Not only does Maine have some of the priciest health care in the nation, the rate of increase for premiums leapt way above the national average in recent years, with premiums up 77 percent here during the last four years as incomes rose 6 percent. This says both that this state more than others must reform its health coverage and that it must do so quickly. The Baldacci administration’s Dirigo Health is part of the response and so is its newly released state health plan, which gives Maine a set of directions by which to build a more affordable system.

The health plan has been discussed through various drafts for a couple of months, but a final version this week alerts the public to what the plan calls “Tough Choices,” which starting this winter is expected to be a series of public discussions that begin with what people already know – that health care is increasingly unaffordable – and takes the next step of asking individuals what they are willing to do about it.

For instance, how much should people be responsible for taking care of themselves so that they don’t get the chronic, expensive illnesses that come from overeating, smoking, drinking to excess and a lack of exercise? How much money should the state pay to prolong the end of life for someone if that means it will deny benefits to many others? What kind of health services must every community have and what services is it acceptable to have regionally, at only one place in the state or even out of state?

The reason for the dour name Tough Choices is obvious: until now, those with insurance could receive plenty of high-quality health care quickly, but their insurance has become unaffordable. Those without insurance eventually get care, but often not when they should, leading to further expensive health problems. Tough Choices is a means for telling the public that if it values affordable insurance and wants to extend it to as many people as possible, then it must rethink some of the services currently in the health care system and accept some responsibility for keeping costs down.

This exercise in changing the culture here may be the most difficult part of extending coverage because, though there is waste, contradiction and in-efficiency in the system that, once removed, will help make it more affordable, the key to lowering costs lies in the public’s understanding that the thousands of nearly invisible burdens everyone puts on the system drives its cost out of reach. Trish Riley, director of the governor’s health policy office, says her office is taking its time in setting up the forums for this discussion because it understands how difficult they will be and want to get it right.

Unlike the some of the other changes through Dirigo, Tough Choices is a long-term project. But it is a worthy one and well worth doing. Engaging the public in this serious debate may be the most revolutionary part of Maine’s attempt to provide affordable care to all.