AUBURN — If MaineCare is expanded to add another 70,000 clients to the rolls, “it will break an already fragile system,” Department of Health and Human Services Commissioner Mary Mayhew said Wednesday.

Such an expansion also would continue to drain resources needed for other necessary social services and state programs, including building roads and funding education, Mayhew said at a Maine Prosperity Event luncheon hosted by the Maine Heritage Policy Center. She will appear at a similar event Thursday at DiMillo’s on the Water in Portland.

The Legislature in January is set to reconsider a plan to leverage federal funding available under the Affordable Care Act to expand MaineCare in 2014. The plan failed last year because the Legislature was unable to override a veto by Gov. Paul LePage.

“Our program has grown at a rate we can’t sustain,” Mayhew said, with 25 percent of all Maine residents now enrolled in MaineCare.

In 2000, Maine spent $1.2 billion to fund MaineCare. Last year, spending reached $2.4 billion as services and enrollment expanded. That growth is too fast and too much, Mayhew said. “It is simply impossible to make good and informed decisions and to plan for the future of this program” when so much effort is required to fund and manage growth.

The better path, Mayhew said, is to look at individual members’ needs and to help people who are able to get jobs and then fund services for the remaining, truly neediest population.

Before introducing Mayhew to the lunch group, MHPC Chief Executive Officer J. Scott Moody said that, according to MHPC and DHHS predictions, by 2016 there will be “just as many people on our welfare rolls as people working in private-sector jobs.”

“That’s the very definition of unsustainable,” he said, calling on Mainers to work toward “reducing welfare rolls through economic prosperity.” Specifically, Moody said, eliminating the income and sales taxes on a county-by-county basis, starting with more economically stressed areas to the north “where 38 percent of the population is on some sort of welfare.” Moody argued that allowing workers to keep that cash would allow them to invest in their communities, sparking the return of economic health.

Mayhew didn’t address that idea but focused her presentation on what she called Maine’s “insatiable appetite” for federal money to fund a growing number of programs. That appetite, she said, has contributed to an unwieldy and inefficient health and human services system that does not best serve the oldest and sickest in Maine.

“It’s very hard to believe after going through sequestration in the spring, the federal shutdown and the looming shutdown debate that there will be federal dollars down the road” to continue current funding levels, so Maine’s only choice is to streamline programs into a form that can be paid for in state dollars, she said.

Speaking to a group of fewer than 20 lunch guests, Mayhew said her department’s mission under the LePage administration has been to focus on the needs of individuals rather than maintaining previous administrations’ programs intended to “fit all.” That cookie-cutter approach doesn’t effectively address individual health and social issues, Mayhew said, and the best way to get people off welfare is to “move people toward improved health, employment and self-sufficiency” for themselves and their families. “Welfare should not be the finish line,” she said, “for any able-bodied Mainer.”

As part of the work to break a welfare-dependant lifestyle, Mayhew said DHHS is aggressively moving away from a strictly cash benefit TANF program and toward funding education and employment training programs to get people the skills they need to get jobs. Every person who qualifies for TANF benefits will be subject to an employment/work experience assessment. DHHS will work with the Maine departments of Labor and Education to individualize training benefits.

“Those ready to work will be on a fast track to a ready job and a chance to get off welfare,” she said. “Thanks to these reforms, TANF will be a pit stop along the way, and not a destination.”

MaineCare members will also get individualized assessments.

Five percent of MaineCare members account for 54 percent of all MaineCare spending, a figure Mayhew said is in excess of $1.3 billion each year, or about $68,562 per high-use member. These individuals, she said, are the truly needy: the elderly, people with intellectual and/or physical disabilities, and people with severe and persistent mental illnesses who live in treatment facilities.

The purpose of individualized assessments will be to reduce the health-care costs of the remaining 95 percent of members, people who do not — for a variety of reasons — access physical and mental health care services at the primary care level, but wait until a medical crisis and then seek care at high-cost emergency departments.

“We pay for the crisis,” Mayhew said, for the acute demand on the health care system. With some coordination of services, MaineCare members can be taught and “incentivized” to access lower-cost preventive care. And when they do, the annual cost to care for these patients is closer to $937 than the $21,011 spent annually for thousands of crisis patients.

If some of the services required by these members could be reduced through home care, particularly providing light housekeeping and meal preparation for elderly members, Mayhew said the system could become even more efficient.

Lewiston and Auburn are sites for a DHHS pilot program to monitor families with two or more members who each access more than $10,000 in medical services every year. Mayhew said these families will be evaluated by a primary care physician and helped to find the best health-care deals for the lowest possible price.

“The days of paying for quantity instead of quality are over,” Mayhew said, as DHHS focuses on improving health instead of simply paying bills for services. And, she said, the department will eventually get to the point of paying medical care providers based on patient results.

Asked whether DHHS is making any move toward requiring MaineCare members to comparison shop for routine medical services, such as colonoscopies, Mayhew said that education outreach is beginning.

And, asked whether DHHS would re-evaluate the fees it sets for MaineCare services provided to public school students, Mayhew said that evaluation is underway.

According to lunch-goer Bill Webster, superintendent of the Lewiston School Department, the Lewiston district is forced to pay the DHHS-set fee of $58.68 for a behavior specialist visit rather than that specialist’s $25 private-patient fee. “That doubles the school’s cost,” he said, “and it ultimately comes right out of Maine taxpayers’ pockets.”

Mayhew agreed that was a problem, and said, as a way to trim costs in the future, the department is looking at prior authorization for in-school services to ensure the services match a student’s individualized education program.

jmeyer@sunjournal.com

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