Now that the Island Health Plan has received a green light from officials on Beacon Hill, leaders of this grassroots affordable insurance program must turn their attention home - enlisting doctors and Island business owners to sign on to this experimental project.
"We all want this to work. Now is the time for all the players to translate their words into action," said Tad Crawford, chairman of the Dukes County Health Council.
Their work is cut out for them, Island Health Plan executive director Cynthia Mitchell says. But the biggest hurdle, she believes, is behind them.
"At this point, there is no reason why this wouldn't work," said Mrs. Mitchell, referring to the passage of the legislation which makes available millions of dollars in state subsidy needed to make the insurance affordable.
The Island Health Plan specifically targets uninsured Islanders earning less than 400 per cent of federal poverty level, about $75,000 for a family of four. Employers must enroll in order for their employees to qualify. The program is ideal, Mrs. Mitchell said, for self-employed Islanders.
No Island physician or medical facility has yet signed a formal contract with Neighborhood Health Plan (NHP), the Boston-based health maintenance organization partnering with Island Health Plan to provide private insurance to Islanders of low and modest incomes. But five primary care providers, the hospital and Martha's Vineyard Community Services are behind the program at least in principle.
"The idea of Island Health Plan is a good thing conceptually. If we can do our part and make that come together for the Island, we will," said Timothy Walsh, Martha's Vineyard Hospital chief executive officer. "It's quite an accomplishment what Cindy [Mitchell] has done, and we want to live up to our end of the bargain."
Mrs. Mitchell now must finalize contracts with these providers and institutions.
"While we were waiting for the legislation to pass, frankly, doctors didn't want to spend the head time thinking about a contract [with Neighborhood Health Plan]," Mrs. Mitchell said.
Mr. Walsh agreed: "Now that we are past that hurdle, everyone is willing to dig in."
Dr. Michael Jacobs, who runs a walk-in clinic offering primary care to many Islanders, said he is interested and willing to contract with NHP. But he said he is uncertain whether or not he will be allowed to participate, because physicians at his clinic have no hospital admitting privileges.
"It may turn out that I'm not eligible," said Dr. Jacobs. "I wouldn't want to be excluded if [the IHP] becomes an integral part of the Island health care system."
The Island Health Plan proposes to make market rate insurance affordable for lower income Islanders currently without insurance. The affordability relies on state subsidies in addition to a sliding-scale copay system. Doctors said they are willing to accept reduced copays from the lowest income participants. Copays would range from $5 to $25, depending on the income of the participant.
Without these subsidies, monthly premiums are about $800 for a family plan and $300 for an individual participant.
The legislation approved last week enables Vineyarders earning less than 300 per cent of federal poverty level - $55,200 for a family of four - to receive subsidies. Employers who participate will also receive subsidies toward their share of premium costs for lower income employees.
Nearly 20 per cent of Islanders did not have health insurance, double the rate of the state's uninsured population, members of the Dukes County Health Council found nearly four years ago. For most of these 3,000 residents - particularly the self-employed Islanders and small businessmen - cost was the barrier. More than half of year-round residents earn less than 400 per cent of the poverty level, about $36,000 for a single person.
"We were told [by employers and self-employed people] that they would participate in a community-driven plan if it's affordable and reputable. We have that now," said Mrs. Mitchell.
Those business owners whose employees fall on both sides of the income eligibility threshold face a particular challenge. They can only participate in the Island Health Plan for their workers who earn less than 400 per cent of the federal poverty level.
"Business owners will come in and say ‘what do you mean, I don't qualify?'" Mrs. Mitchell said.
Business owners in this situation who want to offer health insurance to all employees must sign two different contracts: one for the Island Health Plan and another with an independent commercial insurer. Securing health insurance for a small group of employees is already difficult for small business owners; private insurers may be even less enticed if they can't cover the maximum employee base.
"We are committed to addressing the problem of employers straddling the line. We'll find a way," said Mrs. Mitchell.
Neighborhood Health Plan, in addition to the specific line of business it is opening for those who qualify for the Island Health Plan, is interested in offering a commercial plan on the Island. NHP has already floated this alternative contract with many Island physicians and the hospital.
Mrs. Mitchell said there is certainly a need for this middle-ground kind of coverage. The premiums charged by Neighborhood Health Plan to clients off-Island is cheaper than rates charged by their competition.
But some Island physicians and the hospital may be hesitant to introduce one more commercial insurance provider, particularly an HMO, to the Island.
"We certainly can't offer Medicaid rates to the commercial plan," said Mr. Walsh, who said the hospital is willing to accept these lower reimbursement rates for the Island Health Plan.
They have not yet made a decision about signing a commercial contract with NHP.
"The Island Health Plan - that's what we're committed to and going to focus on," Mr. Walsh added.
Mrs. Mitchell said that three of the Island's nine primary care physicians are willing to sign up with Neighborhood Health Plan for both the Island Health Plan and a commercial plan.
"Other physicians have said they don't want the commercial plan to be automatic when they sign on for the Island Health Plan portion," Mrs. Mitchell said.
Even if NHP contracted with enough providers to offer an adequate base for commercial clients, there would be at least a six-month lag between offering the Island Health Plan and a commercial component of NHP.
"We would want to establish a track record first for the affordable plan before we introduce a commercial plan," Mrs. Mitchell said.
Most of what Mrs. Mitchell knows about the marketability of the plan comes from feedback gathered during focus group discussions with employers hosted two years ago. She is not certain how this anecdotal information will translate into real interest from business owners, although she receives many phone calls from interested employers.
The Island Health Plan has compiled a list of 3,000 employers, including the Vineyard's base of self-employed residents, who might be eligible for the Island Health Plan. Those in the target group will receive further information in early July.
Mrs. Mitchell hopes to be enlisting Islanders in the health plan by September. Within a year, they plan to insure at least 750 Island residents.
"But that may be a low number. We may get much more interest. Our sense is that the need has only grown over the last few years," said Mrs. Mitchell.