The crisis brought by a lack of affordable health care insurance had been discussed so often and at such painful length that John Baldacci’s campaign pledge to actually do something about it was shocking. Would Maine really get to bypass the blather of yet another stakeholders’ group reviewing the extent of the crisis? Could it really make meaningful change? The answer arrived this week. His Dirigo Health plan for universal coverage is remarkable; it is groundbreaking legislation that Maine and other states can use to offer universal coverage and provide better, more affordable care.

More than that: The governor has a mandate to act from the public, the Legislature, health care associations, the business community and insurance-reform advocates. All are suffering under the current system; all want reform. Dirigo Health, the design of which was led by Health Policy Office director Trish Riley, does not merely incrementally expand coverage but demands that cost increases subside and access be offered to everyone. Certainly, questions remain about the hundreds of details of the plan, which will evolve over the next year, but the outline for solving one of the most vexing, chronic problems is at hand.

Maine spends $5 billion a year on health care and often spends it badly. That is the core of the problem and it is the opportunity for reform. Enough money already is paid into the system; the reform plan tries to make more sense of the way it is divided up, what costs are necessary and what information is needed to make better decisions about care.

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Roughly, the problems with health coverage are lack of access, high cost and uncertain quality. These problems overlap and there are many other issues in health care to keep advocates busy for years. But solving these three would improve care in Maine dramatically. Gov. Baldacci’s plan is one of the first to attack all three issues simultaneously. He would do so by pooling individual and small-group premiums, federal matching dollars drawn by qualified participants and a 4.1 percent assessment from insurance companies, worth $90 million of the total $275 million spent annually on bad debt and charity care.

That pool of money would be used to offer subsidized coverage through private insurers for a solid though not spectacular package, with an emphasis on preventive care. Rates would be set on a sliding scale based on a participant’s ability to pay. Significantly, Maine would not rely on Medicaid waivers to reap the federal matching funds.

The governor has properly anticipated the potential problem of adverse selection – the risk that the only people interested in joining such a plan are the unusually or expensively sick – by phasing in the plan; plan administrators could anticipate and act based on who signs up. And it requires that small businesses joining the plan insure all their employees, not just the most expensive, through Dirigo Health. That should produce a broad mix of customers to keep insurance affordable.

All of these steps will expand access, but the underlying reason the number of Mainers without insurance has risen from 140,000 to 160,000 in just over a year is cost. Small-business premiums for comprehensive coverage rose 58 percent between 1996 and 2001. It is an unsustainable rate of increase and it is crippling Maine businesses, which pay some of the highest rates in the nation. The governor’s plan intends to control cost several ways. Some of the most important are through group purchases of insurance, strengthened certificate of need processes to ensure that medical facilities are not buying expensive new equipment merely to gain a piece of a new market and establishing budgets then asking hospitals and physicians to base care on available funding.

Gov. Baldacci is further asking care providers and insurers to hold their price increases to 3 percent and report their results to the public. It is an interesting request because it suggests how important cooperation is from everyone to create a more efficient, more effective system. And like the previous governor, Angus King, Mr. Baldacci has pointed out that many health care costs are self-inflicted – poor diets, little exercise, smoking, etc. Unlike the previous governor, he has placed these observations in a comprehensive reform that requires changed habits from the insured as well as insurers, with an emphasis on money-saving preventive care and an information campaign, like the news stories that told of the overuse of antibiotics, to reduce utilization.

That campaign falls under the plan’s oversight portion and includes a forum to define best practices, Web sites to inform consumers about health care and costs and a constitutional amendment to protect the Fund for Healthy Maine, which spends money on preventive programs and which is a regular target for other cash-starved programs. All of these are aimed at improving not just care but health, thereby reducing the need for care. It will be the hardest of the parts of the plan to measure but essential to offering universal coverage.

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Next up for the lawmakers is an intense review of the governor’s plan. Careful attention will be needed for the cost-containment section, which may not remain sufficient as more Mainers join the plan. They will also have to consider the plan’s effect on attracting health care providers and insurers to the state. These are large issues, but they likely can be solved within the outline described by the governor.

The larger point, and the reason the public should be enthusiastic about Dirigo Health, is that after a decade of talk, after study upon study that defined and redefined the problem, a political leader has come forward with thoughtful, innovative, comprehensive reform to steer the state away from a growing problem that affects everyone. Maine should feel better already.