Jeff Austin, vice president of government relations for the Maine Hospital Association, considered what the state’s health care landscape would look like if the Trump administration is successful in repealing the Affordable Care Act, also known as “Obamacare.”

“It would cause a lot of problems,” Austin said, “for a lot of people.”

Austin was forced to reflect on such a possibility because of a brief filed June 25 to the U.S. Supreme Court in a case brought by 18 Republican state attorneys general (and initially joined by two governors, including Paul LePage of Maine). They, with support from the president, seek to overturn the 2010 health care law on the grounds that its now-hobbled individual mandate is unconstitutional.

Four days after the filing, the Democratic-led U.S. House of Representatives passed a bill that would strengthen and expand the ACA, allow the federal government to negotiate lower prescription drug prices and put pressure on the 14 states that have opted against expanding Medicaid. The Republican-led Senate is unlikely to consider the measure, but it does offer a stark contrast between the two parties in advance of the November elections and no doubt will be the subject of countless campaign ads.

“When you have somebody like President Trump, or states who are saying, ‘Let’s just get rid of the ACA and figure out where we can go from here,’ that is just inviting chaos,” said Aaron Frey, Maine’s attorney general. “And chaos is exactly the opposite of what we need.”

Frey, a Democrat who served three terms in the Maine House before joining the administration of Gov. Janet Mills as attorney general, extracted Maine from what he called “the wrong side” of the ACA litigation and joined a bipartisan amicus brief that supports the landmark health care law.

In Maine, Austin and other health experts described the chaos they believe would follow a successful ACA repeal. The rate of Mainers without health insurance would more than double, from about 51,000 citizens to 134,000, according to a recent estimate from the Urban Institute.

Maine’s uninsured rate had dropped from about 10 percent in 2014 to 8 percent four years later. That was still the highest in New England until last year’s figure dropped to 4.9 percent after Maine voters approved a Medicaid expansion in a 2017 referendum and Mills took over from LePage, who had refused to implement the change.

“Immediately, we’d be looking at 83,000 Mainers who would stand to lose their health coverage because of an ACA invalidation,” Frey said. “That’s just at the front end. That doesn’t explain the different repercussions that might happen when you see the problems of how people are going to access health care and what it’s going to mean for their families.”

Through the end of June, 57,665 Mainers had health insurance through the expansion of Medicaid, known in the state as MaineCare. An additional 62,031 signed up for insurance through the ACA marketplace during the Nov. 1 through Dec. 15 regular enrollment period, although that number may be higher because pandemic-related layoffs trigger a special enrollment period of 60 days following loss of coverage.

“I would say that it’s higher,” said Carol Zechman, senior director of access to care at MaineHealth. “We’re definitely doing special enrollments and seeing people come in that way.”

Ann Woloson, executive director of Augusta-based Consumers for Affordable Health Care, said people can apply for MaineCare anytime. She urged anyone who recently lost employer-provided health insurance coverage to call the state’s Health Insurance Consumer Assistance Program (800-965-7476) for help sorting through options or applying for ACA marketplace coverage.

A repeal of the entire ACA also could mean a reversion to 2010 conditions, when insurance plans could offer fewer benefits and deny coverage to those with pre-existing medical conditions. Whether the Supreme Court could simply strike the individual mandate portion of the law and leave its consumer protections in place remains to be seen.

U.S. Sen. Susan Collins, a Republican, voted in 2017 to zero out the tax penalty for the individual mandate, which says citizens must have health insurance or pay a penalty. Critics say that vote helped set the stage for the current lawsuit.

However, Collins also was one of three Republicans who voted that year against a so-called skinny repeal of the ACA, along with Sens. Lisa Murkowski of Alaska and the late John McCain of Arizona.

In a statement to the Portland Press Herald, Collins called the Trump administration’s decision to submit the new brief “the wrong policy at the worst possible time as our nation is in the midst of a pandemic. The Affordable Care Act remains the law of the land, and it is the Department of Justice’s duty to defend it.”

Collins also argued that had Congress wanted to repeal the entire act, it could have done so.

“Instead, it took a targeted approach by eliminating the penalty on families making just barely more than 400 percent of the poverty level who simply could not afford to purchase insurance,” she said. “Congress maintained important consumer protections in the ACA for people with preexisting conditions such as asthma, arthritis, cancer, diabetes and heart disease.”

Rep. Thom Harnett, a Democrat who represents Gardiner and Farmingdale, said access to adequate and affordable health care should never be a partisan political issue.

“It strikes me as surreal to even be having this discussion,” he said. “We are in the midst of a global pandemic and the worst public health crisis in our country in over 100 years … and seeing our poorer populations suffering terrible health outcomes. Yet despite all that, there are efforts underway to strip 20 million people of the health care they currently receive under the Affordable Care Act.”

Austin, whose association represents Maine’s 36 hospitals, said all of them are nonprofit entities, and that in any given year about half will end up losing money. He said eight of the hospitals have been in the red for five consecutive years and two are restructuring debt in Chapter 11 bankruptcy proceedings.

The COVID-19 pandemic resulted in significant revenue declines from postponed elective surgeries as well as fewer emergency room visits. Austin estimated losses of roughly $600 million from mid-March to July, with federal money providing relief of about $350 million.

“That still leaves a hole,” he said. “And if the ACA goes away and another 150,000 or 175,000 people go uninsured, that’s a massive revenue loss for our guys, because that emergency room door remains open regardless of your ability to pay.”

Frey, the attorney general, said he plans to add his voice “at every opportunity to support the Affordable Care Act and the important access it provides to meaningful insurance for hundreds of thousands of Mainers.”

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