Pills and bills

Democrats, led by House Speaker Michael Saxl, are driving the agenda on healthcare reform in Augusta. But will Gov. King’s laptops and the Republicans’ fiscal conservatism derail progress?

By Lance Tapley

SAXL: can he reform health care?

Health-care reform has taken center stage in the new legislature, and the Democrats have placed it there. In particular, recently elected House Speaker Michael Saxl of Portland is “the champion of this cause,” as his introducer said before Saxl addressed a recent business meeting in Augusta.

“It’s going to be a crazy, wild session” when it comes to health-care issues, Saxl told Maine Businesses for Social Responsibility. It was something of a promise because Saxl is expected to announce soon a major piece of legislation to deal with the state’s health-care concerns.

“We’re writing the model,” he claimed, of how to deal on the state level with what he sees as a crisis.

Even many Republican legislators — not generally noted for their devotion to governmental solutions to social problems — agree that health care will and should dominate the session.

“We haven’t sat down as a caucus and said what we would accept for a reform,” said Mary Small of Bath, a Republican leader in the Senate. “But we have discussed that it’s the number-one priority for this session.”

Both Republicans and Democrats have been getting their input from the street. “You couldn’t help but see the health-care issue as you went door to door in the campaign this fall,” said Saxl.

The concern among voters can be seen objectively, too. MaryEllen Fitzpatrick of Critical Insights, a Portland polling firm, sees health care as the big emerging issue of 2001. In her company’s semiannual poll of Maine residents, conducted this past fall, health care ranked among the top concerns along with taxation, the economy, the environment, unemployment, and education.

“In my opinion you are going to see a higher group concerned with health care in the spring polling,” Fitzpatrick said, because worries over health-care costs will increase in a slowing economy.

What’s the problem?

But what do the words “health-care issues” mean? In Maine political circles these days, two specific concerns crop up.

First, with our relatively low income (38^th lowest per capita) Mainers are finding it harder to afford increasingly expensive health insurance. Twelve percent of Maine people don’t have any. A typical comprehensive health-insurance plan bought by a Maine family of four now costs $1200 a month or $14,400 annually. That’s more than a third of what that family typically makes, and so no one is buying “The individual market has collapsed,” said Saxl.

Businesses and organizations that provide health-care benefits to their employees are also unable to handle the cost. As a result, they are cutting back on benefits, and “towns are having to raise taxes to meet health-care costs” for their workers, Saxl told the Augusta business group.

Second, to add a chronic insult to the acute injury of the costs, this state is a national leader in cancer, heart disease, strokes, diabetes, and lung disease because our population tends toward overweight smokers who don’t get enough exercise and eat poorly. The unhealthiness not only means a lot of suffering, it’s also extremely expensive. There is widespread recognition among health-care professionals that health promotion and education are greatly needed in Maine.

But here’s the problem: Do we deal first with the long-term or the short-term issue? Do we invest in long-range health education or do we attack costs right now? Can we do both? These questions are tough for the legislature in a time of economic slowdown because the state has less money pouring into its tax-collection bins. The budget shortfall for the next two fiscal years is predicted to be $237 million. Even if no new expensive health-care initiatives are undertaken, taxes will have to be raised or services cut.

Although agreeing that health care is the big issue, the two parties remain true to their historic inclinations. The Democrats want to promote both long-range health education and short-range cost controls. Republicans are heavily weighing the fiscal constraints and letting the more instinctively activist Democrats set the agenda.

Yet legislative Republicans may be less obdurately conservative this year. Perhaps they are following President George W. Bush’s lead with a Down East version of “compassionate conservatism.” For example, on a recent legislative Health and Human Services Committee 12-to-1 vote not to cut the state’s current health-promotion efforts, all but one Republican voted with the Democrats.

“Their leadership seems to have given them free rein,” observed a nonpartisan legislative aide about the Republicans, adding, “but the crunch may come in the Appropriations Committee.” This powerful panel, divided between seven Democrats and five Republicans, with lone Senate independent Jill Goldthwait of Bar Harbor as chair, effectively makes the final decisions on carving up the state’s fiscal pie.

Republican Senate president pro tem Richard Bennett also sounded a note of caution. Asked if he had taken a position yet on health-care issues, he responded: “I’m still studying them.” He deferred similar questions with similar responses such as “these are terribly difficult issues” and “there will be plenty of vehicles with which to have a debate.”

Controversy over cuts to health-promotion The state’s health-promotion efforts are financed out of the $58 million a year Maine receives as its share of a legal settlement with the country’s tobacco companies to offset Medicaid and other costs resulting from lung cancer, emphysema, heart disease, and other ailments blamed on cigarette smoking. The state expects to receive $1.4 billion of this settlement over the next 25 years. The money goes into a budget category called the Fund for a Healthy Maine. Gov. Angus King wanted to divert $10.6 million from the $82 million in health-promotion funds already in the pipeline for this fiscal year in order to cover greater-than-anticipated Medicaid expenses. Medicaid finances health care for poor and disabled people. The health-promotion money, although appropriated, hadn’t actually been sent out to the community agencies scheduled to receive it. Also, facing a $237-million shortfall of tax revenues for 2002 and 2003 in an expected $5-billion budget, King has said that he wants to cover Medicaid costs during this period with $64 million of the $116 million set to flow into the Fund for a Healthy Maine. Many legislators, most fervently the Democrats, expected the fund to be used just for health promotion. Much of the fund’s cash is to be funneled to community agencies by the Department of Human Services’ bureau of health and the Department of Mental Health’s substance abuse division. The agencies are public — such as the City of Portland’s public health division — and private, nonprofit — such as PROP, the Portland anti-poverty organization. The activities to be funded include school health education, anti-smoking ads, smoking-prevention programs, substance-abuse programs, expanded free dental health clinics, subsidized drugs for elderly and handicapped people, and child-care and Head Start programs. King’s proposed diversion generated vigorous opposition from many health-care organizations and Democratic Party politicians who felt the state had to make a long-range effort on health care. Said House Speaker Michael Saxl: “These proposals are misguided and short-sighted.” Nate Nickerson, Portland’s public health director, protested that the health-promotion-cut proposals were “penny wise and pound foolish. Three quarters of the disease burden in the state relates to voluntary behavior that we can have an impact on.” After listening to these arguments, the legislative Appropriations Committee said no to cuts in the current year, unanimously agreeing with the Health and Human Services Committee’s previous 12-to-1 vote against them. Appropriations members noted that the current fiscal year would end with an $18-million surplus. King had wanted to push as big a surplus as possible into the shortfall projected for the next biennium. “We feel relief in the short term,” said Nickerson in response to the committee decision. His agency will get $230,000 for community and school health education and $19,000 to help expand free dental care. But out of this recent funding battle have come some bruised relationships ominous for the health-issue fights to come this legislative session. There is a controversy brewing over the fact that some of this fiscal year’s health-promotion grant awards were held up by the King administration in anticipation of cuts. In the Department of Mental Health substance abuse office, director Kimberly Johnson shrank her grants by $1 million to the consternation of some service-provider agencies that thought they were a done deal. “Where does he [Governor King] get the authority to do that?” asked a Democratic legislative leader indignantly, speaking off the record about the reduction in grants. Johnson said her agency’s “request for proposals” specifically stated her office had the right not to issue the grants. Even after the Appropriations Committee’s recent move, it is uncertain whether the out-in-the-cold agencies will get their grants. After meeting with the governor’s office to decide what to do, Johnson would only say “there’s a lack of clarity about the legislative intent . . . I’m trying to figure out what to do.” Some legislators feel burned by another administration action involving these proposed cuts. Human services commissioner Kevin Concannon at one point announced to a mildly stunned joint meeting of the Appropriations and Health and Human Services Committees that he didn’t need, after all, to take the $10.6 million this year from the current-year Fund for a Healthy Maine because of more optimistic projections of Medicaid and nursing-home expenditures. He only needed to take $4.3 million from this kitty, he said. Sen. Susan Longley, the Health and Human Services’ Democratic chair, sarcastically thanked Concannon for his “50-percent-off sale.” She was incredulous at the commissioner’s dropping by more than half what he said he needed to cut from health promotion. She noted suspiciously that Concannon’s reduction in need came within a few days of her committee’s vote against the $10.6-million-cut proposal. Does this lessening of what the King administration said is needed to be taken from the current health-promotion budget mean that less might have to be pared from the biennial health-promotion budget, too? “These trends should continue,” Concannon commented about the reduced Medicaid expenses. Yet Governor King appears inclined to stick to his desire to take a majority of the Fund for a Healthy Maine money in 2002-03 and pay Medicaid bills with it. “You can make a very strong argument that all of that [tobacco-settlement] money can go against the Medicaid budget,” King said. He protested animatedly “growth is not a cut.” It’s just a situation, he said, when all that the state hoped to do with health promotion can’t be done now: “I’m going to cut back a little” on what had been planned, he said. —LT

So what will the Dems propose?

Within a few weeks Saxl hopes to send out his major initiative on health care. He promises an “ambitious agenda” and “a pretty huge bill.” He won’t yet reveal details, but he said the legislation will do three basic things: require Medicaid to cover more people, make private health insurance more available to businesses and individuals by “injecting state resources,” and lower private insurance premiums by “encouraging competition.” His proposal would have some features of health promotion, and he expects to deal with the $1 billion in “administrative inefficiency,” as he described it, that was identified by the recent state “blue-ribbon” commission report on health-care costs.

Rank-and-file Democrats, while awaiting Saxl’s proposal, have not been reluctant to craft their own short-term and long-term solutions to the state’s health-care problems. There are scores of health-related bill “titles” — a one-line description — in the hopper at the State House, most submitted by Democrats. These include proposals to expand free dental clinics and give more people access to the state’s low-cost drug program for the elderly and disabled. And Sen. Small, the Republican leader, is pushing a “circuit-breaker” to give financial assistance to people on prescription drugs in inverse proportion to their income.

Rep. Joanne Twomey, a Biddeford Democrat, and Paul Volenik, a Democrat from Brooklin, are sponsoring legislation to create a Canadian-style, government-paid health-care system. “Even businesses are saying it’s not such a radical idea,” Twomey said, but she nevertheless expects to support Saxl’s proposal. Reciprocally, Saxl is a co-sponsor of Volenik’s sweeping bill, although he thinks his own approach will have a better chance of passing the legislature.

Sen. Longley has a bill in to expand Cub Care for children. Ninety-four percent of Maine children are already covered with private health insurance, Medicaid, or Cub Care, she said. Cub Care, an $8-million-a-year program, covers children whose parents’ income is too high for Medicaid eligibility, yet the parents don’t have coverage at work and can’t afford private insurance. Longley’s bill would extend coverage to the last 10,000 or so children currently ineligible for Cub Care.

Angus’s health-care agenda

The biggest obstacle for the Democrats’ agenda for reform may not be a reflexive fiscal caution of the Republicans but a collision with Gov. Angus King. At the beginning of the session he immediately put health-care reformers on the defensive.

King claims to be interested in solving health-care problems, but press and legislators noted he hardly mentioned the subject in his State of the State address last month. The jokes in the State House these days are about King’s obsession with his perennial $50-million laptop-computers-for-students idea. “It’s the ‘L’ word,” said one state house reporter: “L” not for laptops but for King’s gubernatorial legacy.

At a press conference the day after the State of the State, “What about health care?” was the first question King was asked. He said he would present the legislature with a couple of proposals. “Details at 11,” he quipped to a television reporter. “I’m not going to scoop myself.” But he did discuss the broad outlines.

One of his ideas is to change the way health insurance is regulated in hopes of making it more affordable to Maine people. To accomplish this, King is considering making it possible once again for insurance companies to discriminate against the sick and the elderly, though this was outlawed by the Maine legislature in the early 1990s. If healthy and young people can be attracted back into the insurance market, he reasons, rates for all might be reduced because the insurance companies’ risk would be spread over a larger population.

But Democrats describe King’s idea as risky. Saxl said he feared that, instead of a bigger pool of the insured to reduce costs for those more prone to illness, “you run the risk that the opposite would occur.” The door might be opened to so many expensive “riders” on policies for a specific health status, he said, that old and sick people never could afford them.

“We need those 20-year-olds back in the market, yes, but his idea doesn’t deal with those who can’t afford health insurance,” Rep. Twomey, the Biddeford Democrat, said of King.

The governor feels stung by this criticism. While waiting for his insurance bureau to do the number crunching on his insurance-rate scheme, he promised: “I don’t want to put the proposals out there until they help everybody.”

Another of his proposals, King said, would be in health promotion. “If we abuse ourselves physically for 30 years,” he opined, it’s no wonder health-care costs are sky-high. True to his predilection for computers, he spoke of promoting Web sites containing health information.

But here King has a credibility problem. Legislators raise their eyebrows when he says he’s going to push for health promotion because he’s recently been pushing hard to slash money out of the Fund for a Healthy Maine, the health-promotion effort established last session with millions of dollars from the state’s settlement with the big tobacco companies. The Democrats with some Republican help have had to push back defensively to keep the fund intact (see sidebar). At the same time, King has been pushing his expensive laptop idea.

“We don’t need to take money we have allocated for a healthy Maine and give it to some of his ideas,” Small, the Republican, insisted. “Laptops are not a priority when people don’t have health care.”

But will there be reform?

Considering that looming budget shortfall, though, and considering that the Democrats are already fighting defensively to prevent cuts to the health-promotion budget, what is the realistic fate of the expected big push for health-care reform? Is it really possible for legislators to deal with health-care problems at a time of declining tax collections?

“It’s unknown where we’ll go with this because of the structural gap [the shortfall] in the budget,” said a top nonpartisan legislative aide. “In the end, it’s going to come down to money.”

Saxl concedes that the state is in a difficult financial condition. Although he said his still-developing plan will require a new state appropriation as well as federal money, he is also trying “to generate private resources” such as foundation grants. Recently he met with the CEOs of the state’s four largest health-insurance companies to try to drum up support.

He and other Democrats are confident health-care reform will play well politically. Sen. Longley saw the 12-to-1 vote out of her committee as “a hopeful sign” for bipartisanship. She admitted, though, “there are winds out there that could buffet us around,” referring to the Appropriations Committee and Republican leadership.

Saxl said he doesn’t have a big strategy to win over any reluctant Republicans and Angus King, who holds veto power. “This doesn’t break along party lines,” he said optimistically of the issue. “Businesses, individuals — they’re all feeling the brunt.”

Still, while Mary Small seems enthusiastic about health-care reform, and while Republican chief legislative honcho Richard Bennett expresses a desire to meet the Fund for a Healthy Maine’s “existing commitment,” every time Bennett is asked about his party’s long-term priorities he refers, with a smile, to the Appropriations Committee.

“I would like to see us use the Appropriations Committee to set priorities,” he said. “All the money is susceptible to another look. I think we need to look at all these programs.” Bennett and other legislative Republicans have so far not been obstructive on health-care reform, but their traditional cuts-to-services, no-new-taxes philosophy may come into play in the end.

“I’m optimistic,” said Ed Miller, president of the Maine Public Health Association, a lobbying group. “Maine people have said this is an area they’re interested in — both health care and prevention.”

“I think we’ll make progress,” said Sen. Longley more cautiously. “It’ll be a few steps forward, not a leap forward.”

“It’ll be a big fight in the end,” Republican leader Bennett said enigmatically, continuing to smile.

Lance Tapley can be reached at ltapley@ctel.net.