Medicaid from a narrow corner

Bus in a thousand people to describe the details of what would happen if they lost Medicaid coverage and the Legislature will listen closely. So will the governor. They will listen to accounts of pain, suffering, exhaustion and life-giving treatment that could become out of reach. They will, as they did this week in Augusta, understand health care in a way that spreadsheets showing budget shortfalls can never teach.

Gov. Baldacci certainly heard of the difficulties his proposed cuts – $78 million from Medicaid to close a $160 million budget gap – would cause and he seemed to soften to almost, not quite, but sort of say he might consider or listen to the thought of possible tax increases to lessen the pain of the Medicaid cuts. Naturally, he was killed for that.

Big headlines – “Baldacci shifts on taxes,” “Baldacci will not rule out tax hikes” – were followed by a press conference in which the governor, mindful of his no-tax campaign stand, retreated. What he meant by “maybe,” it turns out, was “no.” He went further: Should a tax increase be sent to him, he would stomp on it, call it names and veto it thoroughly. That was clear enough, but his answer from a day earlier was better because it at least provided the possibility that Medicaid arguments superior to his own may exist.

People who never admit to mistakes make poor friends but successful politicians. It is a human impulse that we prefer our elected leaders to appear infallible. While we would admit in the abstract to making all sorts of mistakes in our own lives, let a politician explain that when he said he opposed raising taxes he hadn’t appreciated the financial hole his state was in nor the pain a no-tax pledge would cause and watch those big, unflattering headlines appear. After that, a deluge of flip-flop comments, followed by sinking poll numbers. The governor tried to block these possibilities with his veto promise Wednesday.

Maintaining popularity – and with it, a public mandate to govern – is especially important to this administration. Maine has become so accustomed to inaction from its state politicians that it is easy to misgauge the complex and broad changes Gov. Baldacci is attempting. To summarize: He is trying to invent a health care system, Dirigo, while remaking DHS, the state’s largest agency, while reforming its Medicaid system while investing in new industries while cutting property taxes while facing an immediate budget shortfall and an expected shortfall next biennium of $900 million. (It’s not as easy as it sounds.)

The governor’s veto promise put him in the narrowest of corners from which to negotiate with the Legislature, where there is growing support for increases in cigarette and alcohol taxes. That the governor understands his predicament could be seen in his offer to delay the Medicaid portion of Dirigo, something that Republicans have wanted but which is largely symbolic. Republicans accepted this olive branch and poked the governor with it – asking how he could say he is opposed to tax increases when he has $12 million in fees proposed in his supplemental budget.

This sort of back-and-forth can go on as it has for decades in the State House and it probably will. Or Maine could realize what an unusual chance it has: A governor willing if not always eager to set the right agenda – health care reform, tax reform, agency reform – matched with budget, economic and demographic circumstances desperate enough to force the Legislature out of its usual habit of endless tinkerings.

This chance might begin with the governor noticing that the public could assume that what he would do to Medicaid in hard times he would do to his new health plan, Dirigo. He is asking small businesses across Maine to trust that their employees can join Dirigo and will receive health care coverage. Will they get coverage even during a shortfall? Which is more important to him: fighting for health care coverage or fighting to keep another quarter off the cigarette tax?

Advocates for the affected programs, however, should examine the savings the state has found through prior authorization for prescription drugs and through setting standards on types of care, such as for nursing homes in the 1990s. The governor wants to expand these cost controls on Medicaid to save money, allowing Maine to keep services. Look around at 49 other states struggling to pay for Medicaid programs. The oversight reform and regional mental-health offices the governor is proposing are the future of state-run health coverage. Providers ought to be embracing these ideas while demanding the governor reduce the paperwork, duplication of effort and bureaucratic jumping jacks agencies must perform to serve their clients.

Maine’s Medicaid system is neither wildly generous nor out of control, as critics charge. It is one part of a dysfunctional health care system that requires substantial repair and it is a commitment the government makes to the frail and ill. Gov. Baldacci has put himself in a tough spot with his veto pledge, but if his larger agenda is correct, its supporters will make certain he is able to free himself.

Todd Benoit is the BDN editorial page editor.