The number of Mainers enrolled for health insurance coverage through the Affordable Care Act declined slightly this year. But overall, the state is trending toward having more people covered by health insurance in some way, either through the ACA, Medicaid, Medicare or an employer-based plan.

Maine’s uninsured rate decreased from 8% in 2019 to 5.7% in 2021, according to the most recent data released last autumn by the U.S. Census, with experts attributing much of that decline to Medicaid expansion.

ACA individual plan enrollment in Maine ticked down from 66,095 in 2022 to 63,388 in 2023, according to state and federal data. Nationally, a record 16.3 million people signed up for an ACA plan for 2023 after the Biden administration eliminated many of the program’s disincentives that deterred some people from signing up.

Aaron Child, 41, of Damariscotta, who is self-employed and owns a tree service business, said he first signed up for ACA insurance three years ago. It’s helped give him peace of mind because he knows he can go to the doctor without worrying about exorbitant medical costs.

“Before (the ACA), I was paying full price for bare-bones plans without any preventative or routine care,” Child said. “I was scared to go to the doctor. But now these subsidies make it so I can get great coverage at an affordable rate.”

He said just in the past year, he’s used his insurance to take care of what he originally thought was a broken wrist, and for tests related to a cancer scare. After a sudden, unexplained weight loss, he ended up testing negative.

He said he didn’t hesitate to go to the doctor, while previously he might have.

Child said 10 years ago, before the ACA was enacted, he was paying $400 per month in premiums for a health insurance plan that didn’t cover much. Currently, he pays $110 per month for a plan that provides comprehensive services.

Mitchell Stein, a Maine-based independent health policy analyst, said Maine people are taking advantage of the improvements to the ACA, including more generous subsidies.

But he said a combination of other factors – such as Medicaid expansion – have resulted in Maine’s ACA marketplace enrollment flattening out over the past few years.

Also impacting ACA enrollment is Maine’s aging population, because when people turn 65 they become eligible for Medicare and no longer have ACA insurance. Changes in the unemployment rate also can affect the ACA. While many ACA enrollees are self-employed, those who start working a full-time job with employer-based benefits become ineligible for the ACA.

The ACA is designed to fill in gaps for people who do not get coverage from an employer, such as the self-employed, workers at small businesses without insurance, or people who work part-time jobs. Before the ACA, many people in those categories would have gone without any coverage at all.

“Changes in enrollment are complicated,” Stein said. “Moreover, all these factors play out differently in each of the 50 states. We know that much of the national enrollment increase occurred in states that have not yet expanded Medicaid. It may be that here in Maine, enrollment in the individual market has plateaued, given our current population and economic conditions.”

STABLE PROGNOSIS

Since 2020, ACA signups have fluctuated between about 60,000 to 66,000 enrollees, signifying stability in the marketplace, Stein said.

Factoring into that stability, Stein said, is Maine’s participation in federally expanded Medicaid benefits, a program that was implemented in 2019 by Gov. Janet Mills. It helped boost the number of people insured in Maine, but lowered ACA enrollment.

Maine people newly eligible for Medicaid under the expansion – those earning between 100% and 138% of the federal poverty limit – went from zero enrollees in 2018 to 106,000 currently. Total Medicaid enrollment in Maine is about 408,000.

In 2019, the last year people signing up for an ACA plan the previous fall would not have been eligible for Medicaid under the expansion, ACA enrollment stood at 70,987. The following year, with more people enrolled in Medicaid, ACA signups in Maine dropped to 62,031.

Stein said if it weren’t for the Inflation Reduction Act maintaining more generous ACA subsidies that began in 2021, especially for higher-income people who previously were paying expensive ACA premiums but now are paying more reasonable monthly premiums, ACA enrollment in Maine may have actually dropped off significantly during the past two years. The new rules ensure that enrollees are paying no more than 8.5% of their income on health insurance premiums, and also gave more generous subsidies to most ACA enrollees.

Child, who owns Apex Tree & Earthworx, said it helps to know that if his business takes off, he won’t suddenly be on the hook for expensive premiums.

“I know I’m not going to go broke paying for my health care,” he said.

According to the Maine Department of Health and Human Services, 83% of enrollees received subsidies to make premiums more affordable, and 10,000 Mainers selected a plan where the monthly premium was under $10.

Of those who signed up for individual plans, 21,157 chose a Community Health Options plan, 20,618 selected an Anthem plan and 20,157 picked a Harvard Pilgrim plan. Taro Health entered the marketplace for the first time, selling only in Cumberland County, with 456 choosing an individual plan. Taro Health plans to expand to other counties in 2024, company officials said. Taro Health primarily works with a network of direct primary care doctors.