From Maine, a Call for a More Measured Take on Health Care
BANGOR, Me. — Hundreds of miles from the health care debate that will begin again this week in Congress, lobstermen here are out in force, bees are furiously pollinating the state’s famous blueberries and part-time workers are preparing for another summer tourist season.
As a result of their short-term spike in income, many of Maine’s working class will likely lose some or all of their health insurance subsidy, a feature of the federal health care law, which has been a complicated blessing for the citizens of Maine.
Senator Susan Collins, Republican of Maine, has spent a lot of time thinking about how to deal with these “subsidy cliffs,” even as her party’s leaders press for the wholesale repeal of the Affordable Care Act, President Barack Obama’s signature domestic achievement.
As she and a handful of other Republican senators think about repairs rather than replacements, discussions that will intensify this week after the Memorial Day break, they are frustrating the grander ambitions of the Senate majority leader, Mitch McConnell of Kentucky — not to mention President Trump — to unravel the law as the House did last month.
Ms. Collins’s résumé (she once oversaw Maine’s insurance bureau), her relentless practicality and her state’s particular vulnerability within the health care debate — its population is old and largely poor, with a sizable part-time work force — have placed her at the center of an issue that conservatives have tried to dominate in Congress.
“There is no denying that the Affordable Care Act has made insurance available to millions of Americans and allowed people to leave corporate jobs and start businesses,” Ms. Collins said. “We are disproportionately affected, which is one reason I’ve spent so much energy on this issue.”
Ms. Collins, omitted from the working group convened by Mr. McConnell, has formed a bipartisan working group that may help build a foundation for future changes should Senate Republicans fail on their own, which seems increasingly likely.
It is reminiscent of when Democrats tried desperately to woo Senator Olympia Snowe, who also represented Maine, to their side in the last health care debate. They won her vote for the health bill in the Finance Committee, only to lose it on the Senate floor.
“Obamacare created a mind-set here that the federal government can be a partner in providing health insurance,” said Lee Umphrey, the chief executive of the Harrington Family Health Center, where 1,500 residents in a rural county east of Bangor have enrolled in health insurance plans since the law was enacted.
“Senator Collins has had an open mind, but it’s hard for her with the more conservative pockets here in Maine and her caucus back in Washington,” Mr. Umphrey said.
The House bill would roll back state-by-state expansion of Medicaid, and replace income-based government subsidies to buy insurance policies on the act’s marketplaces with tax credits of $2,000 to $4,000 a year, depending on a person’s age. It would also offer states the ability to let insurers charge higher premiums for some people with pre-existing medical conditions.
While Maine did not expand its Medicaid program — something providers here greatly lament — the new subsidies increased the number of individual policyholders to 80,000 from 30,000 since the law was enacted.
Should a bill like the House measure pass, Americans between 50 and 64 will be the most vulnerable to steep rate increases. The impact would be particularly acute in Maine, where the median age is 43, the oldest in the nation.
Like many states with high health care costs, Maine is largely rural — and nearly 22 percent of the state’s workers have part time jobs, well above the national average of 17 percent.
But the health care law has allowed self-employed residents and owners of very small businesses to have insurance for the first time in years. “It’s been good to have it,” said Charles Smith, a lobsterman from Jonesport whose wife and three teenagers were sporadically without insurance for years before the law.
Ms. Collins has been a critic of the Affordable Care Act since it was enacted. She has cited the instability in the insurance markets; the increasing costs of premiums, especially in rural northern areas; and the scarcity of health care facilities that accept the plans.
During the Trump presidency, she said, the tension over access “has been exacerbated by the administration’s mixed messages on cost sharing.” The administration has wavered on whether to continue government payments to health insurance companies to offset their customers’ out-of-pocket medical expenses.
“The uncertainty is extremely problematic,” said Eric A. Cioppa, the superintendent of the Maine Bureau of Insurance, who said carriers could not fix their rates without knowing the fate of those subsidies. “If they don’t get a subsidy, I fully expect double-digit increases for three carriers on the exchanges here.”
Ms. Collins also said she would like to see a fix to the “wage cliff,” in which a single dollar increase over the Affordable Care Act’s income threshold can cost a worker the full value of his insurance subsidy. It is a special problem for seasonal workers whose incomes fluctuate throughout the year.
“I really dislike that the law discourages work and pay raises,” she said.
Maine has been viewed by Republicans as a possible model for some reforms. It was one of a handful of states that embraced a “guaranteed issue” policy of health insurance, regardless of pre-existing medical conditions, and it created “invisible” high-risk pools to help sick people buy insurance and stabilize the markets.
Republicans cite Maine as the model for the risk pool in the House measure, but Ms. Collins notes that the House bill does not fund state-based risk pools anywhere near the level that Maine has.
“One of the problems with the exchanges is that the pools are not large enough,” she said. “It would cost $15 billion annually to expand nationally a patient stability fund like Maine did.”
A state bill that loosened community rating rules and deregulated the insurance market could also be a model for a Republican health care bill that allows states more waivers from federal rules. Many state health care experts see that as a way to get more flexibility and experimentation in insurance markets.
For instance, Ms. Collins thinks Maine should embrace a Medicaid expansion modeled on the one adopted by Indiana after the state obtained a waiver from the Obama administration. Indiana included managed-care plans in its Medicaid expansion and a requirement that poor people contribute to savings accounts, which are then applied to the portion of their medical bills.
Maine also has one of the few viable health insurance cooperatives in the nation, which was hugely popular but has struggled to stay solvent because of high health care costs for Maine’s newly insured. It is on a better footing this year.
Maine health care experts are watching Ms. Collins carefully in the debate, which Republicans would like to see reach its climax before the July Fourth recess.
“I think she is very conscious of the fact that if you move forward with a plan that gives tax credits to higher-income people but not a 60-year-old in Presque Isle, that is not a good move for our state,” said Emily Brostek, the executive director of Consumers for Affordable Health Care in Augusta, Me.
Rural Maine voters, who largely supported Mr. Trump in his election, are watching, too.
“I like what I’ve got,” said Mr. Smith, the lobsterman, who is an independent and voted for Mr. Trump. “If they get rid of Obamacare, I would say I would blame the Republicans.”