Health care choice: Dirigo or stalemate

While Maine Republicans find new ways to flay John Baldacci’s popular Dirigo Health program, they should think back to the last time their party, nationally, killed health-coverage reform: 1994, the Clinton plan to guarantee basic care for all Americans. It’s not so much the plan that’s important to remember but what came after. Nothing or next to nothing, for years and even to this day. Millions more uninsured Americans, countless premature deaths for lack of care and billions of wasted dollars later, still nada from Washington.

Despise Dirigo, dismiss its supporters as muddle-headed do-gooders – which plenty of Republicans do – but if you want high-risk pools for the very ill and health-savings accounts for those with savings – ditto – Dirigo is the horse upon which they will ride. Kill it and nothing of substance is going to move in Maine for a long time.

Health care in the United States costs twice as much for less care than in the rest of the industrialized world, and Maine has some of the highest costs in the country – residents of only five states pay more out of pocket. Maine has high costs for a lot of reasons, and no single program can wipe them all out, but Dirigo makes a serious attempt.

For instance, it emphasizes preventative care to lower costs later and would make charges for the same medical procedure more uniform across the state. But the upfront way it is designed to save money for people who otherwise can’t afford health insurance is to subsidize it.

DirigoChoice, the state-created insurance plan administered by Anthem, is not unusual in this – government has for decades subsidized health care for the poor and elderly. What makes Dirigo unique, and fragile, is a source of its funding: the inefficient health care system itself. Dirigo is the only health-coverage reform that attempts to wring the inefficiencies out of the system and, while tracking the quality of care, capture the dollars that result, then use that money to pay for expanded care. Think of it: A voluntary safety-net program that minimizes government cost by demanding responsibility of its participants and insisting on improved outcomes. It is a conservative’s dream come true.

Not that this makes Dirigo perfect. If I had a chance to work on Dirigo, I’d reconsider its dependence on a Medicaid-funding loophole that could close at any time and try to make it more attractive to people who qualify for only the 20- or 40-percent subsidies, rather than all the 80-percent qualifiers who did sign up. Why aren’t more Medicaid participants enrolling? And I’d want to see the numbers on how health-savings accounts work in the mix. Dirigo, much amended from its original version, is just getting started, and, in the right atmosphere, should welcome study, change and criticism.

Republican Rep. Kenneth Lindell of Frankfort, a financial planner and a member of the Legislature’s Insurance and Financial Services Committee, is an active critic. What bothers him most about Dirigo is not so much a specific part of it (though some of those bother him too) as its leaders’ “unwillingness to look at all the alternatives. What I find frustrating is that solutions tried in other states are dismissed out of hand.”

The person frustrating Lindell is Trish Riley, director and, largely, creator of the Dirigo plan. “I appreciate the other side’s position on, for example, community rating” – limits on how broadly premiums may be set, Riley said the other day. “I would revisit some of the issues if we could do it in a thoughtful way, but I’m really tired of people telling me they care about Dirigo and then beating it up.”

The chief beaters are at the Maine Heritage Policy Center, who have called Dirigo disappointing, confusing, inflexible, a costly failure and a cataclysmic failure among other things. It bashed Riley’s office for not listening to the needs of small business when creating Dirigo and this week, when her office announced a listening tour to hear about those needs, bashed it again, with the center’s president, William Becker, saying, “We’re not going to find the answers in a listening tour.”

Outnumbered in the Legislature, Republicans may believe they have to shout to be heard, but the shouting has erased the good will between the administration and its critics. Riley and her Dirigo associate, Adam Thompson, both say they spend most of their time defending the program against charges made by Republicans, which means, Riley says, that the reviews Dirigo should have don’t happen.

Politics being what they are, Dirigo will certainly figure into the next gubernatorial race, in 2006, so Republicans have a political incentive to help the program fail before then. But killing Dirigo and replacing it with nothing – what would pass in the Democratic Legislature and governor’s office before the election? – is not a winning campaign. Dirigo is what Maine has for the next several years, and those who care about providing Mainers with improved coverage will find a way to work within it.

At the bottom of the debate over Dirigo is an argument over the purpose of reform. When I asked Riley what health-coverage problem Maine faced, she said, “Not everybody has it. Some of those with it have spotty coverage. There’s an insufficiently stable connection to coverage” – meaning it’s almost always job-dependent.

When I asked Lindell the same question, he said, “Premiums are too high.”

Those answers are connected, even complementary, though their outlooks are certainly different, making the politics harder. On the other hand, I was surprised that Lindell thought enough of DirigoChoice to have signed up the two employees in his business. It was the subsidies, he said, that made the plan attractive.

Todd Benoit is the editorial page editor of the Bangor Daily News.