AUGUSTA, Maine — Last Wednesday, as incoming Gov. Paul LePage celebrated his inauguration, Trish Riley cleaned out her desk, turned out the lights and left her office for the last time.
No one will take her place as the director of the Governor’s Office of Health Policy and Finance. A LePage spokesman said Tuesday that the new governor intends to dismantle the office and move any essential functions to other areas of his administration.
Riley is widely credited as the principal architect of the Dirigo Health Reform Act of 2003, a multilayered law that aims to simultaneously address the interlaced issues of access, quality and cost in the health care delivery system.
Gov. John Baldacci created the Governor’s Office of Health Policy and Finance shortly after his 2003 inauguration to provide health reform, and Riley, with the full support of his administration.
To its many detractors, Dirigo — the law takes its name from the state motto, which means “I lead” — has served as a lightning rod for all that is wrong with government intervention in the private sector: increased regulation, bureaucratic inefficiencies and an unaffordable consumer product kept on life support by an unpopular tax.
But to the ranks of its supporters, Dirigo offers evidence that through a coordinated effort, the out-of-control health care juggernaut can be tempered and tamed.
At the vortex of this ideological storm — until last week — sat Trish Riley. The day after leaving her office, Riley met with the Bangor Daily News at her home in Brunswick to review Dirigo’s founding, its mission and its uncertain fate in the days and weeks ahead.
Dirigo, Riley said, can be viewed as a microcosm of the Affordable Care Act, the divisive national health reform that squeaked through Congress along strict party lines. Maine’s new attorney general said this week he is “determined” to join a legal challenge to the new federal law.
Many of the measures included in ACA have had their trial run in Maine, she said, including greater regulation and transparency in the health insurance industry, a focus on improving primary care and the notion that covering more people not only is the moral thing to do but also will save health care dollars in the long run.
As a result of the Dirigo experience, “Maine is at a place where we’re so ready to flip the switch” to implement the unfolding national reform, Riley said. But emerging political challenges to the federal reform legislation and to Dirigo are symptomatic of the nation’s growing divisiveness, Riley said, and threaten to undo the hard-won progress of health reform.
Leading Maine to Dirigo
For 15 years before Baldacci’s 2002 campaign for the Blaine House, Riley served as director of the National Academy for State Health Policy, a national nonpartisan, nonprofit organization headquartered in Portland.
Before that, she had developed a public service career that included health policy and administration work under four Maine governors: Democrat Ken Curtis, independent James Longely, Democrat Joseph Brennan and Republican John McKernan.
“I like the idea of people figuring things out together,” she said. “I can think of a hundred ways to solve a problem.”
So when Baldacci approached her about developing a strategy for reforming health care in Maine, Riley stepped up to bat.
“He came in and said ‘I want to do health care reform,’ and I said ‘OK, what do you want?’” she recalled. A few short days after his inauguration, the new governor announced the formation of the new health policy office and named Riley as its director.
In February 2003, Riley convened the first meeting of the Health Action Team, a fractious, 26-member advisory group representing the entrenched and competing interests of insurance companies, consumer groups, hospitals, small businesses, big businesses, government, employee unions, doctors and others.
“Check your guns at the door,” Riley told them, according to a BDN story at the time. “No more hand-wringing, no more task forces. The ‘facts’ won’t always be undisputed. We’re just going to have to make decisions.”
Riley’s git-’er-done style rankled, but she effectively moved the process forward. By April, the group had come up with draft legislation that included a state-sponsored health insurance plan with subsidies for low-income Mainers; caps on hospital growth and spending; quality-improvement measures for health care providers; and incentives for commercial insurers to hold down rates.
The bill was assigned to a special legislative committee for fine-tuning. In exchange for Republican support, several key elements were traded away, Riley recalled, including language to prevent insurers from passing on to policyholders the cost of a contentious “savings offset payment” used to fund subsidies in the new Dirigo-Choice insurance plan.
Democrats had enough votes to pass the bill without the change, Riley said. “But there was a real desire on the part of the governor to get unanimous support, and the insurers were going wild over the assessment.”
In the end, the Dirigo bill was passed out of committee with unanimous support and was endorsed by a bipartisan majority of the full Legislature. Baldacci signed it into law at a Blaine House garden party ceremony on June 18, 2003, just about six months after taking office.
Health reform under pressure
In the years since its enactment, Dirigo has traveled a rocky road. Its best-known program, the DirigoChoice insurance plan, has been undermined by repeated legal challenges from the business community and the insurance industry.
Hard-pressed consumers have ended up footing the bill for the Dirigo subsidies, while critics have made political hay and insurers continue to realize significant profits, Riley said.
The comprehensive benefit packages offered by DirigoChoice have been criticized as too pricey for most Mainers to afford. And an early plan to attract federal Medicaid dollars into the program was nixed by the Bush administration, dealing a harsh financial blow to the program.
Although enrollment in DirigoChoice has fallen far short of original projections, Riley pointed out that some 13,000 Mainers now depend on the program for health coverage, including the employees of about 600 small Maine businesses. There was no premium increase this year for individual policies and only a 2 percent in-crease for small groups — much lower than in competing commercial plans.
“If LePage eliminates DirigoChoice, an awful lot of people will lose coverage,” Riley said last week. “Many of those people have no idea that Dirigo is even under pressure.”
A spokesman from LePage’s office said Tuesday that LePage would not dismantle DirigoChoice without having a workable alternative in place.
“Anything we do will be part of a large package,” said spokesman Dan Demerrit. LePage will release a “broad, comprehensive health care proposal” next month, he said.
Other elements of the Dirigo reforms include the Maine Quality Forum, which collects hospital and physician performance data and posts it online, a tightened-up approval process for big-ticket medical investments, and an every-other-year State Health Plan for allocating medical services throughout the state.
Many of these measures presage the Affordable Care Act. But during the protracted effort to draft national health care in Washington D.C., Maine’s experience with Dirigo continued to stir controversy, Riley said.
“We worked pretty closely with the White House, Health and Human Services and staff on [Capitol] Hill,” she said. “But on the floor of the Senate, Dirigo became a whipping boy and was held up as an example of a failed public program.”
Riley lamented the growing political antagonism at all levels of government. Rather than threatening to undo Dirigo or repeal the Affordable Care Act, Riley said, critics should be focused on strengthening the measures that work and improving the elements that trouble them.
“No law is perfect. But you don’t just repeal it,” she said.
Riley, who will soon turn 60, no longer loses sleep over the fate of Dirigo, but she plans to continue working on health policy. She’s been asked to serve on two national commissions and will lecture part time at George Washington University. She doesn’t rule out the possibility of running for public office.
“Dirigo’s challenge is that people didn’t commit to working with what we had and improving it, and I worry that’s what is going on with the Affordable Care Act,” she said.
“I’m not wedded to any one way of doing this, but you don’t work a whole lifetime on national health policy just to say ‘I’m going to go work in my garden now.’”