Debates about health insurance are so dull they could put a charging moose to sleep in its tracks, a characteristic that hides the fact those debates are about life and death stuff. Lack of health insurance kills people, pure and simple; people without it die sooner than those who have it, have more strokes, and have cancers diagnosed at more advanced stages, etc.

Children without it get fewer vaccines against deadly diseases. As Maine’s people decide the fate of its DirigoChoice health insurance program – which provides subsidized health insurance for people who would probably otherwise not have it – we all need to remember that lives are in our hands.

Why is DirigoChoice in the public’s hands when the Maine Legislature established the program by law three years ago? Because the political commitment sustaining DirigoChoice and a drive to universal health insurance in Maine is embedded in Maine’s current political leadership, all of whom are either up for re-election or will be leaving office after the election in November 2008.

That being the case, the fate of DirigoChoice, which currently insures 14,000 of us, will be tossed to the lions of the electorate in 2008. Maine voters will give it thumbs up or thumbs down in that election by virtue of whether we demand a commitment to universal health insurance from every candidate we elect, regardless of party affiliation. If we make a commitment to universal insurance by some mechanism a litmus test for all candidates for elected state office, DirigoChoice – and thereby Maine’s path to health insurance for all Mainers – will survive in one form or another. If we do not, I believe DirigoChoice and universal insurance baby for Mainers that Governor John Baldacci delivered will ultimately die a premature death. So will some of those who go without health insurance as a result.

Despite toddling on the wobbly legs of tenuous political support and uncertain funding, the DirigoChoice health insurance program is unlikely to fail until the period after the 2008 election, having as it does several things currently going in its favor:

. The current Governor remains as protective of it as a mother bear guarding her cub, and will not let his signature program die on his watch;

. A majority of the current Maine Legislature supports it as well;

. It has 14,000 subscribers, and stripping 14,000 Mainers of their health insurance is a political skunk no politician will want to tick off.

After the 2008 election, however, its future is less certain without voter affirmation. Despite being around for three years, DirigoChoice health insurance is still new, and anything new that’s also not universally popular and costs a lot of money skates on thin political ice. Its funding mechanism has been the subject of a court suit, and a future court decision against the program’s funding mechanism some day could spell its demise.

The funding mechanism for its premium subsidy program is probably not politically viable over the long term, even if it is legally viable. The governor himself wants a new funding mechanism, but a proposal for a different mechanism failed in the Legislature this past session. Lack of additional funding recently caused the state to put severe restraints on new enrollment, which may erode confidence in the DirigoChoice for enrollees and purchasers despite assurances from state government and elsewhere that it will survive.

Key supporters will be leaving government soon; Mama Bear Baldacci leaves office in 2008, as does the current legislature. Trish Riley, the governor’s health policy architect and the political junkyard dog of the Dirigo Plan, will probably leave office with Baldacci. Several of the state’s best potential Democratic candidates for governor, who might have supported DirigoChoice if they became governor, are instead in a pig-pile of Democratic candidates planning to run for Tom Allen’s seat in the United States House of Representatives in 2008.

That leaves Maine Republicans (who have in general been less avid supporters of DirigoChoice) a good shot at the Blaine House in 2008, and if DirigoChoice has no champion there it could slowly die for lack of the oxygen of commitment in the governor’s office. A program as controversial as DirigoChoice cannot survive without partisan supporters at the top of state legislative and executive government who are willing to expend political capital and spill political blood to keep it alive.

Another potential threat to the future of DirigoChoice is, paradoxically, the emerging consensus among American presidential candidates that America must have some kind of national, universal health plan. This potential for a national universal health insurance alternative to state initiatives such as DirigoChoice will be used by Dirigo opponents as a rationale for letting Maine’s plan die and be replaced by a national plan. Unfortunately, that is not a good alternative choice to DirigoChoice because most national health policy experts agree a viable national universal insurance plan is at least four years away.

With the coming change of the political guard, a funding mechanism in need of an alternative, and political commitment to it far short of universal, what DirigoChoice will require to survive is less a shot of money than a shot of voter enthusiasm. That must come in the form of a clear message to political candidates for office in 2008 that they cannot allow Maine’s universal insurance initiative to die. The future of DirigoChoice, or variation thereof, can be guaranteed by voters if they ask their candidates to take what I am calling the Dirigo Pledge; “I will preserve the coverage of those currently enrolled in DirigoChoice somehow, and in my first term introduce or support legislation to expand health insurance coverage to all Mainers.”

Every candidate for Maine’s House or Senate, or for the governor’s office, whether the candidate is Red, Blue, Green, Pink, or Purple, should be asked to take the Dirigo Pledge, and if they refuse, should be denied your vote as surely as their position will deny someone health insurance. For this is not an issue of party affiliation or liberal vs. conservative; excising the malignant tumor of lack of health insurance is an issue of life and death, and we are the surgeons.

Erik Steele, D.O., a physician in Bangor, is chief medical officer of Eastern Maine Healthcare Systems and is on the staff of several hospital emergency rooms in the region.