In July of 2012, former APHA executive director Dr. Mohammad Akhter was appointed by Washington, D.C., Mayor Vincent C. Gray to construct the “Health Benefit Exchange,” the agency responsible for helping to build the District’s health insurance marketplace that will provide residents with more affordable, quality health insurance options. As mandated by the Affordable Care Act, each state must implement a marketplace for Americans to shop for health coverage, also known as “an exchange,” by Oct. 1, 2013. Dr. Akhter took a leave of absence from his previous post as director of the D.C. Department of Health to hire staff, determine the needs of District residents and create policies to oversee and monitor the work of the Exchange. Dr. Akhter and the HBX board hosted meetings with D.C. residents to set the rules, as he said, because “if all the stakeholders and community leaders agree on things, we might as well do them.”
In a conversation with Public Health Newswire, Dr. Akhter discussed the health disparities among D.C. residents, the unique approach the HBX has taken in expanding access to care, and what public health professionals can do to help improve health outcomes across the District’s diverse population. The D.C. Exchange will open to the public Oct. 1.
Q: How does the HBX meet the specific needs of D.C. residents, including the 35,000 uninsured and many more who are underinsured?
First, we offer health insurance to those who couldn’t afford it in the past. Second, we’ve helped our community, which is different from any other place in the U.S., by modifying essential health benefits. For instance, tobacco smoking is the leading cause of death and disability. We decided in our state that smokers will not pay a higher premium than non-smokers, even though the law allows for it. It’s much more likely that a smoker will quit if they have services free of charge. If he’s going to be charged more, he’s not going to tell you he’s smoking and people will continue to smoke. In some states, [premium] costs are 20 and 30 percent more for smokers.
Another big difference is our mental health approach. There’s long been disparity between mental health and regular health services. If you are diabetic, you can go see your doctor 100 times a year but if you have a mental health or substance abuse problem, you can only have maybe four to 10 visits a year. There will be no limit when living in D.C. to how many times a month you can visit health facilities for counseling, or mental health or substance abuse treatment.
Third, lots of people in the city lose their jobs at least part of the year. A lot of people who are on Medicaid, when they get a job, they lose their health coverage. That won’t happen anymore. Instead, those individuals will transition into the private marketplace in DC Health Link. Those people undergoing treatment fighting for their life, going through chemotherapy, will continue to be in that treatment for up to 90 days with their existing providers and insurance will cover their expenses. We have done things that are unique for our population. That was the purpose of having our own exchange. We determined early on we needed an exchange because a cookie-cutter approach wouldn’t work. Our population is very special.
Q: The Affordable Care Act requires community educators, or “Navigators,” to help Americans understand their health insurance options when the Marketplace opens. Who are these Navigators in D.C., and how is the HBX engaging the public?
We’ve adopted three strategies. The information is available online, but we know we are a multicultural society and literacy levels — particularly in health — are not very high. So we needed to find people who could help other people enroll. We have agreements with the D.C. Chamber of Commerce, the [Greater Washington] Hispanic Chamber of Commerce and the Restaurant Association [Metropolitan Washington] to do public education.
Second, we’ve put out grants for community-based organizations throughout D.C. They will apply for it, we will provide them with resources and training and we will certify individuals from these organizations so they can go into their communities and begin educating [residents about the importance of enrolling in the Marketplace]. These individuals are known as In-Person Assistors (IPAs), sometimes called Navigators. They will be available in many states and the District of Columbia, to help educate and assist with enrolling uninsured and hard to reach individuals and small businesses in health insurance plans. In-Person Assistors will navigate their communities to quality health insurance choices under the new law and assist their communities in securing help paying for health insurance beginning Oct. 1. The goal is to make it as easy as possible for people to learn about new health coverage options, determine the amount of financial help they can get to reduce premiums, and enroll in the plan of their choice.
The third thing we’ve done is to work with the city agencies and ask them to provide information to the public. Some are natural, like the D.C. Department of Human Services, which provides food stamps and other social assistance. But some are nontraditional. The Department of Parks and Recreation is a big one; there are 40 recreation centers around the city where young people congregate, and many of them don’t have insurance. Similarly, the information will be available at the Department of Motor Vehicles; when you go to renew your license, you’re sitting there waiting for your turn. This info will be made available to you. We also met with the D.C. Hospital Association and DC Public Libraries to ask them to provide materials.
The idea is to reach as many people as possible, quickly.
Q: As APHA’s former executive director, your roots are in public health. What is the role of public health professionals in supporting the exchanges — both before and after the nationwide rollouts?
There’s sometimes the tendency among public health people to oppose something that does not meet what we would like to see. My request would be to please support the exchanges. This is the next best thing to having a single-payer system [in which the government pays for all health care costs]. It’s much, much better than what we have right now.
Our work is to continue to keep an eye on the public health front. When [the marketplace] comes, many politicians will ask, ‘Why do we need [any more] public health funding?’ But those funds are still important. It doesn’t matter if you have an insurance card if your house is infested with rats or you have mold in your house — your child is still going to be sick.
Finally, we need to make sure people actually have access. If you have an insurance card but there’s no provider in the community, who will take that? It’s our responsibility to bring it to the authority’s attention. And if necessary, we’d open our own clinics to serve the needy. In D.C., our experience has shown that when everyone has insurance, people have difficulty getting access to care. No one wants to come down to Southeast D.C. and build a clinic, where crime is rampant, people are poor and reimbursement not good. What Mayor Gray did before I came here, he took tobacco [tax] money and built 21 new clinics in underserved areas in the city, and gave them two years worth of funding to become operational. In two years, clinics became independent, family qualified and started collecting money. Now with universal coverage, everybody can collect money, and health facilities are competing against each other for better services.
The final thing the public health community can do is lay out the research agenda. How do we measure the health of our communities? Is it improving health of the children, women, minorities? We are working with insurance companies for some of the tracking, but it’s much more important to have fresh eyes independently looking at this and finding corrections we need to make.