Trish Riley, director of Maine's Office of Health Policy and Finance,
tackled a difficult question at the annual conference of the National Academy
of State Health Policy (NASHP) in August.
How can advocates work effectively to expand access to health care in light
of the intense competition for diminishing financial resources?
From 1989 to 2003, Riley was NASHP's executive director and is the
principal architect of DirigoChoice, Maine's effort to provide universal
access to health care for state residents by 2009.
"Most health care reform initiatives have been `big bang'
efforts," she said, citing the Clintons' comprehensive health care
reform plan as an example of that transformative approach.
The DirigoChoice plan, however, combines a number of different initiatives."
Every constituency could find something to love and to hate, [but] no
group could hate it all," Riley said.
"We sold it with the idea of equity," she said. "[People]
could understand that it's not right for a person to get up and go to work and
not have insurance benefits."
The plan, which was promoted by Gov. John Baldacci (D), required approval
by Maine's legislature. Marketing of the plan was scheduled to begin at press
time, with coverage beginning on January 1, 2005.
Health care reform had been an important issue in his 2002 election because
of the severity and longevity of the problems in the state.
According to a January 22 article in the New England Journal of
Medicine by Riley and Elizabeth Kilbreth, "Maine has long been a
hotbed of debate about health care reform, which has been stimulated in recent
years by double-digit increases in premiums, poor health status among many
citizens, and growing numbers of uninsured persons."
Maine has led the nation in per capita growth of personal spending on
health care. One out of eight residents is uninsured.
DirigoChoice, which is billed as a private-public venture, will use a
private insurance carrier to offer coverage for prescription drugs, inpatient
hospital treatment, and outpatient services, including specialty care. The
plan offers parity for mental health and other medical services.
Those eligible for the plan include employees who work at least 20 hours a
week for an eligible small business, unemployed state residents, individuals
employed in businesses that do not offer insurance, and their dependents.
The strategy, according to information on the DirigoChoice Web site, is"
to pool small business, self-employed, and [other] individuals into a
large group to better bargain for good prices. As the plan grows over time, so
will its capacity to bargain for competitive prices for its
Employers will cover 60 percent of the premiums, and employees will pay the
remainder. The state will provide premium subsidies on a sliding scale to
enrollees with annual incomes of less than 300 percent of the poverty level.
(The 2004 federal poverty level is $9,310 for an individual and $18,850 for a
family of four.)
Implementation of DirigoChoice will be accompanied by "modest"
expansions in MaineCare, Maine's Medicaid program, according to Riley.
State officials are encouraging various reforms to control costs and
improve access. Riley told the audience that with foundation support, state
officials mounted a public-awareness campaign with the aim of educating Maine
residents about the reasons why health care costs are accelerating.
The Maine Quality Forum, which was established as part of the DirigoChoice
legislation, will collect and disseminate research on health care quality,
evidence-based medicine, and patient safety. It also will promote healthy
lifestyles and encourage the use of information technology for data reporting
and administration. It is funded partially by an assessment on insurance
Hospitals will be required to post a list of their charges for procedures
and services, although physicians will not.
The plan encourages the use of preventive services, such as flu shots,
mammograms, and blood testing, by covering all costs. Enrollees who complete a
questionnaire and meet goals set with a physician, such as losing weight or
quitting smoking, will receive $100.
The success of DirigoChoice, however, depends on assumptions that are
problematic. State funds, for example, will be required to subsidize premiums
for low-income enrollees. Riley mentioned tobacco-settlement funds and general
revenue funds as sources of those funds, but the former is of limited duration
and the latter is least likely to be available during troubled economic times
when the number of uninsured is most likely to rise.
State officials aim to end or decrease the "hidden tax" that
results from charity care offered by public hospitals and by bad debt incurred
by them. Although lowering the number of uninsured and improving collections
from those who can pay would address those problems, it is not clear how much
new revenue would be generated or when it could be expected.
The plan anticipates an expansion of the state's Medicaid program with
additional funds from the state and federal governments.
Insurance purchasing pools for small employers have not proved to be an
effective means of improving access to health insurance (see article above).
Advocates of that approach assumed that establishment of a pool would enhance
the ability of employers to negotiate with insurance companies.
In fact, when state officials invited bids from insurance companies for a
contract to run DirigoChoice, they received only one. In late August, the
state contracted with Anthem Blue Cross and Blue Shield of Maine to administer
Information about DirigoChoice is posted online at<www.dirigohealth.maine.gov>.▪