any mandates on businesses.
    I believe that most businesses who do not offer health insurance to 
their employees want to but simply cannot afford the ever-escalating 
cost of health care. We must remember that of the approximately 20,000 
of our neighbors here in Howard County who do not have health 
insurance, 85 percent are from working families--people just like the 
Ellicott City woman who sent me the following e-mail after we announced 
our plans for Healthy Howard.

          Mr. Ulman: You have made my day today watching Channel 13 
        news this morning before work. I am 45 years old and have lived 
        in Howard County the majority of my life. I have two children 
        and I have raised them in Howard County from day one. I don't 
        have health insurance offered to me at my work and it seems you 
        are doing something about it. Recently I had problems and 
        needed a doctor. I have ruined my credit and can never buy 
        anything because I had to go to the emergency room. Everyday my 
        cell phone rings with bill collectors from the emergency room 
        visits. Pretty soon I guess my pay will be garnished and I'll 
        be at the food bank trying to feed my kids--finally someone is 
        trying to do something.

    Unfortunately, this woman's story is an all too common one. 
Fortunately, however, through Healthy Howard's partnership, we were 
able to help her enroll in the Kaiser Bridge Program. This is 2 years 
worth of full health insurance subsidized by Kaiser Permanente.
    As you well know, our health care system is broken.
    When an uninsured person goes to a hospital and cannot afford to 
pay, the hospital spends time and effort trying to collect, and then 
after not collecting, refers the matter to a collection agency, and 
ruins the patient's credit. Then, in many cases, the patient files for 
personal bankruptcy, as medical bills are the single biggest cause of 
personal bankruptcy in this country.
    After all that, the hospital then writes it off as what's called 
``uncompensated care,'' but the truth is it is not uncompensated care, 
the hospital is compensated--by the rest of us.
    Maryland is the only State in the United States with an all-payer 
hospital system, meaning that every hospital is required to treat every 
patient who comes through their doors no matter whether they have 
insurance or not. The State sets the rate the hospital can charge for 
every procedure a little bit higher and that extra premium is set aside 
in a fund so the hospital can cover the cost of care for the uninsured 
patient who cannot pay. Every Maryland family with health insurance 
pays approximately $1,070 per year in this hidden health care tax.
    We believe that through our Healthy Howard Access Plan we can drive 
down this cost by getting folks the care they need when they need it, 
by providing access to primary and preventive care, specialist care, 
prescription drugs, as well as personalized health coaching. Every 
Access Plan member is matched with a Health Coach to help them 
formulate a Health Action Plan and take steps toward achieving their 
health goals. This will lead to improved quality of life and will 
decrease the risk of future disease development.
    Our goal is that a significant number of participants will never 
need to set foot in the hospital emergency room, not only saving all of 
us money, but freeing up the resources of the hospital for true 
emergencies. Of course, our program is still quite young, but we are 
well on our way.
    We opened enrollment last October. Today we have 109 individuals 
enrolled in the Healthy Howard Access Plan and another 143 in the 
process of enrolling; and through the Health-e-Link web-based system, 
we have connected approximately 1,100 individuals with other State and 
Federal health care programs for which they did not realize they were 
eligible.
    Today you will hear personal testimony from two Howard County 
residents. Both came to open enrollment in October thinking they were 
eligible for Healthy Howard. Both were connected to health care through 
the Health-e-Link system. One is now a member of the Healthy Howard 
Access Plan. One is enrolled in Medical Assistance for Families, an 
expansion of the State's Medicaid program. In addition, you will hear 
more about Health-e-Link from Claudia Page the Director of the Center 
to Promote Health Care Access and then from our County's Health 
Officer, Dr. Peter Beilenson.
    I thank you sincerely for your interest in Howard County's progress 
and for your tireless advocacy on health care issues at the Federal 
level.

    Senator Mikulski. Well, thanks, Mr. Ulman. What we're going 
to do is listen to the testimony of everyone and then open it 
to questions, and actually maybe even more of a roundtable with 
questions, where everyone can jump in.
    We now would like to turn to Dr. Peter Beilenson, our 
Howard County health officer. A former Baltimore City health 
commissioner and a leading voice in public health initiatives.

 STATEMENT OF PETER BEILENSON, M.D., MPH, HOWARD COUNTY HEALTH 
  OFFICER, HOWARD COUNTY HEALTH DEPARTMENT, ELLICOTT CITY, MD

    Dr. Beilenson. Thank you very much, Senator and 
Congressman, County Executive. It's a pleasure to be here 
today.
    I just wanted to reiterate some of what the county 
executive was saying. We have started our program now. There 
are about 250 people either fully enrolled, or on significant 
approach to being enrolled in our program, that are eligible to 
be enrolled, which is on target for our goal of about 2,000 
people, by the end of this year, being in Healthy Howard.
    Healthy Howard is a combination of a range of services, but 
focusing most intently on primary-care access and health and 
wellness care. The county executive mentioned the different 
components, but what I wanted to focus on here, particularly, 
is the health coaching and the case management--medical case 
management and pharmaceutical case management--at Chase Brexton 
by a care coordinator, and then everybody has a personal health 
coach. We don't know of any other program in the country that 
has all the components that we've put together: primary care, 
prescription drug, hospital specialist, and personalized health 
coaching. The health coaching happens face-to-face, not a phone 
call, as is often done by insurance companies managing chronic-
disease folks, where someone--a nurse will call you from 
Nashua, NH, here in Baltimore or Columbia, to see if you have 
taken your diabetic medications. Here, our health coaches will 
go to meet folks face-to-face, help them, in concert with their 
primary care physician, to develop a Health Action Plan, which 
will help to keep them as well as possible.
    Tai Sophia Institute, which I know the Senator is 
particularly interested in, won a grant from the Horizon 
Foundation, and they are training our health coaches in 
innovative medicine and wellness and ways in which to motivate 
patients, as well. That's one large aspect of what we're doing.
    Our first patients have been seen, starting in early 
January. We've now had dozens seen. They're seeing their 
primary care docs, and our first patients are now meeting with 
their health coach to come up with their Health Action Plan.
    Our evaluation of this is particularly important. Hopkins, 
UMBC, University of Maryland Schools of Public Health, will be 
doing the evaluation that will be looking at health status 
improvements, from enrollment to going on in the program. And 
also, very importantly, the cost effectiveness. Are we averting 
unnecessary hospitalization and emergency room visits?
    In response to what the Congressman was asking a little bit 
earlier, What did we learn that's replicable or applicable in 
other parts of the country? No. 1, clearly, as the county 
executive was mentioning earlier, through our efforts, through 
the comptroller being able to reach out to eligible parents of 
kids with CHIP, to get their children enrolled in CHIP, we sent 
out 20,000 letters or so, at a cost of several thousand 
dollars--only several thousand dollars--and got 1,200 hits in 
the first 2 to 3 weeks. That, combined with our enrollment 
efforts for Healthy Howard, were, as the county executive 
mentioned, able to reduce, in a very, very short period of 
time, by over 10 percent, the number of uninsured people living 
in Howard County. We think that this highlights the issue that 
has been shown, through many studies, that about 25 or 30 
percent of all people who are uninsured in this country 
actually are eligible for existing programs, but either don't 
know it or haven't applied. In a relatively short timeframe and 
relatively insignificant resources, we will be able to knock 
down the number of insured from 50 million in this country, 
with the economic recession right now, to probably into the low 
30 millions. Not solving the problem, but clearly making a 
significant dent.
    Do you want me to stop or should I keep going? I have 
another 30 seconds.
    Senator Mikulski. Yes, you keep going.
    Dr. Beilenson. OK.
    The other----
    Senator Mikulski. We're used to long-winded environments.
    [Laughter.]
    Dr. Beilenson. We're actually--we're pretty----
    Senator Mikulski. So, no, you're pretty crisp.
    Dr. Beilenson. And we speak fast.
    Senator Mikulski. First of all, we have our colleagues, 
that can be chatty. The Senate is the original chat room.
    [Laughter.]
    And then, sometimes we get these experts that----
    Dr. Beilenson. Well, we'll be brief.
    Senator Mikulski [continuing]. Give us their whole Nobel 
Prize statements.
    Dr. Beilenson. So, that's certainly one lesson that we've 
learned, and it's actually--the replication has started, of 
this comptroller letter. The State now does it, through State 
legislation, and several States have called me, actually, to 
ask how we went about doing this.
    The second thing that's applicable or replicable is this 
program, in itself, we don't want to see 3,500 iterations of 
different counties doing these programs. However, putting 
together a network, like we have done here in Howard County, is 
certainly doable, in some form or fashion, in many counties, 
even many urban and rural areas. And so, the lessons that we 
learned, that we'll be showing from our evaluation that Johns 
Hopkins and others are doing, I think will inform whether and 
how much of what we're doing is replicable. But, we're looking 
forward to those results, and we'll have some of them in the 
next several months.
    [The prepared statement of Dr. Beilenson follows:]

            Prepared Statement of Peter Beilenson, M.D., MPH

    Despite numerous attempts at the Federal level to increase health 
coverage over the past 75 years, the number of uninsured Americans has 
continued to grow--with that number now likely approaching 50 million. 
The State of Maryland has made some progress in expanding health 
coverage to certain vulnerable populations over the past few years, but 
the number of uninsured Marylanders still numbers over 700,000. We 
believe that it is unconscionable that in the wealthiest, most 
technologically advanced country in the world approximately one in 
every six of our citizens does not have health coverage. So, rather 
than waiting for other levels of government to act, Howard County 
developed its own program, Healthy Howard, with input, involvement and 
funding from many sources, and a real chance for success.
    No other county in America has embarked on an effort to provide 
comprehensive, affordable health care and wellness services for all its 
citizens. Because employer-based health insurance is shrinking, and 
individual policies are prohibitively expensive for many, thousands of 
citizens in our county have no way to see a doctor for the sinus 
infection that has festered and fatigued them for months; they can't 
get the medicine that would cure it; and they can't avoid infecting 
others. They have no family doctor to tell them to lose weight and 
exercise more to deal with their high blood pressure--or their diabetes 
goes untreated. They have no preventive health care or health screening 
to help them to avoid expensive and potentially tragic conditions.
    So, starting in early October, we began enrolling the first of 
2,200 Howard County residents in the first year of the Healthy Howard 
Access Plan that will provide them up to six visits a year with a 
primary care physician and access to a wide range of specialists. They 
will get many prescription drugs free and others at a steep discount. 
Our local hospital, Howard County General, is not charging our patients 
for hospital stays or for truly urgent emergency room visits. And, very 
importantly, every program participant will have a personal health 
coach to help devise and implement a personalized health action plan--
common sense activities and services that will help our participants to 
live as healthy a life as possible.
    Because we believe that health care is both a right and a 
responsibility, everyone will have to pay modestly to be a member of 
Healthy Howard (either $50 or $85 per person per month, dependent on 
income, with a discount for a spouse or domestic partner), and must be 
substantively compliant with their health action plan to keep full 
involvement in the plan. Who will be included? The vast majority will 
be working folks or members of working families, since most uninsured 
Americans are working class individuals who cannot afford to buy 
insurance if it is not provided at their workplace. Anyone between the 
ages of 19 and 64 (younger are eligible for the Children's Health 
Insurance Program; older for Medicare) with an income below 300 percent 
of the poverty level (approximately $64,000 per year for a family of 
four) is eligible for Healthy Howard, if they are Howard County 
residents and have not been insured for the past 6 months. In response 
to the economic downturn and the significant increase in layoffs, this 
6-month restriction is waived for anyone who can demonstrate that they 
lost their job.
    Is the plan perfect? Of course not, which is why we have arranged 
for a detailed evaluation of Healthy Howard by a team of researchers 
from Johns Hopkins, Harvard and the University of Maryland to help us 
to improve it as we go. If the plan works, as defined by improved 
health status of our participants, costs averted, and decreases in 
preventable hospital and emergency room usage, we hope to expand it to 
include as many of the 15,000 uninsured residents of the county who 
want to join. We obviously need to make the program sustainable and 
self-sufficient. It will not be easy, but it is not impossible.
    We are aided in our enrollment efforts by the use of an innovative, 
web-based electronic application system developed in California, called 
Health-e-Link. Although you will hear more about this application from 
Claudia Page of One-e-App (the developer of the program), in brief, it 
allows for any uninsured individual to go on-line at one of any number 
of service-based community organizations and, with the help of a 
trained assistor, identify what health program they are eligible for 
and then complete the appropriate application. By using this 
application on only eight ``eligibility nights'' we held in Columbia in 
October, we were able to enroll almost 1,100 uninsured Howard Countians 
into health coverage programs. Interestingly, about 750 were eligible 
for existing entitlement programs but had not known it. The rest were 
enrolled either in Healthy Howard or Kaiser Permanente's donated 2-year 
Bridge Program slots. Our experience identifying uninsured but eligible 
individuals highlights an important issue that can be addressed at the 
Federal level. Estimates are that nationally at least 25 percent of all 
uninsured Americans are actually eligible for existing programs. Thus, 
if we invested a relatively small amount of resources at better 
outreach and more streamlined enrollment processes, the number of 
uninsured for whom a new system needs to be devised might well drop 
from around 50 million to less than 35 million. By doing so, it might 
make systemic health care reform a bit easier to achieve as well.
    We hope that our efforts on health care reform in Howard County are 
not only beneficial to the uninsured of our county, but will inform the 
forthcoming health care reform debate in Washington as well.
    Thank you for allowing me to testify.

    Senator Mikulski. Well, thank you very much.
    Dr. Beilenson. Sure.
    Senator Mikulski. And now, we want to turn to Claudia Page, 
who's the director of a software company called One-e-App, from 
Oakland, CA, but we know it in Howard County, Dr. Beilenson, as 
Health-e-Link. From what we understand in our briefings, one of 
the most surprising lessons learned was that so many people who 
came to the community outreach, who responded to the letter of 
invitation, were actually eligible for other existing programs. 
When we say there are 47,000 uninsured people in the United 
States, and there were so many uninsured in Howard County, what 
we found, using some innovative tools around eligibility, that 
they were eligible for other programs. And we understand that 
your contribution was--technology was a tool in establishing 
eligibility. So, why don't you tell us about that.

  STATEMENT OF CLAUDIA PAGE, DIRECTOR, ONE-E-APP, OAKLAND, CA

    Ms. Page. Great, thank you Senator.
    Senator Mikulski. Is that an accurate introduction?
    Ms. Page. Absolutely, and with lots of good touchpoints.
    So, thank you very much, Senator Mikulski, Representative 
Sarbanes, and County Executive Ulman. I'm grateful for the 
opportunity to share some insights, both from the work in 
Howard County, as well as across the country.
    My name is Claudia Page. I am the director of the Center to 
Promote Healthcare Access. We're a nonprofit organization that 
has developed a system called One-e-App--One Electronic 
Application, One-e-App. It is an online screening tool 
connecting families and individuals with benefits for which 
they're eligible. One-e-App is used in four States, including 
Maryland. It's also used in California, Arizona, and Indiana. 
It includes a wide range of programs, which is actually 
growing, actually, by the week, as families find themselves 
more and more in need of a range of programs. So, if you take 
all the programs together that are currently in the system, 
we've got Medicaid and SCHIP, Food Stamps, TANF, Earned Income 
Tax Credit. We've got the WIC program, we've got low-
income auto, low-income energy subsidies--a whole list is 
provided in the written testimony that I submitted. 
Essentially, it's one channel of many that need to be out there 
to help families, an online tool that is either used with or 
without assistance.
    I'd like to just mention that, in Arizona, their version of 
One-e-App is available to the public, who can go on from their 
homes or from libraries and apply for programs directly, 
without assistance, or they can seek assistance.
    As you mentioned, in Howard County the system is called 
Health-e-Link. In Howard County, it currently provides 
eligibility assistance for Medicaid, Healthy Howard, MCHP--your 
SCHIP program--and the Kaiser Bridge Program. It generates 
applications, it stores data and documents, it tracks 
applications, it allows for the selection of a primary care 
provider, dental providers, and it uses kind of a Turbo Tax 
approach to helping families connect to the benefits for which 
they're eligible. It was implemented in Howard County to 
improve the efficiency and generate high-quality applications, 
ultimately getting the families and individuals in the right 
program, the program for which they're actually eligible.
    The current plan is to build out Healthy-e-Link so that it 
has the capacity to deliver applications electronically to the 
State, so that we're really closing the loop for families 
eligible for Medicaid, and hopefully eventually Food Stamps and 
MCHP and those programs that are under the State's purview for 
final eligibility determination.
    I want to use my last couple of seconds to commend the 
leadership in Howard County for stepping out boldly, as you 
point out, Senator, on both the coverage design front, but also 
really taking a look at the way in which families connect to 
benefits, and trying to make that process more rational for the 
families who, more often than not, find themselves being 
referred from one location to another to another, filling out 
the same forms, writing the same information again and again 
and again. It's an irrational way to do business, both from the 
consumer perspective, as well as from an administrative 
perspective, because, at some point, all of those paper forms 
have to be manually data-entered into a system.
    My time is up, by the clock.
    Senator Mikulski. No, go ahead. Keep going.
    Ms. Page. Well, I'm happy to take--answer any questions and 
provide more information----
    Senator Mikulski. Because you're kind of the techno-guru.
    [Laughter.]
    Ms. Page. Well----
    Senator Mikulski. You are both a gateway for eligibility 
but--and we'll talk more about health IT--information 
technology. But, it also is the holder of all the other 
information that people might need.
    Ms. Page. That's right. I think in Howard County, as we 
experienced in San Francisco and, frankly, in most of the 
places where One-e-App is being used, there's usually a 
motivating event. And in Howard County, it was the advent of a 
new healthcare-coverage program for residents. And in that 
moment, there was an opportunity to modernize and reform the 
systems through which families get connected to benefits. I 
think Howard County offers a really important learning 
laboratory to both the State and to the Federal Government and 
policymakers as they look at both components of that--both of 
those important components of healthcare reform: the access 
channels, as well as the coverage design channels.
    Reforming these systems is not easy. These are systems that 
have a long history of siloed systems, siloed administrative 
agencies, siloed fiscal streams, funding streams. You know, 
untangling those silos is not easy. But, using a tool like One-
e-App and Health-e-Link in Howard County, you can use some 
assistance integrator that serves as a data--a smart data-
collection and delivery system, that has a rules engine that 
figures out where you need to send the data and the documents 
and the signatures, stores the data, so when it's time for a 
redetermination or if the family wasn't eligible for that 
program, they shouldn't need to go back and start all over 
again, getting on the bus and going down and filling out paper 
forms.
    I think the lessons learned in Howard County and lessons 
that the center has been lucky enough to learn, with our 
partners in other States and counties, will be valuable at both 
the State and the Federal level.
    [The prepared statement of Ms. Page follows:]

                   Prepared Statement of Claudia Page

                                SUMMARY

    The Center to Promote HealthCare Access (The Center) is a non-
profit technology solution provider connecting people to needed public 
benefits.
    The Center's signature tool is One-e-App, an innovative Web-based 
system for connecting families with a range of publicly funded health 
and human service programs. One-e-App is used in three other states 
(California, Arizona, Indiana) and it provides screening and enrollment 
for a range of public benefits programs such as Medicaid, Food Stamps, 
TANF, Earned Income Tax Credit, Low-cost energy assistance and more. 
One-e-App is used by assistors, eligibility staff and the public 
themselves. A complete list of programs is in the written testimony.
    In Howard County One-e-App is called ``Health-e-Link'' and it has 
been used since the launch of Healthy Howard on October 1, 2008. The 
online system screens individuals for potential enrollment in Medicaid, 
Healthy Howard, MCHP and Kaiser Bridge and generates applications, 
stores data and documents, tracks applications. It uses the Turbo Tax 
approach to screening and enrollment by asking only necessary 
questions.
    Health-e-Link was implemented to improve efficiency, generate high 
quality applications, ensure applicants are enrolled in the right 
programs and make the process more rational for applicants, who 
navigate a complex maze of referrals and handoffs when seeking 
coverage. This leads to cost and process inefficiencies for government 
and frustration and missed coverage opportunities for applicants.
    The County has been successful in its first 5 months of operation 
and they deserve huge praise for implementing a new enrollment system 
at the same time as an innovative coverage expansion program. 
Modernizing enrollment in public benefits is incredibly complex and 
disruptive. But it is also necessary and long overdue. Other facets of 
State government have evolved to be more efficient and consumer 
friendly. Howard County has taken important steps to bring enrollment 
innovation to its residents.
    The current plan for One-e-App in Maryland is to learn what works 
and what does not in Howard and Anne Arundel Counties (next in line to 
adopt Health-e-Link) and to work with the State and other counties to 
support their use of the on-line application with electronic data 
submission capacity. The County is currently working with the State 
Department of Mental Health and Hygiene to assess ways to integrate 
Health-e-Link with State systems to submit applications electronically.
    The Center values its partnership with Howard County and looks 
forward to continuing to work with counties and the State to improve 
the enrollment process. An increased demand for services and a 
worsening and relentless economic crisis create a perfect storm of 
opportunity and need to improve efficiency and make the process more 
rational for administrators and applicants. Thank you for the 
opportunity to provide verbal and written testimony. I am happy to 
answer any questions.
                                 ______
                                 
    My name is Claudia Page and I am a co-director at The Center to 
Promote HealthCare Access (The Center), a non-profit technology 
solution provider improving quality of life by connecting people to 
needed public benefits. The Center's signature tool is One-e-App, an 
innovative Web-based system for connecting families with a range of 
publicly funded health and human service programs.
    The Center has been fortunate to partner with Howard County, which 
is using the One-e-App software to screen and enroll families in its 
pioneering health coverage program, Healthy Howard. Called Health-e-
Link in Maryland, the One-e-App system has been an integral part of the 
new coverage program since its launch on October 1, 2008.
    I am grateful for the opportunity to provide testimony on 
innovations to support improvements in the enrollment process, both for 
administrators and individuals in increasing need of services. I will 
primarily focus my comments in three areas:

    1. Howard County: Making a Difference;
    2. Insights on Enrollment Reform: Experiences in Arizona, 
California and Indiana; and
    3. Next Steps: Building on Progress and Momentum.

    I want to preface my comments by acknowledging that systems reform 
is hard work and happens through strong commitment and leadership. The 
Center is able to carry out its mission-driven work only because of 
partners, leaders and innovators like those in Howard County and our 
partners in other States and counties.

                                CONTEXT

    If there was ever a time to focus attention on the efficiencies of 
the screening and enrollment process for low-income families into 
public benefits, now is that time. Hundreds of thousands of Americans 
are losing their jobs, their homes and their health care as a result of 
severe economic stress at both State and national levels. Economists 
predict the recession will continue to erode employer-sponsored health 
coverage and weaken the financial stability of families and 
individuals.
    For county and State governments, this phenomenon means increased 
demand for government-sponsored programs such as Medicaid, Food Stamps 
and county coverage programs. Governments are facing the largest budget 
crisis in recent history and cannot afford to do business as usual 
under these circumstances. Technology offers promise in redeploying the 
workforce to focus on high-value tasks versus tasks like manually 
entering data from paper forms, calling applicants when hand writing 
cannot be deciphered, correcting common errors and rescheduling missed 
appointments.
    For applicants, the process of applying for programs for which they 
may be eligible in the current environment means completing multiple 
paper forms (supplying much if not all of the same information each 
time), traveling to different locations and navigating an incredibly 
complex maze of referrals and programs. Ultimately, this results in 
missed opportunities for assistance because there is no one place to be 
screened for all programs.
    The current climate offers a perfect storm of opportunity and 
demand to make the process more rational for families and to create a 
more efficient and cost-effective process for administrators.

                   HOWARD COUNTY: MAKING A DIFFERENCE

    In launching Healthy Howard, County leaders were visionary about 
the new coverage model to extend coverage to otherwise uninsured low-
income residents and the enrollment process for screening, enrolling 
and tracking applicants in the program. The new program has captured 
local and national attention on both fronts.
    Engaging community partners to reach eligible individuals is a 
central component of the new program, and the county wanted an easily 
deployable tool to streamline and standardize the enrollment process 
and to ease the learning curve of the new program rules on community 
application assistors. They also wanted to truly close the loop for 
applicants by delivering data electronically to back-end systems 
wherever possible thereby speeding the process and removing the need 
for mailing forms and performing manual data entry.
    Healthy Howard launched on time with almost all of these components 
in place. The system conducts screening and generates applications for 
Medicaid, MCHP, Healthy Howard and the Kaiser Bridge Program. While 
there is (always) more work to be done, with this strong start, the 
foundation has been laid to make enhancements and to extend the 
capabilities of the Health-e-Link system to include more programs, 
features and integration to support users and applicants. To this end, 
Howard County is currently working with the State Department of Mental 
Health and Hygiene to assess ways to integrate Health-e-Link with State 
systems to submit applications electronically.
    This is the hard work of systems integration and reform. The work 
is never done, many IT systems use dated and disparate technology and 
there is minimal data sharing between programs. In addition, leadership 
at many levels must be committed and sustained, appropriate resources 
secured and at the end of the day, progress comes from taking risks. 
Howard County is a tremendous learning laboratory on all fronts for the 
State of Maryland and other counties and States contemplating coverage 
and systems reform to improve enrollment in public programs.

                          ONE-E-APP BACKGROUND

    One-e-App is currently used in Arizona, California, Indiana and 
Maryland by State and county workers and community-based assistors in 
hospitals, clinics, schools, health plans and other locations. In 
Arizona (and soon in California), One-e-App is also publicly 
accessible, which means applicants themselves go online (at home, 
libraries, school computer labs, work) to complete and submit 
applications.
    The One-e-App software was created in 2002 to support enrollment in 
a variety of health programs. Over the last several years, the system 
has evolved to include a range of government and non-government health 
and social services programs. The breadth of programs continues to grow 
with unemployment, low income housing, banking programs and others 
currently being considered.
    The following programs are included in One-e-App, though not all 
counties and States have implemented all programs. One-e-App integrates 
with other systems and wherever possible, applications, documentation 
and signatures are submitted electronically. When electronic delivery 
is impossible, pre-populated, error-checked paper applications are 
generated and mailed or faxed. In some cases, a referral is generated.
Health programs
     Medicaid
     S-CHIP
     Early Periodic Screening Diagnosis and Treatment (EPSDT)
     Express Lane Eligibility (ELE--a School Lunch and Medicaid 
linkage)
      County Indigent Care and Coverage Expansion Programs (for 
adults and children)
     Kaiser Permanente Child Health Program
     Kaiser Permanente Bridge Program
     Medicare Cost Sharing
     Facility-based Sliding Fee
     School Lunch Medicaid
     Family Pact
     Cancer Detection (Breast, Cervical and Prostate)
Social Services and other support programs
     Food Stamps
     TANF (Temporary Aid to Needy Families)
     Supplemental Nutrition for Women, Infants and Children 
(WIC)
     Earned Income Tax Credit (EITC)
     Voter Registration
     General Assistance
Programs to be implemented in Spring 2009:
     CARE (discount electric and natural gas bills through 
major CA public utilities)
     Low Income Auto Insurance
     Child Tax Credit
     Voter Registration

    The impact of this broad range of programs in the system is 
enormous: Imagine a mother bringing her sick child to a clinic and 
being screened for health coverage. She is told she has to pay a share 
of the cost for her coverage. Now imagine she is also told she may be 
eligible for up to $4,700 in earned income tax credit, which could help 
her cover her health coverage costs.

   INSIGHTS ON ENROLLMENT REFORM: EXPERIENCES IN ARIZONA, CALIFORNIA 
                              AND INDIANA

    The following are benefits and insights from other jurisdictions 
using the One-e-App software to inform the Maryland and Healthy Howard 
experience:

     Efficiency gains in time and resources are most 
significantly realized through systems integration and electronic data 
exchange. In Arizona, One-e-App interfaces with two State systems to 
deliver data and signatures and provide document access for Medicaid, 
Food Stamps and TANF. In California, One-e-App interfaces with State's 
Single Point of Entry to deliver applications for children's Medicaid 
and S-CHIP. The system also interfaces with a variety of county 
systems, local health plans, patient management systems and other 
systems.
     Automation reduces errors and speeds time to benefits. An 
assessment of Health-e-App (the predecessor to One-e-App in California) 
revealed a 40 percent reduction in errors and a 21 percent increase in 
eligibility determination time using the online process vs. the paper 
process.
     Public Access is an increasingly important channel to 
reach and engage consumers. In Arizona, for every application received 
online, an estimated 20 minutes or more of State staff time are saved. 
In addition, to date applicants are showing proficiency in navigating 
an online application (fewer than 5 percent of the applicants who 
submitted applications have contacted the help desk). Several 
California counties will soon use kiosks in emergency rooms and schools 
to encourage applicants themselves to participate in the enrollment 
process (while still providing in person and other assistance for those 
who need it).
     Modernizing the enrollment process requires more than 
improving the front end of the process, the back end infrastructure 
also needs to evolve and change. The State of California is undertaking 
a major effort to create a service-oriented IT infrastructure to permit 
data sharing across programs and to leverage assets across departments. 
The effort has begun by establishing governance and oversight capacity.

    The Center looks forward to sharing more information on these and 
other benefits and lessons learned and to connecting interested 
individuals with contacts in other States to learn more.

             NEXT STEPS: BUILDING ON PROGRESS AND MOMENTUM

    The current plan for One-e-App in Maryland is to learn what works 
and what does not in Howard and Anne Arundel Counties (next in line to 
adopt Health-e-Link) and to work with the State and other counties to 
support their use of the on-line application with electronic data 
submission capacity.
    I was struck by a recent quote in the Baltimore Sun in which a 
representative from a local nonprofit which assists people trying to 
navigate the health care system said: ``People don't always know--even 
providers don't always know--which application they should fill out, 
which program they should apply for.''
    This captures the spirit of the challenge: the complexity and 
number of programs (Federal, State and local), the number of forms, the 
categorical nature of programs such as Medicaid and Food Stamps, the 
siloed nature of systems, oversight agencies, financing streams and 
advocates. The main victim in this fragmented system is the applicant.
    Modernizing enrollment in public benefits is complex and 
disruptive, but it is also necessary and long overdue. Other facets of 
State government have evolved to be more efficient and consumer 
friendly. Howard County has taken important steps to bring enrollment 
innovation to its residents. The Center looks forward to continuing to 
support Howard County and others in improving access to benefits 
through innovation and reform.
    Thank you for this opportunity to testify today. I am happy to 
answer any questions you may have.

    Senator Mikulski. Well, that's pretty impressive. We're 
going to come back to you about how that actually worked. What 
you also see, are some of the stumbling blocks. Not only are 
there programmatic silos, but the good news about computers is, 
we've kept computer security, but it also means it's hard for 
computers to talk with--just like----
    Ms. Page. That's right.
    Senator Mikulski. Computers are like people, it's hard for 
them to talk to each other----
    [Laughter.]
    Senator Mikulski [continuing]. And communicate, cooperate.
    Well, now, let's really go to the heart of why all of us 
are here and what prompted Ken Ulman and Dr. Beilenson to do 
this, which is with people of Howard County.
    Howard County, demographically, would seem like it has no 
problems, that it is one of the most affluent counties; it is 
indeed a beautiful county, it's been well managed, it's been 
well planned. There we are. When Mr. Ulman told me, initially, 
the number of people who were uninsured, not even underinsured, 
in Howard County, it was an eye opener for me, because we 
always think of places like Baltimore City, where people are 
having a tough time. We'd like to now turn to the families and 
get a sense from you--How did you come into this program? What 
did this program mean? What did you like about it? What would 
you recommend that we would think about either changing or 
improving, not only for them, but from us. This is the 
laboratory of innovation, and we want to learn from it.
    Ms. Wensil, why don't we start with you.

      STATEMENT OF VAN LYNN WENSIL, RESIDENT, HANOVER, MD

    Ms. Wensil. Thank you for being here. We really appreciate 
it.
    My story is not atypical. My family has lived in Howard 
County for seven generations now, all within about a 2\1/2\ 
mile radius. I was married for 33 years, and that marriage 
ended in divorce. For 18 months, I was covered under the COBRA 
plan. Under that plan, I paid, for an individual insurance, 
$648 a month. That did not include my children, who were still 
umbrellaed under their father.
    When that 18 months started to terminate, I started 
shopping. I was turned down by every insurance company--Kaiser 
Permanente, Blue Cross and Blue Shield--because I had pre-
existing conditions.
    I have COPD; specifically, emphysema, early stage. I don't 
look forward to a real good outcome on that one. I would 
literally wake up panicky that I might lose my house. All it 
would take is a really bad case of pneumonia or an accident, 
and I could be without my home.
    This is such an innovative approach. I just feel like I won 
the lottery the day I got the call that I had been accepted 
into this program. I have already met with my primary care 
physician. I have a referral for blood tests, blood work. This 
is the first time in years. It's been over 6\1/2\ years that I 
have been without insurance. It's changed my--I feel lighter. I 
literally don't feel the weight of worry that I did before.
    I am looking forward to meeting with my health coach. There 
are things that I want to know. I'm sure there are things that 
she wants to know--or he--about me. I just feel so supported. I 
feel supported on level of physician-patient, I feel supported 
by my county, I feel supported by such a band of people that 
really are working to prevent illness, to deal with illness 
and--on a personal level rather than waiting until someone is 
really ill, really hurt, and having to deal with it in the 
emergency room. That is just such a blessing to me.
    I thank you all. I appreciate everything you've done. I 
thank you for your ears today.
    One thing I will say that I loved about the system, and 
just meeting with my physician the one time, they have a 
program that specifically sends you to where the prescriptions 
are cheapest. That was so appreciated. I didn't have to shop 
around. And I appreciate that, specifically.
    Thank you.
    Senator Mikulski. Ms. Wensil, before we go to Ms. Tucci-
Farley, could you step back for 2 seconds and just give a quick 
cameo of how you found out about the program? Where did you go 
to apply for the program, and what happened when you did apply, 
and--take us through those steps.
    Ms. Wensil. OK.
    Senator Mikulski. Your narrative is quite compelling and 
poignant, and if we could get those sequential steps, it would 
be helpful for us.
    Ms. Wensil. Oh, thank you. I first read about it in the 
Howard County Times. Right away, I was like a dog with a bone 
and called the county, was given paperwork, saying how this was 
going to be used, how I was going to be able to access. I went 
to the public library, Howard County Public Library. I took 
paperwork with me, verification of salary, birth certificate, 
identification of who I was and that I was a legitimate 
resident of Howard County. It was a very easy process. There 
was actually excitement in the room. It was a very pleasant 
place to be. Even though the wait was somewhat long, there was 
a cheerfulness, and everybody was rooting everybody else on. 
That was a little bit of a surprise to me.
    Senator Mikulski. It's not typical if we're applying for a 
program.
    Ms. Wensil. Absolutely. I got to know several of the people 
standing next to me fairly intimately, because we were all----
    Senator Mikulski. In it together.
    Ms. Wensil [continuing]. In it together, yes. Absolutely. 
It was a breeze, as far as paperwork. I don't know what else to 
say. It was just very easy, and I was appreciated for accessing 
the plan, but I was also appreciative.
    Senator Mikulski. You were told you were eligible, then 
what happened?
    Ms. Wensil. Yes. I was given access to the healthcare 
providers, where I called to make my first appointment. Within 
the first month, you were to call and schedule your first 
primary care visit. We are allowed six primary-care visits a 
year. Women are allowed one extra. I met with my wonderful 
physician. I got some prescriptions that I hadn't been using or 
even compromising myself by lowering the dosage.
    Senator Mikulski. To stretch it out?
    Ms. Wensil. Absolutely. Absolutely. So, I really 
appreciated my four prescriptions, which cost me, unbelievably, 
only $28. One prescription used to cost me $96. So, like I 
said----
    Senator Mikulski. This is pretty stunning.
    Ms. Wensil [continuing]. This was my lottery number, and it 
is not unappreciated.
    Senator Mikulski. Well, thank you, I think that's pretty 
telling, and we appreciate the detail.
    Ms. Tucci-Farley, now share with us your story.

 STATEMENT OF FRANCES TUCCI-FARLEY, RESIDENT, ELLICOTT CITY, MD

    Ms. Tucci-Farley. My name is Frances Tucci-Farley, and--you 
know, it's funny, I'm sitting here in front of a script, but 
this is my life I'm talking about, and I really shouldn't need 
it, but I want to make sure that all the credit due is not 
skipped over in any way.
    Senator Mikulski. Well, I'll tell you what we're going to 
do to help you out. The way we say it in Congress is, I ask 
unanimous consent that all written testimony be included in the 
record. And speak from your mind and your heart.
    Ms. Tucci-Farley. OK. I think it'll--well, you use it for 
whatever you need to, to make this applicable to everybody that 
needs it.
    Senator Mikulski. But, you've got to pull up the mike so we 
have the record.
    Ms. Tucci-Farley. My name is Frances Tucci-Farley. I'm a 
single mother. I have two children, one in kindergarten and one 
a sophomore in college. I've been a resident of Howard County 
for 20 years, and was married for a total of 28 years, 
divorced, and since then, have suffered an incident that 
impregnated me, and I went through with the pregnancy. With 
that decision in mind, I began full-time work as soon as I was 
able, and--shortly after the birth--worked at a particular 
company for 5 years. In June 2008, with no forewarning, our 
company laid me off and I was completely devastated. My oldest 
son had health insurance through his college, and my youngest 
son had health insurance through his father.
    I just have to pause in between, because it's a--there are 
some details in there I need to just grapple with.
    Senator Mikulski. Well, we understand. There were many 
tragedies that hit you, but one of which was, the father of 
your son passed away.
    Ms. Tucci-Farley. Yes.
    Senator Mikulski. And it was sudden and unexpected, and it 
had great emotional impact and great----
    Ms. Tucci-Farley. Yes. Great reconciliation occurred to 
even allow that climate to be so.
    Just before I was laid off, I was in a car accident. I was 
driving my youngest son to the library, and with no 
forewarning, we were impacted in the rear by two vehicles, and 
I was injured. It aggravated back surgery that I had, 4 years 
ago, which I was completely paralyzed on one side. Since the 
accident, I've been experiencing some of those same symptoms; 
not to a full degree, but I recognize them. Due to my layoff, I 
no longer had health insurance; and so, those symptoms have 
gone unchecked for the past 7 months.
    In the mix of all that--the accident, the layoff, trying to 
land with my feet on the ground--I went to DSS. It's the only 
place I knew where to go. I even went there, scratching and 
clawing, knowing that there is such an oppressive environment 
in there that, if you're at the low point, it's probably the 
worst door to walk through, because you feel completely 
degraded as a human being. There's a certain resignation on the 
other side of the desk that makes you not at all feel welcome 
or even hopeful that there might be a positive outcome that 
would solve your situation.
    I waited in that line--I actually waited in six different 
lines, it took a total of 6 hours while I was there. I was in a 
short line at the very beginning, and then sat, with each 
individual case worker for one interview, one application, 
another interview, another application, and it was just like a 
progressive dinner; I was, for 6 hours, passed from one 
caseworker to the next, and finally went out, only wanting 
health insurance.
    I was told it would be about a 30-day wait, and so, in July 
I began calling to find out the status. Between July and 
October, I received no response. I did receive, however, one 
letter in August that stated that they were unable to process 
my application, due to, and I quote, ``an agency delay has 
occurred beyond our control.'' I called to find out what that 
might mean. I left messages. Each of those voice messages said, 
``If you don't hear from us within 48 hours, call my superior 
and he will return''--and then I went all the way up the ranks. 
Months went by, with no response.
    I remember hearing, back in June, about Healthy Howard. In 
the interim, I happened to catch, on NPR, an interview with Dr. 
Beilenson, and learned more about Healthy Howard, and counted 
the days--literally checked off the days between July and 
October, when I could stand in that line and finally get 
coverage for myself.
    Coincidentally, the tragic death of my son's father 
occurred. And again, though it was a dire circumstance under 
which my son was conceived, there was great reconciliation, and 
a phenomenal cooperation was the result, by that time, of 
arduous efforts to make things work. And by that time, my son 
had bonded greatly to his father. He provided health insurance, 
he was paying child support, and he was cooperating, on almost 
a daily basis, with his homework, just launching him into 
kindergarten and making sure that he was stable and had a new 
foundation, a new beginning. And that's the point that we were 
at.
    On Yom Kippur, October 9, we were actually going to go on a 
day trip. We had some serious conversations to resolve and some 
plans for my son's future that we were going to start founding. 
Went to his house, no answer, couldn't get in, and, in the 
interim, I witnessed an auto accident, so I stopped, because I 
was called to be a witness for that, the officer needed 
testimony, and I asked him, ``Please, there's a friend I have 
that lives around the corner, is it possible, when you're 
through processing this, can you please take me to his house, 
and can you go inside and check? '' And at the time, it was 
completely unexpected, but just something instinctively said it 
was very wrong. They went inside and said, ``He's gone.''
    Senator Mikulski. Wow.
    Ms. Tucci-Farley. So, my son, sitting in the back of the 
car, said, ``Mom, is Daddy OK? '' And I said, ``You know, 
remember when Jesus said he was going to prepare a place? '' I 
said, ``Well, Daddy's place was ready, and the angels came and 
took Daddy.''
    I drove in circles that day, already prescheduled to go to 
Healthy Howard that evening. I went from playground to 
playground, not knowing how to speak the reality to my son, 
because he was still not getting it.
    It wasn't until I was standing in the line, again driving 
to the library with my son; this time, not an accident, but 
another series of blind-sided events. When I was standing in 
the line, there were lots of people in the room. Like you said, 
the atmosphere was extraordinary--it was profound. It was 
positive. People were hopeful. People that didn't speak 
English, people that were Chinese, people that were Asian, 
people that were African-American; every color of the palette 
was there. While we were waiting, it wasn't an arduous wait, it 
was OK to be there. Everybody was understanding. They were 
even--like you said, some comraderies forming. You could hear 
the conversations around the room. An oriental woman came over 
and showed him this little shaky dog that you'd want to take 
your coat off for, and made him cheerful again. I finally got 
to the front of the line, tried to withhold my stoic 
disposition and begin the process of handing over my paperwork. 
And before I could get out of me needing to stay composed and 
contain myself, the process was over. I had handed my 
paperwork, they copied them, they handed them back, they 
smiled, and, of course, the woman said, ``And so, you'll be 
needing healthcare for yourself? '' It was that moment that it 
dawned on me, ``No, I need it for my son.'' At that moment, I 
realized that his health coverage was going to be terminated 
because his father's employment was no longer a viable source.
    So, of course, the woman very discreetly, called over a 
senior representative from Howard County Health Department, and 
she provided me resources for grief counseling, summer camp for 
my son, and just beaucoup resources and numbers in which she 
went over and above the call of duty, and even called me the 
next day to see how my progress was going. She called me the 
next week to see if there were any other resources she could 
provide. It was just over and above the call of duty. I was 
told, ``Make an appointment.'' Make the appointment, you'll 
receive a call, ``We'll evaluate your application and tell you 
what you're eligible for.''
    In that very short--I believe it was less than 10 days--
whereas, with DSS this was going on 7 months--they had an 
answer, they said I was approved. Yet, because my case was 
initiated through DSS, it was pending, and they could not 
process me, because DSS would not release my case, even though 
I only wanted health insurance.
    Through some ingenuity of the director, or one of the 
directors, I believe, at Howard County Health Department, she 
finally figured out a way to have my case released from DSS, 
and which they did so; and, in 3 days, she solved what DSS was 
unable to solve, because of their backlog, lobbies, and system, 
in 7 months. So, I was able to be given a card for health 
insurance, just medications--because my son's medications had 
been suspended in the lapse--was able to resume medications, 
even before getting my cards, and now we're in the process of 
waiting for our official cards so that we can continue and I 
can get care--neurological care for some of the damage that's 
occurred from the accident, and hopefully get feeling back in 
my limbs without having to go through surgery again.
    One of the things I'd like to see changed is for there to 
be some sort of partnership or release for the Howard County 
Health Department and the Health-e-Link system to be able to 
handle the overflow of caseload that DSS is stymied by. I think 
it would be a fantastic improvement in the system overall for 
the country, especially if Healthy Howard is a model program 
for other States to emulate.
    I ended up being eligible for medical assistance, my son 
ended up being eligible for MCHP after all; it wasn't going to 
be a premium-based health coverage, like I initially thought. 
That was a fantastic piece of news. It was a very smooth 
transition, and one seamless action of processing my documents; 
phone call when it was promised, came as delivered, came over 
and above the call of duty, was completely, completely 
regenerative, to the state that we were in.
    Though these ordeals throughout the past months have been 
extremely exhausting--losing my job, being in the auto 
accident, suffering a death in the family, having to be at the 
top of your game with unemployment and following that criteria, 
in light of everything else, is a completely consuming 
undertaking. Now I'm able to focus back on getting re-employed. 
I want to get out of the system as quickly as possible; I'm 
used to being on the other end of giving, not the receiving 
end. It is a bit of a cross to be on this end. Anyway, I just 
wanted to ask if there was a way to possibly use my example to 
illustrate how easily Health-e-Link can facilitate delivery of 
care so that they can move on to the next person and the next 
person and the next person.
    Senator Mikulski. Well, you've already done that.
    Thank you. Is there anything else you want to add? Or you 
want to think a little bit and then come back--we'll come back 
to you.
    Ms. Tucci-Farley. Yes, I need to sit a little bit.
    [The prepared statement of Ms. Tucci-Farley follows:]

               Prepared Statement of Frances Tucci-Farley

    Senator Mikulski and committee members, my name is Frances Tucci-
Farley and I am a resident of Howard County, MD. Thank you for the 
opportunity to share my story with you about what I've gone through to 
get health care for me and my son.
    All of this started back in early June when I was in a car accident 
and injured. Shortly after the accident, I was laid off from my job. I 
went to the Department of Social Services here in the county to apply 
for health care for myself. Thankfully, my son (he just turned six 
earlier this month), had health insurance through his father.
    Between June and October, I tried several times to check on my 
application at Social Services and was unable to get an answer from 
anyone. The only feedback I received about my application was a letter 
stating, and I quote, ``an agency delay has occurred beyond our 
control.''
    Then came October 9. My entire world changed in an instant on this 
day. There was a tragic loss. The father of my son passed away from a 
heart attack. It was a sudden, unexpected, and devastating loss. I was 
devastated. My son was devastated.
    His death had a significant emotional and financial impact. In 
addition, I was concerned about health care for my son because his 
health benefits through his father were terminated upon his father's 
death. Now it was me and my son who needed health care. So, on October 
9, the very same day my son lost his father, I headed to the East 
Columbia Library. I had heard about Healthy Howard and that the Health 
Department was having open enrollment for health care at that branch. 
There were a lot of people at the library who needed health care. I 
waited my turn and was seen by someone from the Health Department. They 
collected my documents and signed me up for a phone appointment to 
figure out what program we were eligible for. When I told the Health 
Department people about my situation, they immediately set me up with 
one of their staff who helped connect me to several community 
resources. They were able to tell me about grief counseling options, 
even a camp for children who have lost a parent that I can sign up my 
son for this summer.
    Compared to what I had been through at Social Services, this seemed 
too easy. I went to the library thinking I was just applying for 
Healthy Howard, but when they worked on my case I was told that I was 
eligible for Medical Assistance. And my son was eligible for the 
Maryland Children's Health Program or MCHP.
    I thought everything was set and then we had another major set 
back. The Health Department called to say that since I had applied at 
Social Services first and my case was still pending there, the Health 
Department wasn't allowed to work on it. Social Services had done 
nothing for me since June but the Health Department wasn't allowed to 
work on my case and get us approved for health care. This makes 
absolutely no sense and must be changed. If the system at Social 
Services is so overwhelmed and they had a way to take one more person 
out of their lobby by allowing another agency to work on my case, why 
wouldn't they want to take advantage of that? I wasn't applying for 
other services, we just needed health care. Thankfully, the supervisor 
at the Health Department was able to figure out a way to get my case 
released and both my son and I were approved for health care. We were 
even able to get a temporary card for my son so he could get his 
medications. He had been without his meds for 5 days.
    I have been going through a lot over these past few months. I was 
injured in an accident, I lost my job and I am now faced with raising a 
child on my own. The Health Department and this new process they have 
to enroll people--the Health-e-Link system--really made it easy. To me, 
it also made applying for health care a humane and professional 
process. It is hard enough as it is to ask for help and it gets really 
frustrating and upsetting when you don't know what you qualify for and 
you can't seem to get anyone to answer your questions or give you an 
update on your case. I wasn't asking to be treated differently from 
anyone else. I did all the right stuff--I went to Social Services, I 
filled out the application, I gathered up all of my important 
documents. I just needed someone to work on my case and see if I was 
eligible for health care. Then, all of a sudden, I needed help for my 
son as well. There was this overwhelming sense of despair and 
helplessness when I first applied for health care at Social Services. 
It was an entirely different feeling when I got to the library on 
October 9. With the Health Department and that Health-e-Link system, I 
got feedback immediately--they told me what we were likely to be 
eligible for and then explained what would happen next with the 
application.
    Even in the best of situations, it is hard work having a pulse. 
Health care is not a luxury item. It is something I need for myself and 
for my son. There must be an easier way to get people access to health 
care. It looks like the Health Department may have a solution with 
Health-e-Link.
    Thank you for the opportunity to share my story with you today.

    Senator Mikulski. First of all, thank you. Thank you, Ms. 
Wensil. These were hard stories to live. They're harder stories 
to relive. And they're much harder to relive them in public. 
So, we thank you, first of all, for your courage.
    Ms. Tucci-Farley. Thank you.
    Senator Mikulski. We thank you for your courage in being 
willing to share this in public. I think we've all been touched 
by it, and, of course, that means we have to be, ourselves, 
moved to action. So, while you kind of regroup a minute, we're 
going to turn to these folks, and then we'll come back to you.
    Ms. Tucci-Farley. Thank you for the opportunity to share.
    Senator Mikulski. Thank you.
    What I'd like to do is ask a couple of questions, turn it 
over to Congressman Sarbanes, and we'll do that for, maybe, a 
couple of rounds, until about 1 o'clock.
    I'd like to kick this off with the county executive, who 
really undertook a pretty bold experiment and had to marshal a 
tremendous amount of community support. I would like to ask him 
what he felt would be elements of the program that could be 
implemented nationally, and what, if any, pitfalls that you saw 
in doing that, and perhaps Dr. Beilenson can respond to those 
two questions.
    Mr. Ulman. Sure. Thank you, Senator.
    Let me also just say, thank you for the testimony and the 
wonderful stories. I also commend your courage in telling those 
stories here. You asked what you could do, and the Senator 
said, ``You've already done it.'' I'd echo that. I mean, we can 
think about policy and talk about policy, but, it's incredibly 
important for people to know your stories; and so, thank you 
for that. Certainly inspirational, and keeps us going in 
fighting harder for this effort. You've put wind behind our 
efforts to keep this going.
    Because we've heard a little criticism. People like to 
criticize when someone takes on a new effort. We knew this was 
going to be hard work. There is no question about it. I think 
the lessons--and I'll ask Dr. Beilenson--the lessons that I 
think we've learned are that there's a lot of people who are 
eligible for existing programs. We knew that, as Dr. Beilenson 
said. But, to see how many people there are like you who got 
into something that your son was eligible for, that you were 
eligible for, that, for a variety of reasons, your experience 
with DSS, you just weren't getting. I mean, this is something 
that the Senator, her leadership at the national level has 
provided funding for, has provided opportunities for, and it's 
just not getting to you. That's been a huge lesson for us, and 
it's buffeted, sort of, our belief that there are folks who are 
eligible for existing programs. And to me, that's one of the 
most exciting pieces.
    The other is that this network that we've been able to pull 
together is functioning. We just started, but, when I hear the 
story about how inexpensive your prescriptions are--we've 
talked about this pharmacy benefits coordinator who's going to 
tell you that Walgreens has it for $4, but Giant now has it for 
free, because they have free antibiotics. We can talk about 
that, but to hear you saying that four prescriptions is costing 
you $28, when one was costing you $96, I just had a huge smile, 
internally and externally, to hear you say that, because we've 
been trying out, ``OK, what's our budget for pharmaceuticals. 
We know they're out there, we know that there are benefits out 
there that we're just not leveraging.'' And so, to hear that is 
tremendously exciting for us.
    I think the one pitfall, if you will, is how hard it is to 
find people. People are busy. We've got to first----
    Senator Mikulski. How hard to find people to do what--to 
participate in the program or to be providers?
    Mr. Ulman. Participate. You read the paper, and you heard a 
radio interview, and you heard about us, and you checked us off 
on your list. Well, there are thousands of people like you who 
still don't know that we exist. That's the toughest lesson for 
us. How do we reach that next group of people that are working 
two jobs and are busy? Because we know this is working and so, 
we want as many people--we want to hear this story for the 
thousands of people who don't have healthcare.
    Senator Mikulski. Well, this takes me, then, to Ms. Page 
and Dr. Beilenson. This goes to eligibility and certification, 
as well as case management. So, I'm going to put my social-work 
hat on. Going back to my days as a social worker, and also 
talking to people who are on the other side of the desk, that 
Ms. Wensil and Ms. Tucci-Farley found so, at times, harsh or 
even despondent, and contributing to the despair, is that the 
workers themselves are so burdened by books and books of regs, 
schoolmarmish requirements, at times even where Congress, in 
its desire to save money, has even created harsh punitive types 
of questions and so on.
    Now, what they just talked about here was, in itself, 
almost revolutionary, that, when they talk about walking into 
this room, and the energy, the vitality, the hospitality; they 
didn't feel like the process was either humiliating or harsh 
and punitive. Also, the people administering it, themselves, 
weren't so worn down and burned out, where they themselves 
needed help to help you. You know, we often, at times, forget 
that the helper needs help to be of help.
    So, my question, then, goes to you, Ms. Page. You've got 
something pretty revolutionary going on here in this--the 
Center for----
    Ms. Page. The Center to Promote Healthcare Access.
    Senator Mikulski. Could you tell us about this? Is this a 
proprietary tool, could you tell us about that? How do you do 
what you do? And how did this come here to create an 
environment that worked for everybody, from those who were 
signing up for the program, but for also those who were--
because if you administer a demeaning program, you yourself 
feel demeaned in administering it. So, could you help us out, 
here?
    Ms. Page. Sure. You know, it's interesting that One-e-App 
actually got its start in California, where the creation was 
funded, in part, by two foundations, two conversion 
foundations, the California Healthcare Foundation and the 
California Endowment, who provided funds to help create the 
system----
    Senator Mikulski. Like an IPO?
    Ms. Page. Kind of. Exactly. And after that----
    Senator Mikulski. Or venture----
    Ms. Page. Well, it's----
    Senator Mikulski. Let me put it this way, if you're a 
social entrepreneur, this was the venture capital.
    Ms. Page. That's right. And after some period of years, 
realized that it wasn't the day-to-day work of foundations to 
continue to manage and oversee, and even though they weren't 
the technology developers, they still had their hands kind of 
deep in the work and decided that it was worthwhile to create a 
nonprofit organization to focus, not just on the technology 
piece, but also on the advocacy and education piece of this 
reform work. And they actually provided seed funding to create 
the Center to Promote Healthcare Access.
    One of the other things that happened in that transaction 
was, the intellectual property to One-e-App is actually still 
owned by those two foundations, who provide to the Center a no-
cost license to then sublicense it at no cost to other 
jurisdictions who are going to use it for this important work. 
So, any new jurisdiction, county, State, who's using One-e-App 
takes as its starting point a core system that then is 
configured and customized to work with the local programs and 
business processes.
    Senator Mikulski. So that a South Dakota and a North 
Dakota, with a very different population size and demographic 
than, certainly, California, which is almost like a nation-
state, in just size and language and so on--so, this is not a 
one-size-fits-all technology.
    Ms. Page. It's a starting point, but not a one-size-fits-
all, primarily because the rules--I mean, Medicaid looks 
different in every State. Medical looks different in every 
California county, even though it's generally the same; the 
business processes and some of the rules are different. You can 
generalize some of them, but we have found that the more 
accurate the screening is at that moment in time where you're 
with the family and you're able to collect as much information 
as you can, the greater the benefit to the family. You're doing 
a more accurate screen and actually sending their data to the 
program. One-e-App also is the final determinant for a handful 
of programs, but for Medicaid, we aren't the system that makes 
that final determination; States and counties make that 
decision. But, we're sending the information there with a 
greater likelihood that it will be approved.
    Senator Mikulski. Well, Ms. Page, we could spend a lot of 
time just talking with you, and I think what we'd like is to 
see more of a report, or like an annual report, or something, 
and we'll come back to you.
    Ms. Page. Great. Thank you.
    Senator Mikulski. But, before I turn to Congressman 
Sarbanes, technology is a tool. Very often, among my 
colleagues, there is a belief that technology is the silver 
bullet, it will solve everything, and so on. But, technology is 
only as good as the people that use it. You need the tool, but 
then you need the people and you need the culture. Technology 
doesn't create the culture.
    How did you do this, Dr. Beilenson? This is so unlike 
anything I have heard, in 30 years of working as a social 
worker, about the so-called intake process, and even in another 
life, when I tried to change that culture myself. How did you 
accomplish that?
    Dr. Beilenson. Well, we have great people, and that's truly 
their mission, not that it's----
    Senator Mikulski. But, great people need a great culture 
and a great organization.
    Dr. Beilenson. Well, I think that, the county executive 
certainly fostered a culture of innovation for the county. And 
when we first met--I don't know, it was a couple--well, it was 
actually the campaign--a couple of years ago, when we were 
talking about this--me moving into this position, the fact that 
he made it very clear that he wanted public health to be one of 
his top priorities as a county executive, obviously sold me on 
this. As you well know, it's extremely unusual for--
particularly for a suburban county executive, to make public 
health a top priority.
    Senator Mikulski. No, we acknowledge that, but let's go to 
the room now. Let's go to the application.
    Dr. Beilenson. These folks, both the architects and the 
enrollment people, are just incredibly dedicated, and they just 
buy into it as a mission. Part of our mission statement is 
making sure that we provide access to healthcare and wellness 
for the county. I mean, it's really as simple as that. And 
we've put together a great team. John knows several of them, 
from other lives, and they've just been dedicated. But, that 
being said, I don't want to neglect, because I'm sure they'll 
point out, that eventually they probably would get burned out. 
You cannot see 1,100 people in 8 days and keep processing and 
processing.
    So, one point to make that I think has been lost in the 
tremendous job that you all have done in expanding--in 
recertifying CHIP and expanding CHIP--is, that all goes to 
services. But, that you've got to do two things. You've got to 
do outreach, because you've got to somehow bring people in. Ms. 
Wensil and Ms. Tucci-Farley heard about this in certain ways, 
but there's got to be a lot more outreach to get people into 
existing programs.
    And second, someone's got to do the enrollment to--and part 
of DSS's problem is, as you said, they're overburdened, and so, 
somehow some of this funding--and it's a small amount that's 
necessary--needs to go to enrollment, to people who would 
actually do the enrollment process, whether it's our type of 
process or DSS's, because otherwise people are going to still 
get burned out.
    Senator Mikulski. Are you saying the money for the 
technology or the money for more workers or----
    Dr. Beilenson. Yes, to all three, although the relative 
expenditure, compared to the healthcare costs, are small. But, 
not to forget that those are three important components.
    Senator Mikulski. John. Congressman Sarbanes. Thank you.
    Mr. Sarbanes. Thank you, Senator.
    Thanks for the testimony. It's very, very powerful. I have 
so many questions and so little time, so----
    [Laughter.]
    Mr. Sarbanes [continuing]. I'm just going to try and jump 
around, here.
    I think, in part, what you've done is, you made it possible 
for care to be delivered in all the ways people wish it were 
delivered, and are frustrated, day in and day out, that it's 
not delivered. So, you're allowing folks to bring the best 
approach to healthcare into this model. And there's a lot of 
pent-up frustration about that, not just here in Howard County, 
but obviously across the country, which is why you're getting 
this call now for healthcare reform.
    On the issue of IT, I'm glad we got to that point, because, 
we just--in the stimulus bill, there's $20 billion now that's 
going to try to boost the health IT infrastructure across the 
country. Much of that is in the form of incentives to try to 
get providers to step up into something that they're a little 
bit reluctant to do because of the expense associated with it. 
But, you're pointing out that there's other places where you 
can direct resources and attention when it comes to information 
technology, particularly when it comes to processing that 
you're doing. So, that's making a huge difference.
    I want to congratulate you on this aspect of connecting 
people to their eligibility, that already exists--they just 
don't know it--because, we just sent, again, a huge influx of 
funds to support CHIP, to support FMAT, you know, Medicaid 
program, across the country. We want to know that the people 
who are eligible for that are getting the access that they're 
entitled to, and that's exactly what you're about. So, I 
congratulate you on that. And also on the State having picked 
up, through the comptroller's office, this obligation. That 
already shows that you're bearing fruit more widely than just 
Howard County, because that model is being used.
    Ms. Wensil, your testimony struck me as having the theme 
that--I mean, you talked about this idea of, sort of, winning 
the lottery. Of course, healthcare in America shouldn't be 
analogous to winning the lottery. I want to make sure that 
people have access, as a matter of course. But, what struck me 
was just how excited you were to access the plan. I think I 
heard in that the reality that people want to look after 
themselves, they want to have healthcare, they want to be 
healthy. That suggests that if the system can step forward and 
make that possible, that there will be an equal investment on 
the part of individuals and families to do their part. I know 
that's part of the design, obviously, of these Health Action 
Plans and so forth. So, I'm interested, interested to have you 
talk to that just a little bit more, this concept that people 
really do want to look after themselves. They want to be fit, 
they want to be healthy, and they're willing to participate if 
there's a system that's going to join them as a real partner.
    Ms. Wensil. Oh, absolutely. I know both of us have cared 
for our children, with the best of intention, sometimes at the 
loss of our health or--so, to feel like, again, I have access 
to that, to basic medication that I wasn't taking or was self-
manipulating, that's a big deal for me. I feel better when I 
take my medication. I want to feel better. I want to get to the 
point where I can walk more. But, with COPD, I couldn't. And 
without medication, I couldn't. So, yes, I'm feeling better 
immediately, but also, I'm not depressed about life and my 
circumstance. I feel, ``OK, I've got somebody backing me on 
this. I've got support,'' which I haven't had for so long. And 
that's a big deal. When you feel like--and maybe that was part 
of the ambience in that room, is that we felt--we felt like, 
OK, somebody's looking at our issues. You know, we're just 
little people, sometimes with big issues, but we felt like, OK, 
somebody's paying attention that this is a real issue in our 
lives, that we may not get things taken care of.
    I broke my finger; I fixed it myself, I strapped it up 
myself. And thus, I have a very crooked finger. But, I wasn't 
going to go to the health--I mean, to the emergency room for 
just a small finger. I thought, well, I pretty much will garner 
arthritis pretty badly because of it. But, those are decisions 
that everyday people are making: Do I take care of this now?
    The problem with this method is that we're not taking care 
of basic health, we're not taking care of routine health. We're 
waiting until something really goes wrong, and then we'll end 
up in the emergency room, for thousands and thousands and 
thousands of dollars more. Whereas, that mammogram would have 
been worth it, that, bloodwork--it's the routine issues that we 
have ignored, being in this circumstance.
    Mr. Sarbanes. Thank you. I've got----
    Ms. Wensil. You're welcome. Thank you.
    Mr. Sarbanes [continuing]. A question for Ms. Tucci-Farley, 
but why don't we--you can go----
    Senator Mikulski. Go ahead. Go ahead.
    Mr. Sarbanes. OK. Well, what I heard from your testimony, 
which was very, very compelling, obviously, and heart-
wrenching--and again, I want to thank you for the courage to be 
here, and you, Ms. Wensil, to tell your personal stories. But, 
the theme that came through to me from your testimony was that 
the last--life throws enough curves at you; the worst time to 
have to be worrying about your healthcare coverage and whether 
that's going to be there for you is when you're dealing with 
other crises in your life. And, of course, that's the situation 
that so many people face. They have this thing that's hanging 
over them, which is this anxiety about whether they can get the 
care they need. And then, when life throws another thing at 
them, the combination of those two things can be, just enough 
to put them over the edge.
    You had a great quote. I guess it was DSS that said to you, 
``An agency delay has occurred beyond our control,'' which is, 
I think, a good slogan for the healthcare system in this 
country. You know, something has occurred beyond our control 
which is preventing millions and millions of people from 
getting access to the healthcare that they deserve. I thought 
maybe you could just speak for a couple more moments to this 
question of what it would mean--because you've obviously been 
in the situation where you didn't have the healthcare coverage 
available to you, and yet, you were trying to field all these 
other things that were coming at you, and what kind of a 
difference it would have made in your life, and a difference I 
assume it's making now, to know that that part of your life is 
under control, that you don't have to get up in the morning 
with that anxiety; and so, you're in a better position to 
handle the other things that are coming at you.
    Ms. Tucci-Farley. There's one instance that comes to mind 
immediately. In the line of work that I do, it may require that 
I do some heavy lifting, as well, along with it. I am an 
exhibit designer by trade, and----
    Senator Mikulski. A what designer? I'm sorry.
    Ms. Tucci-Farley. An exhibit designer. I've got some work 
in the U.S. Capitol. Put that on record, huh?
    [Laughter.]
    There are times when I might be designing a particular 
space, and I have to go into that space and figure out some of 
the logistics. That requires lifting and so on, so forth. When 
I'm on interviews, that's one of the questions. Right now, I 
don't have feeling in my left arm, and I don't have feeling 
down half of my spine, and when I even sit at the keyboard, my 
hands go numb. I'm a little bit disingenuous in promising all 
these great things that I can do, when I'm sitting in an 
interview, trying to get a job, because the light in my 
refrigerator is brighter than the front porch light; meaning 
that there's nothing left in my refrigerator. It's a matter of 
survival for me to get a job. And when I'm sitting at an 
interview, and an interviewer detects that there's any kind of 
tentativeness in your answer, the job market is so saturated, 
you're immediately disqualified. I can't do that. I almost am 
not sure, unless I get medical care soon, if this is going to 
steer me back into having surgery again. And being a sole 
parent, with my son--other son away at college, what do I do if 
I need surgery again? Who takes care of me? I don't have family 
in the State that's available to do that. And so, that 
basically rides in the back of my thinking all the time. You 
know, if something happens to me, there is no other parent now. 
If something happens to me, there's no--it's like doing Cirque 
de Soleil without the net. Knowing that you have healthcare is 
an extraordinary, extraordinary element of having peace of 
mind. There is just----
    Mr. Sarbanes. And confidence as you go out into the world.
    Senator Mikulski. Which, in and of itself is healthcare.
    Ms. Tucci-Farley. Yes, part of the stress is, I think, at 
times--when I'm fighting to not get sick, I'm fighting my own 
decline in well-being overall.
    Senator Mikulski. Dr. Beilenson, did you want to add 
something?
    Dr. Beilenson. Yes, I just wanted to add one thing. When 
you were talking about the health IT, what Claudia was implying 
was that we have this great engine, sort of a search engine, 
Turbo Tax engine, that will help you fill out what you need to 
fill out to get enrolled. But, it doesn't connect to the State 
of Maryland. DSS's system is even worse. And so, if some of the 
health IT money could be used, not just for physicians, but for 
the States to do these things, the value added for that and the 
cost-effectiveness would be vastly greater. You could get tens 
to hundreds of thousands of people enrolled very quickly if you 
had the ability to connect. For example, if we went through 
Health-e-Link, and Peter Beilenson was eligible for MA 
expansion, Medicaid expansion, it would literally--with the 
appropriate technology improvements, I'd be enrolled. I'd get 
my Medicaid card. That does not happen now. They collect all 
the information, send it to the State, and we hope it gets in.
    Senator Mikulski. So, what you're saying is, the State 
system is both dated and it is not interoperable.
    Dr. Beilenson. Absolutely. And some of the IT money would 
be great to go there.
    Senator Mikulski. I want to go on, then, for the final 
round--because it is 1 o'clock and we're scheduled to end--I 
want to focus on this case-management health-coach issue, and 
then John--Congressman Sarbanes--and then kind of a summing-up.
    We've now covered what--the compelling human need--it was 
like to apply, the way you facilitated that and created a 
culture of hospitality. So, you've now seen your primary care 
doc, and you've got your medicines at the best price, and 
you're on your way. Well, in our sick system--because we don't 
have a healthcare system, we have it oriented to sickness--so, 
the person then sees primary. Each one of these women have 
things that will require specialized care, and off they go. And 
no--there is no kind of continuity of who follows them, as 
human beings and as families--because each has children, here--
and then there's this famous thing that you hear, no matter 
what doctor you see, that says ``diet and exercise,'' and they 
give you a little piece of paper, usually given to you by 
somebody overweight themselves----
    [Laughter.]
    Senator Mikulski [continuing]. And no help whatsoever. So, 
if you had a heart attack or you have serious pulmonary 
compromise, what kind of exercise--you could be terrified 
starting to do the wrong thing.
    Now, under the genius of the Howard County system, what 
happens--No. 1, you have a healthcare system, not a sick care 
system--and what happens to help people be able to follow--do 
they have a health plan? How do they follow it? And how is it 
really one that motivates people rather than just simply, 
again, school-
marmish compliance from a call center?
    Dr. Beilenson. Well, the only actual innovative part of our 
five-part program is that it--besides the fact that it ties 
everything together--is the personalized health coaching. We 
don't know of another system that has all the different 
components plus the health coach. And the health coaches are 
specialized in motivation----
    Senator Mikulski. Why don't you describe, though, from the 
stand--I'm a case example, and we've heard that; that's why I 
wanted to hear this--so, follow with me now, not a laundry list 
of abstractions----
    Dr. Beilenson. Right.
    Senator Mikulski [continuing]. Follow with me how this 
works and what happens to a person.
    Dr. Beilenson. OK. I'll use an actual person, but won't use 
their name, obviously.
    Senator Mikulski. Correct.
    Dr. Beilenson. We've had several dozen people come in for 
their initial primary-care visit. You go to the primary care, 
and, as you were saying, we have a primary-care home, which is 
Chase Brexton, who coordinates all healthcare. People are not 
just getting sent to the specialists or to the hospital and not 
connecting back with their health home. So, they have that. 
Then, once they've seen the individual, the individual gets 
assigned a health coach. We have different types of folks as 
health coaches. One of our more creative types is a personal 
trainer.
    Senator Mikulski. Well, why don't you give us a 
description, then, of the categories of people you have as a 
health coach.
    Dr. Beilenson. We have personal trainer, health educator. 
We either have or are having a social worker. I may have 
actually misstated that we have one.
    Senator Mikulski. I think you ought to.
    Dr. Beilenson. I agree. My wife's a social worker, too, 
went to the University of Maryland, just like you.
    [Laughter.]
    No, were at Catholic University, right?
    Senator Mikulski. No, I was--Maryland.
    Dr. Beilenson. Maryland. So, she was just like you. And 
then, nurse. So, we have--and depending on what your issues 
are, you'll have a specific health coach who works in concert 
with the others, so there's the team approach to it.
    Let's just say, Patient X is seeing their primary care doc, 
they're diabetic, they have a wound that needs care. They would 
work with their health coach on what types of things they'll 
need to do to better control their diabetes, whether it's see 
their primary care doc on a certain regular basis to get their 
sugar checked and to get their wound checked, to improve their 
nutrition and exercise. We have community resources that are 
brought to bear, whether it's walking programs, yoga programs, 
nutrition classes that they be assigned to. The care 
coordinator at Chase Brexton, who actually would coordinate the 
referral to the wound center at Howard County General Hospital, 
which will, of course, be done pro bono. And then, all of that 
is connected back, and the health coach makes sure that all 
those things were done, and the care coordinator makes sure 
that the care has been coordinated, as well.
    Obviously, if any prescriptions are needed, as Ms. Wensil 
was saying, those are dealt with in a value-based formulary, as 
well.
    Senator Mikulski. Well, Dr. Beilenson--because then I want 
to listen to our two other witnesses here, their families--what 
is the difference between the health coach and something you're 
calling the care coordinator or are they one and the same?
    Dr. Beilenson. They are not one and the same. The health 
coach is more of the motivational, wellness, keeping people 
healthy, getting them motivated to do the things that will keep 
them healthy, following them regularly, meeting with them face-
to-face. And that's--I'm not sure if you actually have yours 
yet or----
    Ms. Wensil. I don't. I haven't met with mine.
    Dr. Beilenson. She'll be getting hers shortly.
    Senator Mikulski. So, what's the care coordinator?
    Dr. Beilenson. The care coordinator literally coordinates--
sits at Chase Brexton. You come out of the primary care doc's 
office with a prescription for diabetic medication and a 
referral to an orthopaedist. That care coordinator makes those 
medical referrals and signs you up for the pharmacy assistance 
program, or whatever the cheapest pharmaceutical program is, to 
get you those medications as inexpensively as possible.
    Senator Mikulski. What does the care coordinator do? Do 
they watch everybody's progress? Do they host team meetings, 
where they just, then, kind of--and that's no small matter, 
telling you where to get the cheapest prescription. As we said, 
it was a make-or-break bit of information.
    Dr. Beilenson. The care coordinator manages the 
individual's clinical care. The health coach takes care of the 
holistic person. So, it's much more that a health coach is sort 
of managing and motivating the individual's health and wellness 
plan.
    Senator Mikulski. But, I'm still back to this care 
coordinator----
    Dr. Beilenson. Yes.
    Senator Mikulski [continuing]. And who's in charge of the 
patient? If this, in fact, is their--so, we know it's the 
doctor.
    Dr. Beilenson. Yes.
    Senator Mikulski. We've heard that. But, doctors don't 
follow patients. They really don't. They follow you when you 
come back for your routine visit, but not from that visit to--
let's take your diabetic. OK, so if you've got a wound that 
doesn't heal, that's one whole thing. But, you're going to have 
to do a whole variety of other things.
    Dr. Beilenson. Correct. Well, understanding that it is 
solely a tool, we do have an electronic clinical record that 
keeps track of all these things. So, they can be queried by the 
physician, by the care coordinator, and by the health coach to 
make sure that things are being done in an appropriate fashion. 
And it's a team approach to looking at this. Our health coaches 
meet with our--and I don't know if he's here, but he--some of 
our staff is here. Liddy's probably here, our executive 
director. They meet in a team, to go over each patient to make 
sure that the appropriate things are being taken care of. The 
care coordinator is much on location, and, as you said, has a 
difficult job, but is not so responsible as are the health 
coaches for making sure that everything that needs to be done 
is done.
    Senator Mikulski. Do you see my question?
    Dr. Beilenson. I do.
    Senator Mikulski. You've got a lot of people, which is 
excellent, and you've got a lot of moving parts, which is 
excellent, and you've also looked at the behavioral 
encouragement, which is really so fresh and innovative--it's 
very fresh and innovative--but, the current healthcare system, 
first of all, doesn't pay for case management, it doesn't pay 
for even the most dated-of-thinking case management. And the 
case management is--your primary care doctor says, ``This is 
what you need to do, this is the specialist you need to see, 
and this is that famous diet-and-exercise kind of thing,'' of 
which nobody takes any responsibility to followup. So, maybe 
you come back to your primary care doc, maybe your A1C now is 
at 10 or more, heading to the danger zone.
    Dr. Beilenson. Right.
    Senator Mikulski. Have you done the diet? No. Have you done 
the exercise? No. Did you see the specialist? ``No, the line 
was busy.'' So, who----
    Dr. Beilenson. The idea is, the health coach----
    Senator Mikulski. The health coach. That's their job?
    Dr. Beilenson. Correct. Because they can query everything 
and see if it's not done----
    Senator Mikulski. And who----
    Dr. Beilenson [continuing]. In a vacuum, however. I mean, 
they may need to talk to the care coordinator. Can we find the 
person a specialist visit at a time that's more appropriate for 
them, or whatever?
    Senator Mikulski. OK.
    Dr. Beilenson. But, the evaluation will also show how well 
we're doing on all this, so that's why we're very pleased that 
we have this large-scale evaluation that's ongoing.
    Senator Mikulski. Well, we're going to come back.
    So, you haven't met with yours, yet.
    Ms. Wensil. No, I have not. I have not met with the health 
coach yet. I have----
    Senator Mikulski. But, you've embarked upon--and, again, I 
don't want to pry, here--but, you've embarked upon, 
essentially, what was the medical sequencing of what you needed 
to do to even get you ready for that next step of the health 
coaching.
    Ms. Wensil. Right.
    Senator Mikulski. Is that correct?
    Ms. Wensil. Right. One of the things that the physician 
fills out on your first visit is basically an outline of your 
health and what you are capable of doing, all the way from 
strenuous cardiovascular to yoga and relaxation techniques. So, 
when you ask, ``Who's responsible? '' it's an interesting 
question for me----
    Senator Mikulski. Well, the first one is you.
    Ms. Wensil. Right. And that's the way I feel. I feel like, 
OK, I've finally been given the power back to take some of that 
responsibility. It's not that I didn't have the 
responsibility----
    Senator Mikulski. No, I understand.
    Ms. Wensil. You understand that.
    Senator Mikulski. But, there could be a 45-year-old guy, 
with the acute wound that doesn't heal, who has just been 
divorced, his job is teeter-tottering, he's depressed as the 
dickens, he doesn't want to cook for himself, he's sitting 
there, watching TV, eating potato chips or drinking Coca Cola 
or beer--his blood sugar is going sky high, and he's going into 
a deep depression. That's a little bit different than how 
you're going to take responsibility for yourself, because you 
need somebody to help take responsibility, to help you even get 
to that point.
    Ms. Wensil. That's true.
    Senator Mikulski. So, you see----
    Ms. Wensil. That's true.
    Senator Mikulski. I really do sound like a social worker, 
don't I?
    [Laughter.]
    But, Ms. Tucci-Farley, you kind of had almost that. You 
know, as you now signed up for your program, and you ran into 
all kinds of bureaucracy, obviously you are a woman of 
incredible spunk--both of you are. I mean, not only the 
personal courage, but, you have a lot of spunk, in terms of the 
activities of daily living. Now, where are you in this process, 
have you had a health coach?
    Ms. Tucci-Farley. Not yet.
    Senator Mikulski. Or you're not there yet.
    Ms. Tucci-Farley. I have not yet declared a confirmed 
provider. Some of the names that I was given as participants 
within the medical assistance program are no longer 
participating, so I have a card that has a doctor's name on it 
that I never selected and don't know who they are.
    Senator Mikulski. OK.
    Ms. Tucci-Farley. So, that's one of the things that perhaps 
needs to be looked at, too, is updating the system.
    Senator Mikulski. I think that's an excellent suggestion.
    Ms. Tucci-Farley. I received a phone call this morning, 
from a representative of the Health Department, giving me 
several more names of referrals.
    Senator Mikulski. This is my last followup and then I'll go 
to John Sarbanes.
    So, I've given you this 45-year-old guy who comes in to the 
doctor and the doctor says, ``You've got to get blood work? '' 
And the plan has been an excellent plan, and he sat there and 
said, ``Aha.''
    Dr. Beilenson. The health coach.
    Senator Mikulski. And what would the health coach do?
    Dr. Beilenson. Well, again, you would know if the person 
got lab work, because it's electronic records. You would know 
if the person went to nutrition classes, because they're 
connecting, as well. The one thing we're having a little 
problem on accountability with is the exercise program, because 
let's say the exercise program is 3 days a week, a hour a day, 
at Centennial Park, walking. Well, it's going to be hard to 
check that. You know, in the wintertime it's easier to check, 
because they've gone to yoga class, et cetera, et cetera.
    Senator Mikulski. Got it. Go ahead.
    Dr. Beilenson. It's all in an electronic medical record. It 
is done in concert with the others, however. It is done in 
concert with the primary care doc. So, the health coach is the 
one that's predominantly responsible, but----
    Senator Mikulski. So, then what would the health coach do? 
They know that he didn't do it.
    Dr. Beilenson. As the county executive said at the very 
beginning--this is based on rights, like healthcare is a right, 
but also responsibility. As part of the sign-up process, if you 
are not substantively complying with your program, your 
behavioral action plan, your Health Action Plan, you actually 
go on probation and could eventually lose most of the services. 
So there is a stick.
    Senator Mikulski. So, that's the stick. But, let me ask you 
this. And now we're really running over on time. The health 
coach sees this--and this happens every day in just about every 
case that we could go to for a variety of things, in every 
setting, from being followed at some of the most prestigious 
institutions, to poor rural areas. Would the health coach 
essentially call George and say, ``George, gee, what's going 
on? '' and essentially do personal outreach to engage the 
person and actually ask them why, and see if they could come 
by, or could they drop by and have a conversational 
relationship to identify this?
    Dr. Beilenson. Yes. That's exactly correct. And when it's--
--
    Senator Mikulski. Because the health coach brings great 
individual expertise, from nutrition to, being a nurse, but it 
is the relationship that makes or breaks the health coach. Am I 
right?
    Dr. Beilenson. You're 100-percent correct.
    Senator Mikulski. Isn't it based on, not only formalized 
credentials, but a relationship?
    Dr. Beilenson. Absolutely. That's why we're so pleased. 
Kate Hetherington's here, as I'm sure you know, from Howard 
Community College; they're going to be doing some training of 
our health coaches. Bob Duggan's here, from Tai Sophia; they 
are, as well. But, we specifically hire people who have 
demonstrated great rapport with folks, because it is completely 
the relationship.
    Senator Mikulski. So, then would they call this person?
    Dr. Beilenson. They would not only call them, they would 
arrange a meeting with them, face-to-face. They might go to 
their home to see what the issues are going on there. They 
might meet them at the mall, because that's near where the 
place that person works, at the auto store or whatever. That's 
the whole point of the program. That's why we're most hopeful 
that this is different than other programs, and will show 
better outcomes, because we have----
    Senator Mikulski. Well, it sure is different. Then, let's 
say they found--again, it's the 45-year-old guy on the verge 
of--so, then the health coach would say, ``Well, OK, my job is 
really--I'm very good at exercise. What you need is a couple of 
other things.''
    Dr. Beilenson. Yes.
    Senator Mikulski. ``And let me see how I could help you get 
connected.''
    Dr. Beilenson. Yes.
    Senator Mikulski. So, they'd come back to the care 
coordinator or----
    Dr. Beilenson. Well, we also have a community--I don't mean 
to throw too many wrenches in the thing, but----
    Senator Mikulski. No, but, you see, you have a lot of 
people, but I want to know who they come back to.
    Dr. Beilenson. The health coach. The health coach is the 
center of their care universe who will make referrals, as need 
be, but will followup. If they need a program, a nutrition 
program, they'll call their community resource coordinator, who 
will find such a thing. The person--and getting back to your 
point about meeting people where they are, that's the whole 
key. So, here's a great example----
    Senator Mikulski. That's a social-work phrase, too, 
``meeting people where they are.''
    Dr. Beilenson. Yes, my wife has explained that to me.
    [Laughter.]
    I would never have thought of this, but if you go on 
Comcast--we all get Comcast, living in the city.
    Senator Mikulski. Kind of.
    Dr. Beilenson. I didn't know you could do this, but----
    Senator Mikulski. Kind of.
    [Laughter.]
    Dr. Beilenson [continuing]. But, on the----
    Senator Mikulski. It's like eligibility----
    [Laughter.]
    Dr. Beilenson. No, I actually get Comcast. You know----
    Senator Mikulski. I----
    Dr. Beilenson. I know. But, if you go to ``On Demand,'' and 
you go through the ``On Demand'' things, there's actually a 
fitness program. Let's say you can't initially get out; you 
don't have a car, you can't get to Centennial Park. You just go 
on, and for 3 days a week, you do the 25 or 30 minutes of 
what's on TV--like Tae Bo, that kind of stuff. I would never 
have thought of this, but our personal trainer did--so that you 
meet people where they are. They may not be able to get out 
yet. And that's the whole point of the wellness program.
    Senator Mikulski. Well, which would be true of Ms. Wensil 
and Ms. Tucci-Farley. They're not going to go out and go for 
the burn, ooh-ah, ooh-ah------
    [Laughter.]
    Senator Mikulski [continuing]. Because of breathing 
problems, and then the other, neurological manifestations.
    Well, I think I've got a good picture. Again, we could take 
each one of these areas, but there's two pretty innovative 
ideas here. One, the way you enroll people and the culture of 
hospitality is pretty significant. And then, once you enroll, 
you don't feel like you're on your own, that you're not a 
medical record being passed along, et cetera, et cetera. This 
is pretty innovative.
    Congressman Sarbanes, you want to go for the last round, 
and then we're going to wrap it up.
    Mr. Sarbanes. Thank you, Senator. I don't have any more 
questions, because I know we're running short on time. I just 
had some closing observations.
    First of all, thank you, again, to the panel, for being 
here. Terrific testimony. Congratulations, to County Executive 
Ulman and to Health Officer Beilenson, for their work on this.
    One thing that occurred to me as I listened to the 
testimony, first of all, you didn't have to do this. You really 
did not have to do it. Nobody would have noticed if you didn't 
do it, but you decided to do it anyway. That's the first point.
    The second point is, the logistics of what you took on, I'm 
sure, made you think, every other day, ``Let's forget about 
this, it's too hard.'' Now, once you launched it publicly, you 
couldn't go back, but I know, leading up to that public launch, 
you must have, many times, thought to yourself, ``It's just 
trying to break through the system in so many ways is just too 
hard,'' and many others probably that--the terrain is littered 
with people who probably set off with all the best intentions 
and then abandoned them. So, I just congratulate you for 
pushing through.
    If all you'd accomplished was to spot this phenomenon that 
many people who are eligible for benefits are not getting them, 
and connected those to them--if that's all you had 
accomplished, it would have been a terrific success. You really 
ought to chalk that one up. But, obviously you want to go 
further, you want to explore what the best design is of 
providing care.
    This notion of focusing on prevention--I'm glad we had this 
hearing right in the wake, Senator, of the stimulus bill, 
because there are so many things that are in that bill that 
align with the testimony that we've had today. There's a 
billion dollars going to wellness and prevention, there's a 
billion dollars going to looking at good outcomes and 
researching the effectiveness of different treatments, 
alternative treatments. And then, of course, there's the 
resources going to support Medicaid and SCHIP and all the rest 
of it. So, these are things that we have to focus on if we're 
going to fix the system in a positive way.
    And then, the last, I guess, observation I had was that, 
managed care has been a term that's been thrown around for many 
years, and in the commercial arena, managed care has not scored 
well, in my view and in the view of many. You're talking about 
a different kind of managed care, which I think is working. And 
when you look at connecting people to eligibility, that's about 
thinking of managed care on the front end, managing the 
opportunities for people to get access. It's sort of like the 
public version of managed care. And it, I think, really informs 
what we need to do, going forward, in designing a healthcare 
system that works across the country.
    Your testimony today has just been invaluable to us. We've 
got it all recorded. We've taken notes. And you can bet that we 
will plow this into the discussions on how to reform the 
system, going forward.
    Thanks again, Senator, for letting me participate in the 
hearing.
    Senator Mikulski. Thank you, Congressman Sarbanes.
    Well, I'd like to, too, give a few concluding observations.
    One, we want to thank all who participated in our hearing. 
We also want to thank all who make the Howard County Health 
Initiative such a success.
    Really, I think I said, this hearing's a matter of public 
record and goes into the history books of what we're embarking 
upon. But, I really think, echoing Congressman Sarbanes's 
words, to you, County Executive Ulman, and to you, Dr. 
Beilenson, this is pretty bold, and you were willing, not only 
to undertake an enormous undertaking, which is trying to deal 
with the uninsured or the underinsured, primarily with the 
uninsured, but also to bring bold ideas in changing a whole 
healthcare system that's focused on insurance and payments and 
how do you get into it and how do you get out of it and what do 
you get out of it, to really focusing on patient-centered 
healthcare, from the minute you walk in the door to the minute 
you have to keep going to other doors to be healthy. So, we 
want to thank you for that.
    Observations that you've made, and we've picked up, is, 
first of all, the whole concept of uncompensated care is a 
myth, that care is compensated, but it is compensated by 
essentially a hidden health tax on everyone who pays to 
subsidize where ERs become the primary care physician. When we 
then look at cost-saving, which must be part of any equation or 
calculus in doing what we're doing, that cost-saving, first of 
all, if we look at the concrete nature of it, this should be, 
presuming it all works as we've heard, lower or eliminate the 
use of ERs for primary care. That's a big deal. If we could go 
to any one of our institutions, not only those--like a Hopkins 
or a Maryland, but a Holy Cross, Mercy, St. Agnes--their rising 
uncompensated or people doing this, particularly in these tough 
times, is emerging.
    Second is the whole concept of prevention. And the way we 
heard it today was a couple of kinds of prevention. One, 
recidivism, that if you are treated in an acute-care facility 
for that open wound or failing to come in because you can't 
catch your breath, that whatever treatment you get, because you 
go into something, it should reduce returning to acute care for 
a chronic condition.
    Third, the management of chronic illness and, again, 
prevention. If you have a diabetic propensity, you might not be 
able to beat those genes, but you can delay the consequences. 
My definition of prevention is, not only, like, let's make sure 
we don't get malaria, and vaccinations and so on, but it's also 
the prevention of a chronic situation, deteriorating to 
debilitating. Again, going to that diabetic, if we can do the 
right intervention, see, then that person doesn't progress to 
kidney dialysis or the melancholy nature of an amputation. So, 
if we can intervene there and keep them on a regiment where 
they might be insulin-dependent their whole life, but that's 
the only thing they'd be dependent on. That would be it.
    And then, also, the better use of physicians. Instead of 
the physician saying, ``Let me sort out those drugs. Are you 
really doing a diet? Well, let me tell you about broccoli''--
nobody's going to have that time, and we've got to hear about 
broccoli and eating vegetables and all of those things. So, 
within our healthcare team, we make highest and best use of 
what people are best at doing. Therefore, lower the stress on 
that.
    Also, what you're saying is, there's the technology issue. 
Technology is a tool, but, by and large, the most important 
thing is that, once enrolled in a humane, efficient, and 
probably more error reduced program you're going to have a 
better outcome. We haven't even talked about the followup, both 
with the physician and other modalities of actual healthcare 
and the health coach. When people talk about a primary-care 
home, they usually mean a doc, and we're hearing continuously 
about how health IT's going to solve everything. But, it's not 
a techno-case manager. Even those calls, which are prompters, 
like, ``Have you taken your heart medicine today, or your 
insulin? ''--that's only a prompter, that's not a motivator. 
This is what quality is all about. It's a culture of patient-
centered care. It's providing a continuum of care. It's using a 
variety of trained people. And at the end of the day, people 
are better off and our society is better off.
    We thank you for what you've done. I also want to announce 
that there are two more important issues. One, the committee 
will be examining our workforce issues, because, whether it's 
the Massachusetts model or the Howard County model, there's 
going to be more stresses, first of all, on physicians and the 
need for primary care, more on people who already are in 
healthcare, but there is a workforce shortage in nursing. And 
you're doing very creative things in Howard County Community 
College, and our School of Nursing at Maryland is doing the 
same.
    The other is a concept that I will be holding a hearing on 
next week; it's called Integrative Healthcare. I note in the 
audience is Bob Duggan, from Tai Sophia, who will be 
testifying. Integrative Healthcare is what we're talking about 
here. At the same time next week, there will be an Institute of 
Medicine Summit on Integrative Medicine. That's not necessarily 
integrative healthcare, but it is a good step, because, at the 
end of the day, it has to be about people, not about insurance, 
not about technology, not about trying to shoehorn yourself in.
    Next week we will be holding a week-long focus on 
integrative--IOM will do medicine; the Kennedy committee, under 
my direction, will be doing integrative healthcare. Stay tuned 
to C-SPAN. And, most of all, know that our President has told 
the Congress that he wants to be sure that, by the end of this 
year, we have made a major step towards healthcare reform.
    We hope to have a complete bill done by then, but, if not, 
we will have the elements, and it will be done before the 111th 
Congress concludes.
    Before the Congress concludes, we'll have it done, but 
today, this concludes the hearing on quality in healthcare in 
Howard County.
    Thank you.
    [Whereupon, at 1:25 p.m., the hearing was adjourned.]

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