The Maine.gov website says the Dirigo mission is

"a health system in Maine that is comprehensive,
understandable, affordable and fair. It must meet the
following principles:

• It must provide health coverage for all Mainers - individuals
  and families as well as businesses, small and large.

• It must cover the full range of needed benefits,
  including prevention and prescriptions, for Mainers of all ages.

• It must establish quality standards, and provide
  benchmarks and an easily understandable way to compare providers and facilities.

• It must embrace efficiencies to reduce waste and
  administrative costs and assure affordability over time."

We aren't getting what we pay for.

Compared to the British, Americans spend twice as much per person on health care, yet they are twice as likely as the Brits to suffer from diabetes, cancer and heart disease, according to a new study in the Journal of the American Medical Association. The researchers say Americans' lousy health stems from financial insecurity and stress, not from poor health care. "It's not just how we treat people when they get ill, but why they get ill in the first place," says Michael Marmot. Thus we learn once again that the "social determinants of health" are extremely important. [more]

That means we don't incinerate trash and dump the resultant pollutants - mercury, asbestos, dioxin - into our environment because it is bad public health policy. It means we build public transportation because the quality of life issues created by our automobile and fossil fuel dependent society are matters of public health. It means that good work and good food matter.

Rather than conceive Dirigo as individual health insurance - where the provider profits most by offering the least - we should reconceive Dirigo as a public health service - comprehensive, understandable, affordable and fair. Universal, where the only precondition is residency in Maine.

There is a universal constituency for vaccinations, blood pressure, mammograms, AIDS tests - the most basic wellness, preventive, pre-natal and post-natal care. We all need it. From a public health point of view, we all win the more the services get used.

For public health services, we can avoid much of the administrative expense of our current insurance system. The savings will be real. Private plans need no longer include whatever services Dirigo Public Health provides - some will and some will not. We all win if our population is healthier.

Basic wellness services can easily be provided at the community level by community based cooperatives dedicated to serving their local membership. These member cooperatives, operating from a public health perspective, might expand their scope of operations to include clean water, clean air and our general environment. None of our for-profit insurers will help set up community agriculture, but a member cooperative interested in the general well-being of its membership and community might well do that.

Educating ourselves that too much soda pop, sugar and salt are bad for us is not enough. The explosion in diabetes and obesity is a public health issue as are the toxins we continue to dump into our environment.

I'd like to redirect Dirigo. Rather than start with a limited constituency that gets a lot of coverage, focus on a universal constituency that gets a smaller range of services necessary from a public health viewpoint. Provide the services at a community level with cooperatives. Focus on health care, not insurance. Focus first on the limited, basic services everyone should have. We will still need insurance to pay for individual care beyond the basic wellness package, but getting from where we are now to a system of universal coverage will be easier if we first take care of everything that falls under public health. Beyond those who fit the current Dirigo guidelines, our first priority should be to expand Dirigo to cover everyone with the a limited set of public health services.

We will not be able to provide a full range of services to everyone. There is always a new and expensive treatment. Who decides what is fair and just? Who decides what a plan covers? It cannot be done by a for-profit industry; but it can be done by membership cooperatives. Over time, Dirigo might evolve to offer a range of plans - Dirigo Kids, Dirigo Hospice and so forth - where the membership determines the mix and emphasis of the particular plan.

It's not often these days that government proactively compels an industry to act in the public interest. With Dirigo, the State of Maine is dutifully exercising governmental authority in an area of vital to the public interest. It's a good thing, but not enough.

Let's keep that vision: health care for all.