The good news for Maine Medicaid is that even a budget crisis has not interrupted progress on an ambitious plan to transform MaineCare into a value-based, accountable care program.

The bad news is there may not be enough money to fund the transformation.

In February, Maine's legislature slashed the budget for Medicaid for the remainder of the 2012 fiscal year and is expected to cut again before the 2013 fiscal year begins in July. The 2012 budget cuts will take 14,000 Mainers off Medicaid by reducing eligibility from 200 percent of the federal poverty level to 133 percent. The budget also eliminates dental care and cuts coverage for branded prescription drugs from four per month to two.

Gov. Paul LePage, a Tea Party Republican, cites MaineCare's rapid enrollment increases (78 percent since 2002) and the 21 percent chunk it takes out of the total state budget as reason enough to chop spending. Others have pointed out that underlying causes the state's rising poverty, unemployment and uninsurance rates have caused enrollment to grow to nearly 30 percent of the population.

Even as the storm clouds gathered in 2011, Department of Health and Human Services Commissioner Mary Mayhew, formerly vice president of the state hospital association, announced that the state was scrapping a plan to move MaineCare to managed care. Instead the state intends to bypass managed care plans entirely and negotiate risk-based contracts directly with providers organized as accountable care organizations supported by community care teams of midlevel providers.

Maine already has eight community care teams working with members of 26 existing patient-centered medical homes, part of the Centers for Medicare and Medicaid Services patient-centered medical home pilot.

Most of the largest health systems (and health plans) in the state, along with advocacy groups and behavioral health organizations, have expressed interest in participating in the new program. The bottom line from their responses to a state request for information released in late February 2012 is that while interest is high, most providers aren't prepared to accept risk in the first year, a caveat the state is prepared to accommodate.

So, despite the budget crisis, implementation of the new model is still expected to begin in October 2012. And that in itself is a testament to the proverbial Maine ethic of working through adversity.

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