Obamacare for the average Midcoast residentAlso a local look at Medicaid expansion
Approximately 70,000 Mainers live without health insurance.
With the roll out of the Affordable Care Act in October, more options for those seeking insurance is available. Open enrollment ends March 31, but Malory Shaughnessy, outreach and education specialist of Maine Community Health Options, said if somebody moves to a new state, leaves a job, or has a child, they can enroll or change plans during a special qualifying period, usually a 30- to 60-day window that opens up throughout the year.
Premiums — monthly payments for coverage — are based on age and geography. Tax credits are based solely on income.
Health coverage plans range from gold, silver, bronze, and catastrophic coverage, depending on what you want to receive for care and what you can afford.
Catastrophic plans are only available to people younger than 30, or if you qualify for a hardship exemption, according to the State Bureau of Insurance. Maine Community Health Options and Anthem Blue Cross and Blue Shield are the providers to choose from.
All plans must offer the following basic services: preventative care, doctor visits, prescription drugs, hospitalization, and maternity and newborn care.Tax credits under the Affordable Care Act are available to people making between 100 and 400 percent of the federal poverty level — $11,500 to $44,000.
The penalty for not having insurance the first year is $95, or 1 percent of your income, depending on which is more, according to the Bureau of Insurance.
The median income of individuals in Knox County is $40,463 for men, and $30,853 for women, according to the U.S. Census Bureau.
The median age in Knox County is 46.
Tax credits under the Affordable Care Act are available to people making between 100 and 400 percent of the federal poverty level — $11,500 to $44,000.
Nationally, 2.2 million people have signed up for a private health care plan from state and federal marketplaces between Oct. 1 and Dec. 28.
54 percent of those signed up are female and 46 percent are male
79 percent of people in the U.S. selected a plan with financial assistance, according to the Department of Health and Human Services data.
13,704 Maine residents have signed up for insurance, the majority of those are women, at 55 percent, according to department data.
13 percent of Mainers live below the poverty line.
In Knox County, 11.5 percent of residents live below the poverty lineFor a Knox County resident, age 46, earning $40,463 a year, the bronze community option plan through Maine Community Health Options -- the least expensive plan -- would cost $257 per month, with a $53 credit applied to the premium.The deductible is $5,000, basically what you will pay for before insurance begins to cover your costs. There is no charge for primary doctor visits, Emergency Room visits, a specialist visit or generic prescriptions.
The same plan, applied to somebody age 46, but earning $30,853 (the average yearly salary for women in Knox County) would cost $158 per month with a $152 credit applied. The deductible is also $5,000 per month.
Adding in different ages earning $30,853, this is what options are available for the bronze plan:
Age 60: $143 a month.
Age 25: $179 per month.
Prices for the same plans in different counties varies slightly.
Shaughnessy said the reasoning for the varied costs is due to the tracking of medical costs by the Bureau of Insurance. Rural areas typically have higher costs for medical services than urban areas, she said.
Community Health Options was set up as a nonprofit entity to allow more competition in the state after the Affordable Care Act became law. The co-op was given a loan from the federal government to start, and they are designed to offer competition and a not-for-profit alternative to residents seeking healthcare coverage. The co-op is mandated to run as a non-profit entity, she said.
To see what plans may be available to you, visit enroll207.com, or call 1-800-838-0388.
Maine did not expand Medicaid, known as MaineCare, in the last legislative session. Although it passed in the House and Senate, Gov. Paul LePage vetoed the bill.
Shaughnessy said when the Affordable Care Act was adopted into law, the legislation mandated states to accept federal money for the expansion of Medicaid. The Supreme Court struck this clause from the law, and made the option voluntary for states.
"Federal policy is set up in pieces," Shaughnessy said. "The original policy never intended to cover individuals below 100 percent of the poverty line, it was not set up to do that, and the law has not been changed," she said.
When the court made state participation voluntary, that one piece was nixed, leaving a gap of uninsured Americans.
Eligibility of MaineCare comes in two parts. It is based on income, and also a categorical need. Shaughnessy explained a category as an individual having a disability and or having a minor child in the home.
Under this system, a 30-year-old making less than $11,500 a year is not eligible as only their income qualifies them for state aid. This is the individual the Affordable Care Act hoped to cover with the expansion of Medicaid.
Speaker of the House Mark Eves, D-North Berwick declared LD 1578, An Act to Increase Health Security by Expanding Federally Funded Health Care for Maine People, an emergency, as required to be heard in the second legislative session. He is the sponsor of the bill.
The bill allows for federal money totaling $3 billion to cover the costs of expansion of the program for three years, until 2016, and would fund up to 90 percent of the costs at the end of that term.
The bill, if passed, expands medical coverage under the MaineCare program to adults 19 to 64 who qualify under federal law with incomes up to 138 percent of the non-farm poverty line.
Independent Jeffrey Evangelos of Friendship, a co-sponsor of the bill, said there is a three year opt-out provision, where states can back out before encountering costs in the event expansion does not work as planned. Also, during the three years of federal funding, the state establishes a savings account to offset the fourth year, and more costs.
Expansion requires people who become eligible and utilize services to have some skin in the game, Evangelos said. Patients on MaineCare will be required to pay a co-pay for care. The amounts paid through a co-pay are still under negotiation, said Evangelos.
He believes the law will pass this round, with two-thirds of the Legislature available to override the governor's veto if necessary.
"This bill is not about welfare, it is about working men and women who currently lack health insurance and who earn between 100 percent and 138 percent of the poverty level. Unless we approve LD-1578, these Maine families will continue to struggle without health insurance," he said during testimony to the Health and Human Services Committee in January.
Evangelos said the federal government and Federal Reserve has spent trillions of dollars on undeclared wars and bailing out bankers in New York. "With these facts in mind, I believe it is high time we reordered our nations priorities and accepted the health care expansion plan, just as eight other Republican governors have already done."
Republican Ellen Winchenbach of Waldoboro also co-sponsors the bill. Winchenbach said she has spoken with constituents, clients, family and friends about the need to pass Medicaid expansion.
"I believe everybody has a right to affordable health care," she said. Adding, she hopes expansion will pass to give hardworking people the care they need for preventive services.
"People are not lazy, they are trying to make a living and are not abusing the system. A lot of the people in the gap are single men and women who need it," Winchenbach said. "They are too proud, and some don't know where to go for help."
"What is a life worth? It's the right thing to do," she said.
Winchenbach said she would override LePage's veto if he was to exercise his executive power as he did in the last session.
LePage said Maine agencies are cannibalized by welfare spending, and that services will cost $2.2 billion in the next two years, even without expansion.
He said in an press release, MaineCare spending is taking funds away from education, law enforcement, economic development and programs to protect natural resources.
If MaineCare is expanded, the program is expected to account for 45 percent of the General Fund revenue, he said.
"We simply cannot keep throwing money at an inadequate welfare program. The state is not meeting the health care needs of vulnerable Mainers, and adding more people to the welfare rolls will only exacerbate the problem, " the governor said. "Expanding welfare a decade ago did not increase access or improve the quality of care, nor did it help uninsured Mainers. Now it is threatening all of the other programs and services Mainers expect from their state government."
Locals express views
Testifying before the Health and Human Services Committee Jan. 15, two local women with differing opinions on expansion expressed their concern.
Sara Hotchkiss, a professionally trained hand-weaver from Waldoboro, said allowing everybody access to affordable healthcare means we have healthy, productive people.
Being self-employed, Hotchkiss said her income varies from year-to-year, is marginal, and was affected by the recession. Expansion of Medicaid would offer a safety net for the years when she has a lower income, and allow access to the preventative care she sometimes declines, she said.
She said a $15,000 catastrophic policy is not an option as premiums are not affordable.
Paula G. Sutton of Warren, a state Senate candidate for District 12, said she opposes Medicaid expansion for two reasons. First, she does not think expanding the program to non-disabled Mainers is the proper role of the government. Through welfare generosity, people have forgotten or never learned to care for themselves, she said.
She said seeking medical care is often an issue of prioritization. She believes reforming and improving the existing system would help people. Although Sutton said she is concerned for individuals who need help, leading her to help the Knox County Republicans raise money for heating fuel for needy families, she believes extending services to to non-disabled people of working age fails to serve those who are most needy. She said it may also diminish their self-sufficiency.
Financially, she also thinks expansion is unrealistic, and does not trust the federal government to foot the bill.
The bill has been referred to the Health and Human Services Committee.
A Second Proposal
Another proposal to expand the MaineCare system inched forward March 3, when the Department of Health and Human Services Committee approved LD 1487 to be carried over into the 126th legislative session. The bill is sponsored by Republican Senator Roger Katz of Kennebec.
The bill proposes a managed care system to be implemented into the MaineCare program. Managed care requires the Department of Health and Humans Services to contract with health insurance providers or networks to provide care at a set price.
"The fee for service program is spending billions with little concentration on prevention, inadequate accountability and high and frequent cost overruns," Katz said to the committee during his testimony.
He also stated the bill is not about how many people should or should not be enrolled in the MaineCare program.
Other states have implemented managed care systems with mixed results, he said, adding Maine can learn from the mistakes and build upon the best practices to improve the state's health care system.
The bill would require the Department of Health and Human Services to select three or four plans from nationally accredited providers which would compete for enrollment of MaineCare patients statewide.
The provider would be paid a capitated rate by the state for each enrollee and would manage the care for each patient. Capitated rates take into consideration age, sex and geographic location, as well as employment.
Katz said this system would save $30 million per biennuim.
Although the devil is in the details, he said, the managed care system is designed to ideally improve health outcomes and lower costs. There is a good and bad way this can go, he said. One, the program could deny access to care, and lower reimbursement rates to providers, but it also could provide a more effective way for patients to get care, he said in his testimony. Ensuring the system functions the way it should, is up to the contracts with plan providers, he said.
"This is not a Republican idea or a Democratic idea. This is a best practice, good government idea," Katz said.
Courier Publications reporter Juliette Laaka can be reached at 594-44-1 ext. 118 or via email at firstname.lastname@example.org.