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If You Ask Maine

State officials in Maine wanted the people's opinion. They got answers they didn't expect.

dirigo choiceOver 130,000 Maine residents—12 percent of the state’s nonelderly population— don’t have health insurance. Even those with insurance face high deductibles, reduced coverage, and escalating medical costs. Thirty-eight percent of Mainers with insurance pay more than five percent of their income on insurance premiums, and the median deductible is over $4,000. People across the nation are struggling with the same concerns, but there is a difference: In 2003 the Maine Legislature passed the Dirigo Health Reform Act—sweeping new health care legislation to expand access, improve quality, and contain costs. And Maine officials are reaching out in new ways to involve ordinary citizens in developing strategies to meet those goals.

What’s the law?

The legislation included an integrated set of strategies:

DirigoChoice — a new insurance program targeted to small businesses, sole proprietors, and un- or underinsured individuals. It offers robust benefits — including prescriptions and preventative care. It provides sliding-scale discounts, for those with household incomes under 300 percent of the poverty level, that can reduce or entirely eliminate the monthly premium, the annual deductible, and out of pocket costs. DirigoChoice is a groundbreaking step toward more universal coverage in Maine.

A two-pronged effort to improve the quality of care in Maine by encouraging the medical community to integrate best medical practices, and providing consumers with health information and comparative data on health care providers.

Other system reforms, such as cost containment, overseen by the Governor’s Office of Health Policy and Finance and an 11-member Health Care Systems Advisory Council, which includes consumer representation.

Creation of a biennial health plan to make Maine the healthiest state in the nation. The plan sets health goals for individuals, communities, and government, and identifies initiatives to improve cost, quality, and access. The legislation earmarks savings produced by Dirigo Health Reform to fund these initiatives, including low income subsidies for the DirigoChoice insurance product. For example, if cost containment efforts reduce the cost of health care for insurers, the savings can pay the subsidies in the Dirigo- Choice program.

Hearing from the people

A core goal of Dirigo Health Reform is to engage ordinary people in an informed conversation about health care reform. Traditional surveys are limited in that they do not provide substantive background information and participant discussion. Public forums are often dominated by paid lobbyists representing specific interests. Maine officials wanted a new approach, one in which a representative group of people could learn about the issues, discuss options, and express their opinions. After an exhaustive review of alternative citizen engagement models, the Governor’s Office of Policy and Finance selected the AmericaSpeaks “21st Century Town Meeting™” model, because of its use of “deliberative democracy,” to begin the process with a forum called “Tough Choices.”

The deliberative democracy model requires that a large number of people work collaboratively to understand the issues, engage in lively and informed dialogue, learn from each other, and come to understand differences in perspective. An additional advantage of the “21st Century Town Meeting” was the ability to include participants from across the state through simultaneous linked videoconference.

To ensure that Tough Choices would draw on the informed voices of Maine’s people, organizers recruited nearly 400 participants for the May 21, 2005, event who were broadly representative of the state in gender and race. The youngest and oldest age groups were somewhat underrepresented; income levels were close to state benchmarks except for the lowest income level of $14,800 or less.

Participants wrestled with complex health-care policies and priorities. Initial discussion generated broad agreement on values that should guide policy development:

  • Health care should be a right, not a consumer good.
  • Everyone should have access to affordable health care.
  • High-quality health care should be available to everyone.
  • Health care should be affordable for employer and employee.
  • Costs to individuals should be based on ability to pay.
  • Funding prevention saves money and improves health.
  • People need to take personal responsibility for their health.
  • Health care should include mental health and substance abuse coverage.

The meeting structure called for participants to focus on options presented by the forum organizers. But participants insisted on adding their own, including reducing cancer-causing agents in the environment, providing universal health care, eliminating insurers, and capping insurance company CEO pay.

During the course of the day, participants generated additional options and participated in more than 40 rounds of substantive voting. The degree of agreement waxed and waned, and participants frequently flexed their muscles. Participants were strongly against mandating that individuals carry their own insurance (as Massachusetts has subsequently done); mandating employer coverage; limiting insurance benefits for prescription drugs, tests or procedures, reducing insurance regulation; and segregating high-risk individuals into a “high-risk pool” as other states have done.

Participants spontaneously and vigorously demanded adding the option of promoting a single payer health care system. By the end of the day, no single system change garnered a majority, though 48 percent expressed support for a single payer system, followed by expanding DirigoChoice and MaineCare (30 percent).

Participants endorsed incremental strategies including increasing focus on preventative health; encouraging, but not requiring, individuals to increase healthy behaviors; establishing best practice standards and treatment guidelines for medical care; creating a statewide system to allow providers access to electronic medical information; and creating report cards on the quality of care for consumers.

The toughest part of Tough Choices was focusing participants on tradeoffs needed to increase health care access or quality, or decrease cost. There was significant support for cost reductions that might be achieved by eliminating private insurance and reducing CEO pay. When asked to consider a scenario where additional reductions might be needed, participants were unable to come to agreement on other strategies.

What effect?

The voices heard at Tough Choices did have a powerful influence on the new State Health Plan, which includes many of the strategies that came out of Tough Choices and subsequent traditional public forums. Prevention is a major focus; there are initiatives to encourage healthy behavior; there is a strong emphasis on medical best practices; and the plan endorses electronic medical records. The plan stops short of establishing a single payer plan for Maine. It recommends continuation of DirigoChoice and MaineCare.

A national conversation is now underway through the congressionally appointed Citizens Health Care Working Group, which has used the AmericaSpeaks model to gather input from thousands of Americans, and now has draft recommendations posted for public comment.

There is contentious debate between state offi cials, insurers, and hospitals over how much money the broad Dirigo Health initiative has saved, and whether those savings will fund the subsidies needed for DirigoChoice. The state’s superintendent of insurance has extensively examined the issue and concluded that there are $43.7 million in system-wide savings to fund Dirigo Health initiatives. Insurers and some businesses disagree.

As the legislative session closed and the smoke began to clear, it was clear that DirigoChoice would continue, despite defeat of a legislative proposal to allow the state to be self-insured and administer DirigoChoice rather than fully insured through a private insurance company.

As the November elections approach, the issue of health care is front and center, with different candidates taking different positions. The Tough Choices exercise was not intended to be vox populi, but it does tell us one thing. Health care is on the citizens’ agenda in Maine. And it’s likely to be there for some time to come.


tishtanskiTish Tanski is President of T_ Strategy in Bar Harbor, Maine. This article is based on a prior publication with Ron Beard of the Cooperative Extension Service of the University of Maine.

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