MACHIAS — A severe nursing shortage, an aging population in a poor county, and the cost of treating people responsible for their own illnesses were among topics discussed during a public hearing in Machias on Tuesday.

The session, one of four statewide, was sponsored by Maine’s Blue Ribbon Commission on Health Care.

The five-member commission was established by Gov. Angus King in February to address steep increases in health care costs in both the private and public sectors. The group is to make its recommendations to the governor by Nov. 1.

The commission opened the hearing by outlining preliminary estimates indicating that Maine spends $4.9 billion a year on health care, approximately $4,000 per person.

The $4.9 billion is expected to climb to just under $9 billion by 2009.

Maine’s elderly and poor, while only 30 percent of the population, account for an estimated 50 percent of the state’s total expenditures for medical care, according to the commission.

The majority of Maine’s medical expenditures are paid by tax dollars, either through Medicaid or Medicare or privately insured public employees, such as state and municipal employees and those who work in education.

The figures were a surprise to many of the approximately 20 people who attended the Machias hearing as was commission chairman Robert Woodbury’s comment that administration accounted for an estimated 25 percent of all medical expenses.

Some questioned the ability of the commission to reconcile its mission with the three key principles it has identified. The principles are: access to basic health care for all Maine residents regardless of income or location; excellence and appropriateness of care based on scientific fact; and efficiency so that expenditures go directly to health care and disease prevention with minimal administrative costs.

Philo Hall, executive officer of Down East Community Hospital in Machias, said he has participated in previous studies where the goals for medical care could be described as “fast, good and cheap.” Medical care can meet two of those criteria, but it can’t meet all three, he said.

Deborah Murphy, the supervisor of nursing at DECH, said the nursing shortage in Washington County is adding to costs because the county must compete with other areas that are offering incentives and bonuses. Maine’s current nursing work force is heading into retirement and not many people are going to nursing school, she said.

“It is very difficult to recruit professionals to Washington County unless they already live here,” Murphy said.

Prevention is also difficult although the county has received a number of grants for prevention and rehabilitation. But once the grant is gone, the program is gone, Murphy said.

Hall said that during the last 50 to 60 years, a number of factors — including government subsidies and employers paying health insurance premiums for employees — have increased the capacity and ability to deliver health care and removed economic barriers to that care.

“Are we ever going to have a discussion about what is the right amount [of care], when is life over, when is too much, too much and not enough?” he asked.

The average age of Washington County’s population is 46, and there is a high incidence of cardiovascular and pulmonary diseases and cancer, brought on by smoking, poor diet, obesity and alcohol, he said.

Woodbury said that, generally speaking, under the current payment system, neither the health care provider nor the consumer needs to know what it costs for health care. How can the commission foster a discussion about that, he asked.

Paul Weston of the Acadia Health Education Coalition said both Hall and Woodbury were talking about the great percentage of health care expenditures that come during the last few months of a person’s life. Weston asked if the commission had talked about limiting services, as Oregon has done.

“It is hard to decide what are the last six months of a person’s life,” Hall responded.

The conversation returned frequently to the question of what is basic care and what the figures for health care expenditures mean.

Eastport Mayor George “Bud” Finch said his group found it difficult to address the key principles without a breakdown of the reasons for the expenditures.

“We think there is a difference between people who have a history of heart problems versus someone who may have cut a finger off in an industrial accident or riding through the woods on an ATV,” Finch said.

Among the suggestions that participants asked the commission to take to the governor were: a cap on medical malpractice awards; state attention to work force shortages, including the lack of registered nurses; some form of credit system for good health practices; closing the loophole on transfer of personal property for people entering long-term care; long-term care health insurance; and government responsibility to pay the true costs of medical care through programs such as Medicaid and Medicare.