The health care system in Maine, as in the country, is in widely acknowledged disrepair and has been the focus of many well-intended attempts to fix it. With the dust settling on the fractious first session of Maine’s 122nd Legislature, some lawmakers, policymakers and pundits took time recently to reflect on the successes and disappointments of the last few months.

Out of a total of 1,692 bills presented to the Legislature over the past few months, 148 had their first hearings before the Joint Standing Committee on Health and Human Services; 66 of those were enacted into law. Another 40 or so health-related bills debuted before the Insurance and Financial Services Committee, while others were debated in a scattering of different committee rooms.

Though they ranged far afield in their intent, collectively the bills focused on six broad areas: insurance, mental health, prescription drugs, hospitals and doctors, public health, and the various elements of Gov. John Baldacci’s contentious Dirigo Health Reforms.

Against a dramatic backdrop of the state’s recently re-organized Department of Health and Human Services, a pernicious shortage of cash in the General Fund, and a devastating computer problem that left 7,000 Medicaid providers without regular payments for months on end, officials, lawmakers and lobbyists debated at length how to improve health care for Maine residents.

Dirigo leads debate

The Dirigo reforms drew the most attention, as Republican lawmakers – and some Democrats – scrambled to gain legislative oversight of the complicated initiative. Dirigo boosters say the many-faceted system will hold down health care costs while improving the quality of care and providing affordable coverage to low- and middle-income Mainers. Critics say the plan undermines the free-market environment needed to support a competitive marketplace for insurers, doctors, hospitals and other players.

Dirigo enjoyed broad bipartisan support when it was enacted in 2003. But Sen. Peter Mills, R-Skowhegan, said in a recent interview that the original legislation is full of “awkward pitfalls” that demand retooling. Mills, who supports the broad goals of the initiative, said too many details have been worked out behind closed doors, leaving legislators in the dark on key matters.

Of primary concern, Mills said, is the funding mechanism for DirigoChoice, the subsidized health insurance plan offered through a partnership between the state and Anthem Blue Cross and Blue Shield of Maine. Legislation that passed in a tight vote at the end of the session calls for a fine-tooth review of that funding, clarification of several terms and processes, and a schedule of mandated reports to the state’s insurance superintendent and specific legislative committees.

Mills, who serves on the insurance committee, said, “We now realize that what we’re managing is a program that requires a whole lot of state funding … [and] has tremendous political stock invested in it.”

A flurry of other bills sponsored by conservative Republicans sought to undo long-standing health insurance regulations – repealing mandated coverage of certain services, eliminating some consumer protections and calling for the creation of a high-risk pool. Though none of these measures passed, supporters maintain that easing regulations is essential to attracting for-profit insurers to Maine and enabling them to offer more affordable coverage.

But Joe Ditre, executive director of Consumers for Affordable Health Care, believes the regulations are what keep health insurance from becoming a mere fantasy for all but the wealthiest Mainers. Ditre said the bills failed because they were poor public policy, fiscally irresponsible, and represented a narrow view of health care that doesn’t sit well with most Maine residents.

“In some ways, this has been a very beneficial session,” Ditre said. “Dirigo has put on the table a path and a vision of health care, and lawmakers have had to say what they stand for. It’s a fork in the road. Either we continue down the [Dirigo] path of reducing costs, capturing savings and plowing those savings back into providing coverage, or we take the path proposed by the extreme free-market camp, where it’s everyone for themselves, where if you can afford coverage you can get it and if not, you only get the care you can afford. … It was a pretty stark contrast, and it led to a good, healthy debate.”

Public health

Dirigo and other insurance reforms aside, legislators wrestled with other important issues this session. Public health initiatives received a lot of support, according to Dr. Dora Anne Mills, sister of the Republican senator and director of the state’s Bureau of Health. For example, in the event of a disease outbreak or widespread exposure to toxic chemicals, an updated reporting system will enable a rapid and effective response from the health care community. The same legislation expanded the state’s Family Medical Leave Act to protect the jobs of individuals who must be quarantined at home to prevent the spread of disease.

Other public health initiatives include a new fee on paint manufacturers to fund education about the dangers of old lead paint, and a measure that beefs up lead paint notification requirements. Schools will help combat obesity by posting the calories contained in some foods, and school vending machines will offer milk as an alternative to soda and sweetened juice drinks.

Mills applauded a new tax on cigarettes and the passage of several bills that tighten and clarify Maine’s laws against smoking in public places. The Fund for a Healthy Maine, fed each year with dollars from the 1998 Tobacco Settlement, did not get constitutional protection against being raided for nonhealth projects but weathered the session’s financial stresses with a minimum of diversion, she said.

Mills added that she testified in opposition to bills that would have weakened abortion rights in Maine; none of the measures passed. “Once again, the Legislature has affirmed its support for comprehensive family planning, including abstinence as well as access to reproductive health care,” she said.

Doctors and hospitals

Gordon Smith, executive director of the Maine Medical Association, said the Legislature’s failure to support proposed liability reforms for physicians was disappointing, but he hailed a 15 percent increase in the amount paid to doctors by the state’s Medicaid program, MaineCare.

“At a time when the state was faced with cutting millions [of dollars] out of the MaineCare budget, we were able to get an increase that brings MaineCare fees up to about 55 percent of what Medicare pays,” he said.

Smith was a strong supporter of a “no-brainer” seat belt mandate that failed, he said, because it was included in the governor’s budget bill instead of being debated on its own merits. The MMA also supported a new law that repeals the legal protection of parents and practitioners who treat critically ill children solely through prayer or other spiritual interventions.

A proponent of the DirigoChoice insurance plan, Smith said the MMA opposed other Dirigo initiatives approved by the Legislature, such as mandatory reporting of physician performance data and the continued regulation of physician-owned day surgery centers.

According to Mary Mayhew, vice president of government affairs and communications at the Maine Hospital Association, hospitals were kept busy over the past few months defending their practices, their patients and their bottom lines. Between the underfunded Medicaid budget and regulatory aspects of Dirigo, she said, “This was really one of the most difficult sessions for us.”

The MHA successfully fended off a repeal of the certificate of need process, which is intended to ensure a statewide distribution of medical services and facilities while eliminating redundancies. Other measures that loomed large but were amended to less contentious levels included a voluntary cap on hospital costs and profits, and the reporting of standardized pricing information.

Mayhew said lawmakers recognize that hospitals are still owed millions of dollars in delayed Medicaid payments. “There was a lot of concern in the Legislature that further damage not be inflicted on hospitals,” she said.

Mental health coverage

Carol Carothers, director of the Maine chapter of the National Alliance for the Mentally Ill, strongly opposed bills that would have lifted insurance mandates – mental health coverage, she said, always gets short shrift if not required.

NAMI took no official position on a controversial bill that would enable the courts to require some people with mental illness to take prescribed medications or face involuntary commitment in a state hospital.

“We sure have gotten a lot of calls about it,” she said, “but I think the real issue is making sure people have access to the community services they need.” The bill won support in the House and Senate but cannot take effect unless its $600,000 price tag is funded.

Carothers said the session’s biggest challenge to the mental health community was a series of funding cuts in the MaineCare program, affecting not only the services people rely on to keep them living in their communities but also access to the medications they need to control their illnesses.

“It’s so shortsighted, when you think you can save money in mental health by cutting services,” she said. “We can expect to see a lot of cost shifting in the next year as these people show up in our emergency rooms, homeless shelters and the criminal justice system.”

While some people may not want to take their medications as ordered, others simply can’t afford them. Sharon Treat, former Maine Senate majority leader and current director of the National Legislative Association on Prescription Drug Prices, said the federal Medicare drug benefit that takes effect in January may make matters worse for some elderly Medicaid recipients. She applauded legislation passed in Maine this session to establish a state “wrap-around” benefit to pay for gaps in the federal program.

Treat also supported a new law that will replace “telepharmacies” in remote rural health clinics – vending machines with a computer link to a real, live pharmacist. It’s not an ideal setup, she said, but an important alternative to rural residents.

She lauded several new laws that affect drug manufacturers, including one that requires companies to post on the Internet the results of all of their drug trials and holds them accountable for claims made in their television and print ads. Treat predicted there will be more state-level interest in monitoring the marketing practices of drug companies.

The committee

Two Health and Human Services Committee members, Sen. Richard Rosen, R-Bucksport, and Sen. Arthur Mayo, D-Bath, both observed that despite the contentious nature of the many bills that came before them, the majority came out of committee with a unanimous or near-unanimous recommendation.

“This has been a really good group to work with,” said Mayo, the Senate chairman of the committee.

Both lawmakers gave high marks to a new law that makes the ingredients for manufacturing the dangerous and addictive drug methamphetamine harder to come by. Mayo said a new law that establishes a special group to study the future of the MaineCare program is critical to state planning. Rosen, serving his first term on the committee, said that even though efforts to revamp the taxing of hospitals and nursing homes failed this session, the issue received a good hearing and will be revisited in the future.

The Legislature’s second, shorter session is due to convene in January.