ACA 101

In Maine, the Affordable Care Act exchange will be run by the feds

Posted Sept. 30, 2013, at 5:17 a.m.

Maine is different.

We worship the whoopie pie. We use phrases such as “wicked” and “jeezum crow.” We know how to drive on two inches of ice covered in a foot of snow.

We went our own way with the Affordable Care Act.

The 900-plus-page act is a federal law, yes, but states have some leeway. They can run their own marketplace for the sale of health insurance, or not. They can expand Medicaid to cover the very poor, or not. They can cut Medicaid, or not.

Maine didn’t, didn’t and did.

So what does that mean for you as a Mainer, now and in the future?

A wicked unique situation.

Maine and the marketplace

It’s been called the exchange. The marketplace. That new spot where you can go to buy insurance.

Health insurance will continue to be sold elsewhere — you can still buy from a broker or agent, for example — but under the ACA individuals can only get a federal subsidy to help pay for insurance when it’s bought through the marketplace. Some small business owners can only get a tax break for buying insurance for their employees through the marketplace.

It’s one of the backbones of the ACA and open enrollment starts Tuesday, Oct. 1.

States had a choice when it came to the marketplace: create their own, partner with the federal government or let the feds do all the work.

Seventeen decided to do their own, including four of the six New England states — Connecticut, Massachusetts, Rhode Island and Vermont. Seven states are partnering with the federal government. Twenty-seven are letting the feds have at it.

Maine is one of those 27.

“I’m not lifting a finger,” Gov. Paul LePage said in an interview with Bloomberg news at a Republican Governors Association meeting in Las Vegas last November. “We’re not going to get involved. We’re going to let Mr. Obama do a federal exchange. It’s his bill.”

That means Maine has little input into the marketplace that Mainers will use, including how it’s managed and how users will get help. The feds will decide all that.

That’s not to say the state had no involvement at all. The Maine Bureau of Insurance had to take a look at the plans of the two insurance companies that applied to sell from the marketplace, Maine Community Health Options and Anthem Blue Cross and Blue Shield. (Some other states have more than a dozen insurance companies clamoring to sell through their marketplace. Maine’s unusual, too, that it only had two, one of the reasons its marketplace rates will be among the highest in the country.)

The bureau approved both, with some stipulations for Anthem, and forwarded the plans on to the Centers for Medicare and Medicaid Services for federal approval. CMS approved those plans earlier this month.

Maine also created the Maine Health Exchange Advisory Council to serve as a kind of liaison between Mainers and the marketplace. That group just had its first meeting last week.

So what does this mean to you? Well, you should direct your ire — or kudos — to the feds, not the state, when the marketplace goes live Oct. 1.

It’s hard to say how the marketplace might have been different if Maine had created, managed and overseen it. There would have been local control, but whether that would have been good or bad, better or worse, is anybody’s guess.

You will be able to get marketplace help from local people, including so-called “navigators” and certified application counselors. (See our information box for help and links.) But in the end, it’ll be up to the feds to run it and those local people will be following federal rules.

Maine and Medicaid

Michael is in his late 50s, lives in Franklin County and cares full time for his wife, who has multiple sclerosis. He’s pretty sure he’s going to lose his health insurance.

He’s probably right.

That’s because Michael’s on MaineCare, the state’s version of Medicaid. Maine cut 8,000 people like him — adults who aren’t disabled and don’t have kids at home — from the MaineCare rolls earlier this year. It also cut about 14,000 people who have children at home but earn more than the federal poverty level.

The state also declined to accept federal money to expand Medicaid to 55,000 others who are very poor.

Maine can do that — the U.S. Supreme Court said so. Twenty-six states have agreed to expand Medicaid. Three are still debating it. And 22, including Maine, have declined to expand.

Experts believe few states actually cut Medicaid. One was Maine.

Michael has been told he’ll probably be one of the Mainers getting the boot.

“There are lots of people out there that are completely unaware that their health insurance will end at the end of December,” said Michael, who asked that only his first name be used because his wife will remain on government insurance and they’re worried that speaking to the newspaper will put her coverage at risk.

Like so much with the ACA, there’s good news and bad news.

The good: Michael and others like him won’t have to pay a penalty for not having insurance. The feds will give an exemption to anyone who would have qualified for Medicaid but who lives in a state that didn’t expand.

The bad news: Michael and others like him won’t have insurance. Not unless they buy it themselves and pay full price.

Since Michael and his wife make less than the federal poverty level — currently $15,510 for a family of two — they won’t qualify for a federal subsidy to buy from the marketplace. That’s right: They make too little to qualify for a subsidy. Subsidies are available only for people making between 100 percent and 400 percent of the federal poverty level. Make less than the poverty level and you’re out of luck.

That’s because the ACA had intended for those very poor people to be covered by Medicaid, no subsidy needed. But the U.S. Supreme Court ruled that states didn’t have to expand Medicaid if they didn’t want to. Maine didn’t, which means very poor Mainers will not get Medicaid coverage or a subsidy to help them buy their own insurance.

In October the state will officially notify those Mainers getting cut from MaineCare. Not all will lose their coverage right on Jan. 1. Most of the 14,000 people who have children at home can receive up to an additional year of MaineCare as part of a transitional program. And the state will ask all Mainers facing MaineCare cuts to complete a form for review so officials can gauge whether they might fit into a different MaineCare category and find coverage there.

If Michael were pregnant, for example, he could get insurance.

But Michael isn’t expecting. His wife, disabled from MS, will keep her coverage, but Michael is too young, too poor and too healthy to keep his.

At least too healthy for the moment. He says his doctor has expressed concern over a blood test — one that could, worst case, indicate cancer. Michael has rushed to schedule a follow-up test, while he still has insurance to pay for it.

“Then I’m going to have to just let it go,” he said. “This will be the final test until some kind of health care is in place.”

Maine and the future

So what will Maine’s health care system look like down the road because of this whole ACA thing and the way Maine has chosen to deal with it? Better, worse, cheaper, more expensive, easier to access, more difficult to get?

Experts say… it’s hard to say.

Here’s what they tend to agree on:

• Get ready for a greater focus on preventative and primary care. It’ll be cheaper for you — preventative care is free for most insured people under the ACA — and potentially more lucrative for your family doc, who will get paid for keeping you well rather than paid just to treat you when you’re sick.

• It could be harder to get an appointment. As demand for primary care increases, so could wait times.

• Hospitals will have to cooperate and collaborate if they want to stay afloat in the coming age of primary-care-rules. And even then, some may not make it.

What they don’t agree on:

• Whether Maine will eventually expand Medicaid. There’s been talk that lawmakers will take up the issue again in January, but there’s disagreement about where that will go.

• What expansion would do to — or for — the state. (Or what it would have done if Maine had expanded.) Some, such as the governor, say expansion helps only able-bodied adults who don’t deserve the handout, and eventually will cost Maine millions of dollars a year, a sum the state can’t afford. Others say Maine is leaving its poorest people without health insurance, a situation that will come back to bite the state as those people wait to get care, enter hospitals sicker and then can’t pay — leaving hospitals to foot the bill and get that money back by charging insured patients more.

• How primary care doctors will deal with increased demand. Some say family docs are likely to be unprepared and overwhelmed. Others say docs are already working on ways to deal — such as having patients do check-in paperwork in advance to keep appointments on schedule and allowing patients to be seen by a nurse practitioner or another medical professional in the office rather than funneling everyone to the doc.

• Whether care will be cheaper or more expensive for patients. Experts say that depends on too many factors — insurance companies, hospitals, doctors, patients, health care innovation — to accurately gauge. Some guess it will be cheaper, at least for people who get preventative care and head off a medical crisis. Others predict it will be more expensive, at least for the people who could get by with low-cost, high-deductible plans until the ACA, and who now must, by law, pay for health insurance with more benefits.

And then there’s the big question: Overall, will the ACA help or hurt the health care system in Maine?

These days, the prediction seems to depend on which side of the political aisle the predictor falls.

“The people who hate it, hate it. The people who love it say it’s perfect. And neither is correct,” said Trish Riley, senior fellow in health policy and politics at the University of Southern Maine’s Muskie School of Public Service and former chairwoman of the governor’s Affordable Care Act Steering Committee under Gov. John Baldacci.

But experts say the health care system wasn’t sustainable as it was, with rising prices, fewer insurance benefits and too many people going without care. They hope the ACA will help.

Time, they say, will tell.

“Either we fix this,” said Kevin Lewis, executive director of Maine Community Health Options, “or we’re just changing the chairs on the deck of the Titanic.”

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