Maine's policy lesson to the U.S. - update
Leading the Way? Maine’s Initial Experience in Expanding Coverage through Dirigo Health Reforms
By Debra J. Lipson, James M. Verdier, and Lynn Quincy
The Commonwealth Fund
Mathematica Policy Research, Inc.
December, 2007
Since enacting comprehensive health care reform in 2003, Maine’s Dirigo Health program has helped expand coverage for low- and moderate-income individuals. By September 2006, about 16,100 individuals were enrolled in two coverage initiatives: DirigoChoice, a subsidized insurance product, and a Medicaid eligibility expansion for low-income parents of dependent children. While these programs are making health coverage more affordable to low-income individuals, small firms, and sole proprietors, with subsidies targeting those most in need, by late 2006, the initiatives had enrolled less than 10 percent of previously uninsured residents.
http://www.commonwealthfund.org/usr_doc/Lipson_leadingthewayMaineexpDirigo_1079.pdf?section=4039
Quote of the Day, June 14, 2003, predicting failure:
http://www.pnhp.org/news/2003/june/maine_succeeds_in_ad.php
Comment:
By Don McCanne, MD
Today’s lesson: Most of the nation’s leading politicians who claim that their proposals will achieve health care coverage for everyone are being dishonest with us. Worse, their positions are being supported by highly respected, presumably credible members of the policy community. Politics is displacing policy science in the national discourse on reform.
Effective health policies are not based on measures that we wish would achieve our goals of universality, comprehensiveness, quality, access, equity, efficiency and affordability. Rather they are based on principles well established within the discipline of health policy science.
Let me explain, using the example of Maine.
In 2003, Maine rejected single payer reform, but passed Dirigo Health claiming that it would achieve, within five years, the same goal as single payer, but without being disruptive to the current system. Well, it certainly has not been disruptive in that 90 percent of the uninsured are still without coverage.
For political reasons, Maine substituted for single payer a series of wish-they-would-work policies. The impact of those policies were completely predictable. In fact, if you read the Quote of the Day for June 14, 2003 (link above), the failure was fully predicted - not on guesswork or hunches, but on fundamental principles of health policy science.
Current efforts in other states to achieve universal coverage will not be mentioned here other than to state that all proposals that are not single payer are doomed to fall far short on our goals of reform because they are based on wish-they-would-work policies which have already been demonstrated to fail the tests of health policy science.
Because we are in another window wherein reform is possible, we need to look at the leading proposal which is most likely to be adopted, possibly as early as 2009. This is the proposal of the leading Democratic candidates. They contend that their model of a market of private health plans, with a competing public, Medicare-like program, would achieve all of the goals listed above. Again, the politicians and their policy advisors are using wish-they-would-work policies rather than the fundamentals of health policy science.
Let’s suppose their proposal passed in 2009. What would our health care system look like five years later, in 2014? Those with greater health care needs being left out by our current system would flood to the public program. Adverse selection would cause premiums to skyrocket resulting in a death spiral as everyone would bail out since they couldn’t possibly afford the premiums. Health care costs would continue to escalate due to a lack of effective cost containment measures. That would cause a further decline in private coverage, even with an individual mandate since individuals cannot pay premiums for which they simply lack the funds necessary. To try to make coverage more affordable, underinsurance would become the standard, but then financial barriers to actual health care would increase, further impairing access.
With this proposal, the politicians promise us universality, yet many more would be without coverage. They promise us comprehensive coverage, yet the majority of the plans would be stripped of benefits to slow the rise in the cost of insurance premiums. They promise us quality, yet an underfunded delivery system weighted down with charity care, would lack the resources to identify and correct quality deficiencies. They promise us access, yet they would fail to provide the most important first step to ensure access - comprehensive insurance coverage for everyone. They promise us equity, yet they would destroy what little equity we already have by ensuring that only the wealthy could access all of the care they need. They promise us efficiency, yet they reject the single payer model that would bring us that efficiency. And they promise us affordability, yet combined insurance and health care costs would be much worse for individuals, but, ironically, health care cost increases might well begin to slow for society as a whole. How? Health care would become so unaffordable for individuals that they would begin to relinquish care that merely maintains or improves quality of life, and access only life saving services.
Supporting a private insurance industry that thrives by keeping us away from care, and backing that industry up with a bankrupt public program creates an absolute guarantee for failure.
We know that many politicians distort and lie to get elected. But shame on their policy advisors. Reinforcing distortions and lies for political purposes compromises the ethics of their profession.
Instead of supporting wish-they-would-work policies, let’s support effective, proven policies based on the foundations of health policy science. If we really want to achieve these stated goals of reform, let’s enact a single payer national health program. A truly rational system of financing health care would move us a long way toward these goals.