ELLSWORTH — It has been eight years since Congress passed the Patient Protection and Affordable Care Act, often shortened to the Affordable Care Act (ACA) and more colloquially known as Obamacare.
Four years after the law took effect in full, results are decidedly mixed. The average cost of premiums will be down this year but won’t offset huge spikes last year.
Thousands more Mainers are insured than before the law was passed, but 24,000 still fall into the coverage gap — making too much to qualify for Medicaid but too little to receive ACA subsidies.
“The ACA has been a good first start, but there are gaps that it doesn’t quite connect,” said Lornie Smith, owner of Ellsworth-based Maine Coast Insurance Agency and an agent certified to help residents navigate ACA coverage.
Smith said it’s still early (enrollment opened Nov. 1) but he’s had “a few more calls than last year” from individuals and businesses looking to re-enroll or sign up for the first time.
Several years in, “Most people have a general understanding of it,” Smith said.
“Still,” he added, “a lot of people don’t.”
Many feel there’s a stigma attached to qualifying for the ACA, Smith said, and are surprised to learn that even “with two decent incomes supporting a household” they are often still eligible for subsidies.
“Don’t be worried about the stigma with it because this is the program we have,” Smith said.
Around 75,000 Mainers were enrolled through the exchanges last year, with the vast majority (87 percent) receiving a subsidy (averaging $413) to help defray the cost, according to data from the Kaiser Family Health Foundation and the Centers for Medicare and Medicaid Services.
Three companies — Community Health Options (CHO, formerly Maine Community Health Options), Harvard Pilgrim and Anthem — are offering plans on the exchange for 2019.
The cost of a plan with Anthem is decreasing an average of 8.7 percent, while those for Harvard Pilgrim and CHO are going up (4.6 and 6.9 percent, respectively.)
It’s been a rocky couple of years for the ACA. President Trump has been a vocal critic of the law, which a Republican-led House of Representatives has attempted to repeal dozens of times since it was passed. The Trump administration cut the enrollment period in half (to 45 days) and reduced funding for advertising and health care navigators, agents who help residents choose plans.
Congress also effectively repealed the penalty for not having insurance by reducing it to zero dollars as part of the 2017 tax reform bill, which critics worry will result in a smaller group of sicker patients and higher premiums as healthier patients opt not to buy insurance.
In 2017, President Trump ended federal payments to insurers known as cost-sharing reductions, which caused many insurers to raise rates dramatically (52 percent on average in Maine last year) and for Anthem to leave the Maine market altogether.
Over the past four years, premiums have risen more quickly in Maine than elsewhere in the country (around $52 per year since 2014, compared to $41 nationally), according to data compiled by the Kaiser Family Health Foundation.
Smith sells several types of insurance out of his Ellsworth office, but, “Health insurance is certainly the one that’s the most frustrating for everybody. I’ve had people almost in tears saying it’s just not affordable.”
Rates have stabilized and Anthem returned to the marketplace this year after the LePage administration reinstated a program known as Maine Guaranteed Access Reinsurance Association (MGARA), which reimburses insurers for claims over a certain threshold (between $47,000 and $1 million, as well as partial reimbursement for bills beyond that).
Consumer operated and oriented plans, or co-ops, also have faced challenges. The plans were added to the original law “to placate Democrats who had pushed for a government-run, Medicare-for-all type of health insurance program,” writes Louise Norris in an article on trade industry site healthinsurance.org.
Co-ops are nonprofits initially supported with federal grant money, but all except four of the original 23 — including Maine’s CHO — have failed, “often due in large part to a combination of premiums that were too low, benefits that were too generous, enrollees who were sicker than anticipated [and] competition from bigger carriers with larger reserves,” Norris writes.
CHO turned a profit for the first time in 2017 after posting losses the previous two years, and rate hikes this year are less than last year.
There will be more options for coverage in 2019, including cheaper, short-term insurance plans. The plans can cost as little as between $30 and $50 per month, but are also short on coverage and don’t pay for pre-existing conditions, mental health treatment and prescription drugs.
“They’re not meant to replace ACA plans,” Smith said.
Short-term plans have been around in some form for several years, but the Trump administration increased the maximum allowable duration of the plans from three months to 364 days, renewable for up to 36 months.
Maine law is more restrictive — the plans may be sold for terms up to 364 days but are not renewable and are limited to a combined term of two years. In a post explaining the plans, the Maine Bureau of Insurance cautions “even though your premium may be lower with a short-term plan, your overall costs could be much higher, particularly if you need hospitalization, surgery or other costly care.”
Smith said he often deals with residents who fall into the coverage gap, making too much to qualify for Medicaid and too little to receive subsidies, which can result in premiums of over $1,000 per month.
“Those people are very frustrated,” Smith said.
When it was passed, the ACA called for states to expand their Medicaid programs to help close the coverage gap. But in 2012, the Supreme Court ruled that states could not be forced to expand Medicaid. As of June, 18 states, including Maine, had not done so.
Mainers voted in 2017 to expand MaineCare, the state’s version of Medicaid, coverage to cover those earning up to 138 percent of the federal poverty limit, but Governor LePage has vetoed funding and repeatedly fought the measure, citing financial concerns.
Smith said he identifies with his clients’ irritation and confusion over the cost of health care.
“I can afford the premium,” he said, “but this year — looking at my own personal health issues — I’m going to probably have to come up with $6,000 or $7,000 out of pocket. That can be crippling.”