Many observers believe that Maine’s first-in-the-nation Dirigo Health Plan will arrive at a crossroads early in 2005, and will be faced with three options as how best to proceed: move ahead slowly, “damn the torpedoes, full-speed ahead,” or stop and turn around before it’s too late.

All three schools of thought were advanced to some degree recently at a meeting of the Maine Quality Forum Advisory Council, an adjunct of Dirigo Health that was created by Gov. John Baldacci as Maine’s giant step toward universal health care and lower health care costs.

Early next year, the administration and Legislature will receive the first indication of how many small businesses and sole proprietors are actually enrolling in DirigoChoice, the insurance component of the plan. Two months into the initial sign-up period, 140 small businesses had expressed an interest.

Dirigo supporters declared the numbers were acceptable for a new product, while detractors said they were not as high as anticipated. Critics had begun to express concern even earlier when it was revealed that DirigoChoice policies – brokered for the state by Anthem – cost about the same as insurance products already on the market.

The core promise of Dirigo is to eliminate charity care and bad debt for hospitals, providers, and ultimately for insurers, by covering all Mainers through either existing policies, Medicare, Medicaid, veterans’ benefits, or DirigoChoice. If Dirigo fails to keep that promise, how will subsidies and discounts that are attracting some buyers be funded after a Medicaid grant runs out next year? The nub of the plan is to impose a 4 percent premium tax on current policies, a price hike that would ideally be offset for the insurance companies by elimination of bad debt and charity care they – or providers – have sometimes been forced to eat or pass on to other policyholders or patients.

Dirigo officials are quick to note that the off-setting savings will not only come from DirigoChoice revenues, but through more efficient management of hospitals, and the creation of a healthier society through “wellness.” Just how Dirigo will determine savings in the system, and who or what will receive credit for them, has not been determined, but the complex formula will go a long way toward deciding who will pay for subsidies and discounts if Dirigo moves forward as planned.

The voices saying “slow down” declare that the sign-on numbers and future financing should be closely examined before the state ventures too far down an unfamiliar road containing some sharp bends. The Legislature is already slated to take looks at Dirigo recommendations that could possibly close some hospitals and alter the mission of others, and the lawmakers could decide that Dirigo over-stepped its bounds earlier this year by seizing control of the state’s certificate of need process through emergency rulemaking. Had to, argued Dirigo. No time to waste!

The “stop and turn around before it’s too late” crowd says the insurance product is never going to be attractive to small businesses that thought they were going to see significantly reduced premium costs when Dirigo was envisioned by the governor and approved by the legislature. Not only did Dirigo rates prove comparable to those already available on the insurance market, but small business owners also discovered they had to pay for at least 60 percent of the total premium, and insure 75 percent of their employees, including some part-timers.

The same firms are concerned that if future subsidy and discount enticements are paid through premium taxes on existing policies, the plan ultimately becomes only socialized medicine with some paying for all or part of the insurance premiums of others. One MQF member reported being at a business meeting were “half of those in attendance said “stop Dirigo now.”

Dirigo doubters also say the Legislature or some independent body should take a close look at the companies and individuals who have initially been attracted to Dirigo. The stated goal of DirigoChoice was to cover the 130,000 uninsured in Maine, but some of the initial takers say they already had policies and were enticed to switch because some of their employees qualified for subsidies, and thus they could save money by trying Dirigo. Indeed, Dirigo’s paid marketing and advocacy campaign makes it clear that subsidies and discounts are available for some employees. One small business owner was quoted in newspapers as saying the money he can save will be used to give his employees pay raises.

If that’s the case, is the state-sponsored plan creating unfair competition between businesses by requiring government or other firms to pay a portion of the insurance rates and employee benefits of some and not others?

Dirigo advocates say that the complex, innovative program is intentionally on a fast track. “The governor created it in the first six months of his administration and has three and a half years to make it work,” Trish Riley, Dirigo’s chief architect and promoter, told the Maine Quality Forum. “While he does not intend to sacrifice quality, his feeling is that we can’t lose a minute.”

That explains the full-speed-ahead option waiting at the crossroads.

But, the “take it easy” contingent constantly reminds anyone who will listen that Dirigo is a first-in-the-nation experiment that will change the entire face of health care in Maine, and that fact alone demands caution.

Jim McGregor is executive vice president of the Maine Merchants Association, and has monitored health care issues in Maine for more than 20 years. He was appointed by Governor Baldacci to serve on Dirigo’s Maine Quality Forum Advisory Council.