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AUGUSTA – Years after her bout with cancer, Helen Hoad found herself in the emergency room with a gall bladder attack. When the hospital saw she had no insurance, it sent her home with a list of surgeons she could call.
The self-employed massage therapist – who paid more than $4,000 out-of-pocket for the surgery – hopes Maine’s new universal health care system means she’ll never again be left without coverage when it’s needed most.
“It’s a step in the right direction,” said Hoad, 51. “It’s not the solution yet, but it’s a step toward the solution.”
Maine took a bold step earlier this year to create one of the nation’s most far-reaching health insurance plans, naming it Dirigo, the state’s Latin motto that translates as “I lead.”
Dirigo Health is expected to sign its first enrollees this summer. The plan is designed for tens of thousands of people like Hoad, workers whose employers don’t provide insurance, self-employed workers who can’t afford private insurance or those who don’t qualify for government programs.
Hoad, who works in Augusta and lives in neighboring Windsor, said she cannot afford private insurance. The cheapest, bare-bones policies she could find cost nearly $400 a month with a deductible of $500 to $1,000. Even then, there was no dental or catastrophic coverage.
“They won’t even talk to you unless you’re going to sign up with them,” said Hoad. “Private health care is a rip-off.”
In one of his first acts as governor, Democrat John Baldacci last January ordered the design of a universal health care system. After extensive negotiations with hospitals and the insurance industry, his bill won legislative passage in June.
Dirigo Health will fill the gaps in coverage starting next July, when the first 31,000 Mainers will be insured under the program. The remaining 130,000 uninsured Mainers will be covered by 2009.
In a public-private partnership, the state will soon advertise for bids from private insurers to provide coverage to those who need it, said Trish Riley, an architect of Dirigo who heads the state Office of Health Policy and Finance.
Dirigo enrollees who are not eligible for Medicaid will pay for coverage, with premiums based on ability to pay.
Coverage will also be available under group policies made available to businesses and municipalities with 50 or fewer employees, and to the self-employed.
Employers who sign on, and their employees, will pay for a portion of coverage.
In addition, MaineCare – Maine’s Medicaid program – will be expanded to cover more low-income people.
Funding comes from four major sources.
Besides premiums paid by enrollees, Baldacci is counting on $52 million in one-time federal fiscal relief money to start up the program. Another major portion of the funding will come from savings resulting from reduced bad debt and charity care that hospitals – and ultimately insurers – have to pay for people who get medical treatment and can’t pay for it.
Insurance companies will pay up to 4 percent of annual premium revenues to help fund the Dirigo plan. Insurers will recover those payments by no longer being stuck with the expenses of uninsured charity cases, because everyone will be insured.
Finally, the law also generates savings through voluntary 3 percent caps on hospital operating margins and 3.5 percent on annual cost increases.
To fine-tune the program, Riley’s office is planning focus groups among small businesses and workers. It is also monitoring hospitals’ costs to see if they’re being kept within the voluntary limits.
“We want to get the design of the product right,” said Riley. “We want to get a program people want at a price they can afford.”
Besides giving all Mainers access to coverage and controlling costs of the system, a priority of the new program is to assure quality of care.
While it will be months before Dirigo’s first clients are signed up, Baldacci sees encouraging signs already in slower rates of growth in insurance premiums in the small group market.
“This is heartening news and mirrors recent reports from hospitals that the health care industry is taking Dirigo Health seriously and has begun to comply with its request for voluntary cost constraints,” the governor said.
The conservative Maine Heritage Policy Center, which has been scrutinizing the program, says the drop in insurance premium rates “is as attributable to Dirigo Health as it is to the weather.”
The center’s executive director, Bill Becker, said the drop in health care premium increases is part of a national trend as the insurance industry responds to an unsustainable skein of fee increases and competition from smaller carriers.
Becker’s group labels Dirigo “fiscally unsound,” warning that it will increase Maine’s Medicaid caseload as the state faces a potential $113 million Medicaid shortfall and considers cutbacks in the program.
It also says that past expansions of Medicaid have not significantly reduced the rates of uninsured Mainers.
For people like Sandra Flynn, Dirigo cannot start up soon enough.
Flynn, her self-employed husband and their three children have been without insurance for nearly 10 years. It’s not that they don’t care, but the Flynns find the $16,000 annual premium with $5,000 deductible to be excessive.
Flynn, who works part time in a local school, is eager to see what the rates will be under the Dirigo plan.
“It certainly has to be better than living with no insurance,” she said.
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