This winter has been really hard on the roads. There are a lot of potholes and road wear that, if not repaired, will cause damage to our cars.

Our government will repair the roads, which are used by those who pay taxes and those who don’t pay taxes, the working and the non-working, the able-bodied and not so able-bodied. Some municipalities, though, don’t have enough money for road repair. A local town manager told me that health insurance premiums for the town employees have gone up so much that there is nothing left to give employees raises. In fact, there isn’t enough money to do preventive maintenance on all the roads, maintenance that would avert higher repair costs in the future.

Somebody pays for all health care. There is no free health care. Insurance premiums and charges for services go up as the cost of health care goes up.

Nationally, providing care for the uninsured is estimated to increase insurance premiums for the average family’s health insurance by about $1,000 per year. Hospitals and care providers shift costs to those who can pay to cover those who cannot. Just like the road maintenance, we all pay for health care.

If the federal government came along and offered our state $250 million per year to repair roads, money that would create jobs, generate revenue in local taxes, and improve our transportation system, I doubt there would be any who would turn this down. There might be some administrative costs to make this all happen, but with roads needing repair, this would meet little resistance.

Congress, through the Affordable Care Act, has set aside money, about $250 million per year, to help some of the people of Maine who cannot afford health care. This isn’t road repair money; it is for health insurance, Maine Medicaid.


This money will pay 100 percent of the cost for these newly eligible people for the first three years. If the state doesn’t accept these funds to expand MaineCare coverage, the money will go to help fund health care in other states.

Whether or not Maine accepts this funding and expands MaineCare, the money for these 69,000 Maine residents to receive health care will be spent and will be paid and, in most cases, it will be paid by the residents of Maine through cost shifting, raising costs for those who can pay.

The expansion of MaineCare would not bring new people into the health care system but would set up a system to deliver care and to pay for the care that Maine residents already receive and that all of us already pay for.

Who will be covered by this expansion? Many make minimum wages, yet can’t afford even the small premium or copays under the insurance exchanges. Some see me at the federally qualified community health center where I work. Yet even at this health center, there are copays and laboratory fees, diagnostic testing and medications that are not covered, costs that limit patients’ care.

The way we have been doing health care in this country is neither efficient nor effective. The ACA, and the resulting Medicaid expansion, is a start, an attempt, to changing how we do health care in this country.

Michael Porter of the Harvard Business School says the solution is better value, better health outcomes per dollar spent. He says that achieving and maintaining good health is inherently less costly than dealing with poor health. By expanding coverage for health care and access to health care to more people, we can encounter patients when they are healthier, in the primary care clinic, rather than in the emergency room when health has deteriorated to such a point that high-value care is impossible.


Effective and efficient health care is really about a relationship with a primary care provider, and without access, they don’t develop this relationship. Porter makes the point that lack of access to health care creates inefficiencies and makes high-value care difficult to achieve.

Some say we shouldn’t increase the burden on a broken system of MaineCare. Decreasing (or not expanding) MaineCare beneficiaries does nothing to solve these inefficiencies. The solution is to use this as an opportunity to begin to change how we provide health care with MaineCare jumping on at the start.

The ACA will succeed or fail, but we must let it do that on its own. By pulling out pieces, such as Medicaid expansion, we may be responsible for its failure. I believe health care is a responsibility. We must be responsible as a community, as a state, to be sure everyone has access to health care, and we must be responsible as individuals to take care of our health, to work to maintain our health through the way we live and interact with the health care system.

Tom Bartol is a nurse practitioner at the Richmond Area Health Center and is on the board of directors of the Maine Nurse Practitioner Association. He can be reached at [email protected] or on Twitter: @tombartol.

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