In two days, the health insurance marketplace will open for business, a pivotal moment in the short history of the Affordable Care Act.
The multi-million dollar ad campaigns and rhetoric from politicians that’s 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 and 400 percent of the federal poverty level.
The Maine Sunday Telegram and Kennebec Journal talked to four families interested in buying insurance on the marketplace, including a couple in Gardiner whose part-time jobs put them over the MaineCare limit, a single 27-year-old from Farmingdale no longer eligible to be covered under his parents’ plan, a single mom 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 teh day as the battle over how to avert a government shutdown Tuesday wages. There was no update by press time.
In Maine, the fight has mostly centered 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, defaulting 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.
But states like Maine that defaulted 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 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 to 8 percent of the population, or 65,000 to 104,000 people, will sign up for 2014 benefits.
Mills said the complexity of the law has made it difficult for people to figure out whether the ACA is good or bad until they start shopping for the insurance on 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 the independent spirit of Mainers will make it difficult to sign people up for benefits, experts say.
But 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, Delaney 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 currently 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.
But some are expressing interest now, and below are the stories of those who may seek health insurance on the marketplace.
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 ending 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 racked up over $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 an unidentified inflammation in his blood.
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, 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 on buying health insurance off the exchanges. An online subsidy calculator estimated she and her husband may only have to pay $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.
Leet, 27, of Farmingdale, coaches junior varsity soccer at Hall-Dale High School and works part time for a general contractor.
He’s been without health insurance since he turned 26 last year, which booted him off his parents’ plan.
Leet worked in grounds and maintenance for the city of Augusta until two months ago, but he said he couldn’t get insurance through the city because he was considered seasonal.
He would like to buy health insurance off the exchange through the Affordable Care Act, but, like many others, said he doesn’t know much about the law.
He said he thinks the administration could have done a better job advertising and explaining the law.
Leet said he makes around $17,000 a year at his two jobs. That would making him eligible for a subsidy of nearly $2,000 from the federal government. His monthly premium could range between $67 to $365 after the subsidy, depending on the plan.
Leet hasn’t needed health insurance since losing it, but he said he’s worried his active lifestyle could lead to an injury that would require a costly trip to the hospital.
“I’m good for a hospital visit one or two times a year,” Leet said, “sprained ankles, broken bones or just getting sick.”
Last winter he went snowboarding less because of concerns he could end up injured. He said he’s also more cautious when playing in adult softball and basketball leagues because he doesn’t have insurance.
“You don’t realize how important it is until you’re sitting there with a broken arm,” Leet said.
Adria Moynihan Rusk and Bruce Rusk
The Falmouth couple married a few weeks ago, and they said they’re excited about buying insurance on the marketplace after going 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 Rusk 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 Rusk, 51, said. “But you’ll still be mostly destitute.”
He 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 on $5,000 in out-of-pocket costs he had to pay. But he said if he had instead had surgery last year, 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 Rusk, 34, said she 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,” she 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 Rusk 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,” he said.
Burkhart, 33, is a single mother, nursing student and interested in purchasing insurance on the new marketplace.
The Portland resident pays $120 per month for insurance that only covers 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 issues over 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, saying she’s already paid several hundred 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 working on a master’s degree in nursing to become a nurse practitioner. She’s buried in debt from 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 that she didn’t sign herself 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.
But 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 Maine Sunday Telegram.
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.”
Kennebec Journal Staff Writer Paul Koenig contributed to this report.