Saturday, December 7, 2013
By Joe Lawlor firstname.lastname@example.org
In two days, the health insurance marketplace will open for business, a pivotal moment in the short history of the Affordable Care Act.
Evan McSwain, a cook at Selah Tea in downtown Waterville, has been uninsured for the last five years.
Staff photo by Michael G. Seamans
Meaghan Carlson, of Gardiner, at her office Thursday.
Staff photo by Andy Molloy
Waterville Public Library will host information sessions for residents seeking information about the Affordable Health Care Act at 2 and 5 p.m. Tuesday.
The multimillion-dollar ad campaigns and rhetoric from politicians that have been inescapable in recent weeks?
Personal experience is glad to meet you.
Starting Tuesday, the uninsured and underinsured can begin buying discounted insurance and judge for themselves the merits of President Barack Obama's signature domestic policy achievement, signed into law three years ago.
While there's a wide range of options and prices that consumers will pay — based on income, age, subsidies and family size — a typical out-of-pocket cost for individual insurance premiums including subsidies would be about $150 per month for a mid-level plan, according to state and federal figures released in the last few months. The subsidies kick in for those earning between 100 percent and 400 percent of the federal poverty level.
The Maine Sunday Telegram, Morning Sentinel and Kennebec Journal talked to four people interested in buying health insurance on the marketplace: a single Waterville man who hasn't had insurance in five years, a couple in Gardiner whose part-time jobs put them over the MaineCare limit, a single mother from Portland and a newly married Falmouth couple.
How those personal interactions play out, experts say, may trump the ad campaigns, 21-hour talk-a-thons on the Senate floor, television news pundits and YouTube videos.
"A lot of people in Maine who have never been able to buy insurance will be able to, and that is going to make a difference for a lot to people," said Dora Anne Mills, vice president of clinical affairs at the University of New England and Maine's former state health officer.
Obama, in a speech touting the law on Thursday in northern Virginia, predicted that people will find the insurance beneficial once they try it themselves.
"Even if you didn't vote for me, I'll bet you'll sign up for that health care plan," Obama said.
Saturday, House Republicans demanded a one-year delay in enacting the health care law and said they'd pass legislation enacting that delay by the end of the day as the battle about how to avert a government shutdown Tuesday wages. There was no update by press time.
In Maine, the fight has centered mostly on whether to expand Medicaid, with Gov. Paul LePage vetoing efforts by the Democrat-led Legislature to do so. The Medicaid expansion, called MaineCare in the state, is another cornerstone of the ACA, but the U.S. Supreme Court ruled that states could opt out, and many states with Republican governors did so.
LePage also declined to sign up for a state-operated health insurance marketplace, leaving that job to the federal government.
State-run marketplaces were eligible for millions in federal marketing money, used to create slick ad campaigns to encourage customers, especially healthy young people, to buy insurance.
However, states such as Maine that left that job to the federal government could not tap into those advertising resources, and Mills said because of that, most of Maine's outreach efforts will start after Tuesday, when people actually can sign up for the coverage.
Mills said while she believes the law improves the health care system, it's unknown how the law will be received or how many people will sign up.
"It's just like asking how the Red Sox are going to do in March. Call me back in October," Mills said.
In Maine, the Bureau of Insurance has estimated that 5 percent to 8 percent of the population, or 65,000 to 104,000 people, will sign up for 2014 benefits.
Mills said the law's complexity has made it difficult for people to figure out whether the ACA is good or bad until they start shopping for the insurance Tuesday.
"When you hear health insurance options, people's eyes glaze over," Mills said. "It's such a complicated morass."
For 2014 coverage, residents will have until the end of March to sign up. About 125 "navigators" paid for through federal grants are helping people sign up for insurance all over the state, with many stationed at community health clinics.
Mills said health plans under the ACA will be more standardized than previously, with preventative screenings free, all plans containing certain "essential" benefits and a cap on out-of-pocket costs.
Still, despite improved health care coverage, a big unknown is whether Mainers' independent spirit will make it difficult to sign people up for benefits, experts say.
If the experience of Massachusetts fishermen is any guide, having affordable insurance available will reduce the ranks of the uninsured.
"The fishing industry in general has a lot of very independent people," said Brian Delaney, communications director of Massachusetts-based Fishing Partnership Support Services. The group won a $66,000 federal grant to help Maine lobstermen sign up for health insurance on the new marketplace.
Delaney said the rate of uninsured among Massachusetts fishermen has declined from 50 percent to 10 percent since the late 1990s. That was over the course of about 15 years, he said, so making inroads in the uninsured could take time; but Massachusetts did not have a comprehensive health care reform system until former Gov. Mitt Romney signed a law in 2006 that's similar to the Affordable Care Act.
He said Maine lobstermen are busy making their living at the height of the lobster season, so the efforts to sign them up for insurance won't begin in earnest for a few weeks.
"In Maine, we don't know yet. We don't know what the reaction is going to be," Delaney said.
Even so, some are expressing interest now, and below are the stories of those who may seek health insurance on the marketplace.
Evan McSwain, 28, who manages the kitchen at Selah Tea Cafe in Waterville, has been uninsured ever since he left a job in Boothbay Harbor that provided him with it five years ago.
McSwain has bounced around in restaurant jobs since he was 12. He moved to Waterville nine months ago, starting at the cafe a month later.
He's recovering from an opiate addiction, and said he pays for a $100 weekly counseling appointment himself.
"I'd love to have insurance," he said. "I have a weekly appointment at the hospital that I have to pay for out of pocket, and it's been very expensive."
After he went through a rehabilitation program for his addiction two years ago, McSwain said, his medical bills skyrocketed.
"I've dealt with some medical situations," he said. "That's why my bills are outrageous."
McSwain, who has stayed clean since entering rehabilitation and attends a weekly meeting at MaineGeneral Medical Center's Thayer Campus, said the meetings help him maintain his sobriety.
He works six days a week at Selah Tea Cafe and said it's the sixth day that pays for his weekly meeting.
He said he is optimistic that getting insurance will help his situation, yet he admits he's not sure whether it would cover his weekly meeting.
McSwain said he applied for MaineCare but expects little from that effort.
"I sent out the paperwork and was told the waiting list was ridiculous," he said.
McSwain, who lives in Waterville with his girlfriend, said while he admits he knows little about the health care changes, he's welcoming the opportunity to be insured.
"I'd love to have insurance again. I've been thinking about, but I haven't looked much into it," he said. "I need to start working on that."
Meaghan Carlson and her husband, K.C., of Gardiner, have been without health insurance since February when working more hours at her part-time job put them over the eligibility limit for MaineCare.
Meaghan, 34, now works part time for the city of Gardiner, but the job is expected to end in January. K.C., 34, works part time at a farm in Gardiner and is looking for a more permanent position.
Their 2-year-old daughter is still covered under MaineCare, so Meaghan said they didn't think it was big deal that they lost coverage.
Since losing insurance, however, Meaghan said, she and her husband have racked up more than $10,000 in medical bills with back-to-back illnesses.
Meaghan fell ill with an intestinal infection soon after losing coverage. Then, K.C. was diagnosed with pneumonia and a blood issue.
The bills are down to $5,000 to $6,000, but the experience made Meaghan realize the importance of having health insurance.
"I have a folder this thick and it's all medical bills," she said, holding her fingers and inch-and-a-half apart.
"I don't think it's something you can imagine unless you've been through it," she said.
Meaghan estimated that insurance could have cost them at least $300 each per month, if not more, before the Affordable Care Act.
She said she needs to research more about how the law and exchanges work, but they plan to buy health insurance off the exchanges. An online subsidy calculator estimated she and her husband may have to pay only $160 a month, a total they could afford, she said.
Rather than dealing with multiple bills whenever they need health care, Meaghan said she would rather just have one bill for insurance.
"It's just so, so overwhelming when you've already been really sick," she said.
Adria Moynihan Rusk and Bruce Rusk
The Falmouth couple married a few weeks ago, and they said they're excited to buy insurance on the marketplace after having gone without or being underinsured for many years.
With a combined income of $80,000, they would not be eligible for subsidies on the marketplace, although if they had children in future years they would more likely qualify. A family of four can earn up to about $90,000 per year and still qualify for subsidies, and the subsidies will adjust for cost-of-living increases in future years.
Bruce is an independent contractor working in information technology, while Adria is a self-employed artist. For the past five years, Adria has gone without insurance about half of the time, while Bruce has a plan offered through his contractor that offers few benefits.
"It's insurance in that it keeps you from being completely destitute if something really bad happens to you," Bruce said, "but you'll still be mostly destitute."
Bruce, 51, said the plans being offered through the contractor kept getting worse in recent years. He had major abdominal surgery several years ago, and he still owes some of the $5,000 in out-of-pocket costs he had to pay. But he said if he had had surgery last year instead, he would have been on the hook for more than $20,000, based on the deteriorating coverage in his health plan. He said his plan also keeps restricting the number of doctors in the network, reducing his choices.
Adria, 34, crossed her fingers and went without insurance for a few years, getting her primary care coverage from the Portland Community Health Center. But Adria said without insurance, there's a reluctance to go to the doctor.
"When you don't have insurance, you definitely delay going to the doctor, just letting your sickness work itself out more," Adria said.
Without subsidies, the two would be paying a combined $500 to $600 per month, depending on what plan they choose on the marketplace.
They said even without a subsidy, it would be worth having good insurance. Bruce said just being able to go to the doctor without paying "through the nose" will be a relief.
"I want the doctors to know me. I don't want to be the next guy in the waiting room," Bruce said.
Burkhart, 33, a single mother and nursing student, is interested in buying insurance on the new marketplace.
The Portland resident pays $120 per month for insurance that covers only catastrophic medical conditions, such as if she got in a traumatic car accident or acquired a deadly disease.
"It's irritating that I'm paying something and I'm not really getting anything for it," Burkhart said.
Burkhart has an 18-month-old daughter, Lumi, and she's been struggling with mental health problems because of her breakup with Lumi's father, financial anxiety and coping with being a new parent.
"I'm paying for mental health counseling out of pocket right now, and it's very expensive," said Burkhart, adding that she already has paid several hundred dollars and she just started counseling sessions. "I believe in mental health care."
Mental health care is one of the "essential services" mandated by the Affordable Care Act. Screenings are free, and mental health counseling is a covered benefit, which means a mid-level plan would pay for 70 percent of the counseling sessions.
Burkhart is going for her master's degree in nursing to become a nurse practitioner. She's buried in debt for college, taking out more than $100,000 to pay for her tuition and living expenses. For the most part, she's not working while she's going to school.
While she qualifies for MaineCare, Burkhart said she declined to sign up for it, although she signed up her daughter.
"I don't feel like I should be taking the place of someone else who really needs it. My situation is stressful, but it's not dire," Burkhart said.
However, because she decided to forego MaineCare even though she qualifies, Burkhart would have to pay for insurance on the marketplace without the benefit of subsidies, health care experts told the Press Herald.
Depending on what plan she selected, Burkhart would have to pay about $250 to $300 per month for coverage, without subsidies; but Burkhart said it would be worth it, and better than what she has now.
She said when she finishes her master's degree in three years, she should be able to get a good-paying job, be financially secure and have good health insurance.
"I don't mind paying into the system," Burkhart said. "It's the responsible thing to do."
Morning Sentinel staff writer Jesse Scardina and Kennebec Journal staff writer Paul Koenig contributed to this report.
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Erika Burkhart and her 18-month-old daughter, Lumi Stone, spend time together in their Portland home.
Maine Sunday Telegram photo by Amelia Kunhardt
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Artist Adria Moynihan Rusk and her husband, Bruce Rusk, are a middle-class family but haven’t had good health insurance for years.
Maine Sunday Telegram photo by John Ewing