Just before fleeing Washington for the April recess, Republicans unveiled a new amendment they said would revive their struggling bill to repeal the Affordable Care Act—a policy based on a program in Maine that aims to bring down health insurance premiums by funneling older and sicker people into a separate individual market subsidized by the federal government.
Though some lawmakers and staff privately admitted it was merely a stunt to create the appearance of progress on the stalled health care overhaul, others insisted the proposal would breathe new life into the moribund bill.
“This amendment alone is real progress and it will help us build momentum on delivering on our pledge to the country,” House Speaker Paul Ryan (R-WI) said.
But health care policy experts in Maine and in D.C. paint a different picture, telling TPM that not only was Maine’s system not as successful as the lawmakers claim, but it was propped up by several other policies—including the Affordable Care Act itself, which the GOP is gunning to repeal.
A series of reforms passed in Maine, in addition to setting up the high-risk pools, allowed insurance companies to charge older people, small businesses, and people in rural areas much more for their health coverage. It also allowed the companies to sell skimpier plans with sky-high deductibles that did not cover things like maternity care and many prescription drugs. At the same time, the system depended on charging all Mainers $4 per month, whether they were insured through their employer or on the individual market, to help cover the costs of people in the high-risk pool. The GOP’s national plan purportedly modeled on Maine does not include this crucial funding structure, and includes no funding at all after the first nine years.
And while the lawmakers singing the praises of Maine’s program and calling for a national version are correct that coverage expanded dramatically since its implementation, most of the credit for that goes to the ACA—which penalized those who did not buy health insurance and offered tax credits to many who did.
A Northern experiment
In 2011, when the Affordable Care Act had been signed into law but not yet implemented, Maine passed PL90, a law that allowed insurers to shift high-cost patients—such as those with chronic illnesses—into a separate health care pool on the individual market. The companies were also given the green light to sell policies that covered far few services. For example, the state’s biggest insurer stopped covering maternity care altogether in its post-PL90 plans, and multiple plans began requiring a separate deductible for prescription drugs. The law additionally changed the state’s rating bands, allowing insurers to charge members much more based on their age and geographic location.
“Rather than building as big an insurance pool as possible so the costs got meted out more broadly, what the program did is sequester those people,” explained Garrett Martin, the executive director of the Maine Center for Economic Policy. “It provided an opportunity for the insurance companies to underwrite much cheaper policies for younger, healthier people and jack up costs for older, sicker, people.”
The costs of people in Maine’s high-risk pool were subsidized by a fee levied on everyone in the individual, small-group, and employer-based markets of $4 dollars per-person, per-month—which added up to nearly $22 million per year for the insurance companies.
Republicans in Congress point to data in Maine showing that the law cut insurance premiums in half for older members and by a whopping two-thirds for those under 19 years old. But experts say these numbers are misleading.
“The proponents of this system are only looking at Maine’s new policies that didn’t cover much that only healthy people were buying,” said Emily Brostick with the Maine-based health advocacy group Consumers for Affordable Health Care. “This law wasn’t a cure-all.”
Key context is also missing from the impressive numbers. For one, prior to PL90, insurance companies had to cover everyone regardless of pre-existing conditions, but had no subsides to bring down those costs. Maine also has the oldest population in the country, and people too old to work but too young for Medicare were overrepresented in its individual market, along with people too sick to work.
“Premiums were really high and participation was really low,” explained Gary Claxton, the vice president of the Kaiser Family Foundation. “So when you made a change where you subsidized it from outside the market—a lot of money to subsidize a really small population—of course it made a big difference.”
Thanks to these subsides and the ability for insurers to sell skimpier plans, costs did come down for some in the individual market. But they sharply increased for many individuals and small businesses.
In the year after the law’s implementation, 100 percent of individuals over 60 years old saw rate their premiums increase 18 percent or more, while 100 percent of people 39 and younger saw their premiums go down, according to a report by the advocacy group Consumers for Affordable Health Care.
The vast majority of small businesses also saw rates jump, some by more than 40 percent, CAHC’s report found, as Maine’s law allowed them to be charged more based on the employees’ age, location, industry, and several other factors. One small publishing company on the Eastern shoreline had to pay $75,144 more to insure their 31 employees, even though the new plan had a higher deductible and less coverage.
“If you’re older or live in rural places, you got creamed,” Martin said. “The law blew those folks out of the water. So it really is ironic that people want to copy this, because Maine is no model of success. It only worked because it relied on such a tremendous level of subsidy and allowed insurance companies to offer crappier products. It’s just smoke and mirrors.”
Health care experts warn that it’s impossible to judge the merits of Maine’s high-risk pool system on its own, because the Affordable Care Act was implemented just a few years after Maine’s law was enacted. The large increases in the number of people insured in Maine since 2011, for instance, are far more due to the ACA’s individual mandate, tax credits, cost sharing subsidies, and insurance regulations than to the state’s high-risk pools.
“That’s where the bulk of our growth in coverage was,” Martin said. “To suggest it was a result of PL90 is on its face laughable.”
A report by Gorman Actuarial commissioned by Maine’s government in late 2011 backs up this analysis: “By 2019, the Individual Market will have almost tripled in size due to the ACA. PL90 slightly accelerates a portion of this growth to occur sooner but does not significantly change the final outcome.”
The report predicted a growth of just 6 percent in the individual market due to the lower costs for younger, healthier people brought about by Maine’s law, compared to a growth of 170 percent in the individual market due to provisions in the ACA.
In 2012, before the full implementation of the ACA, Maine experienced one of the sharpest increases in the number of uninsured of any state in the country. The number of uninsured dropped significantly over the next few years, but the state’s rate of uninsured resident remains the highest in New England.
The ACA also prevented insurance companies in Maine from raising rates as high as the state’s law allowed. Before Obamacare’s implementation, PL90 gave companies leeway to charge older patients five times more than younger members. The ACA set a limit of a 3 to 1 ratio.
In total, says Brostick, much of the cost decreases and participation increases touted by boosters of Maine’s model are more accurately attributed to the national system they want to repeal.
“The ACA was passed around the same time and was being implemented at the same time [as PL90], so you can’t easily tease out one from other,” she said. “But the individual insurance market has grown so much since 2011, and that’s definitely because of the ACA.”
The amendment GOP leaders unveiled in early April and rushed through a hastily scheduled Rules Committee markup before leaving D.C. was sold as a national version of PL90. The lead author of the Obamacare repeal bill, Rep. Greg Walden (R-OR), described it as based on “a great model coming out of the state of Maine where it has decreased premiums and increased enrollment.”
Like Maine’s program, the GOP plan in its current draft would allow states to offer cheaper insurance plans that cover fewer health care services. Like Maine’s program, it is projected to significantly increase costs for older, sicker Americans who do not yet qualify for Medicare. But unlike PL90 in Maine, with its monthly fees structure, it includes no ongoing funding to bring down costs for people in the high-risk pool.
“What they’re proposing is not exactly what we had here in Maine,” said Brostick. “They’re not requiring states to collect a per-member per-month fee. They’re not allocating enough money to really do a reinsurance program.”
In lieu of a fee or tax, the GOP bill allocates a flat $15 billion dollars over 9 years to help states pay for coverage of those with the most severe health care needs. What would happen after that funding expires is not addressed. And even conservative economists estimate that a national system for covering people with pre-existing conditions with high-risk pools could require as much as $20 billion per year in federal subsidies, just to cover about 4 million people on the individual market.
“Fifteen billion [over 9 years] may not be close to enough,” Claxton told TPM. “If you wanted to do a true high risk pool that meaningfully covers sick people, you’re talking about at least that much per year.”
Still, on Capitol Hill and in town halls back in their home districts over the past week, Republicans have continued to insist that their national version of Maine’s high-risk pools is the answer to the nation’s health care woes.
“We have a model for this in the state of Maine,” the amendment’s author, Rep. Gary Palmer (R-AL), told reporters when introducing the idea. “They have a risk-sharing arrangement that’s worked very well there. It brought down premiums and actually increased the number of people who are insured, and we believe that what’s we’re going to have too.”
“It’s based on proven results at the state level,” added Rep. Kevin Brady (R-TX), the chair of the House Ways and Means Committee and lead author of the GOP bill.
With a renewed round of pressure from the White House to pass some kind of health care reform, including threats to sabotage Obamacare, GOP lawmakers are latching onto Maine’s model as their latest in a long line of silver bullets. Like health savings accounts, the elimination of Essential Health Benefits, and block-granting of Medicaid, the Maine solution is more fraught and less effective than its supporters claim.
As President Trump himself noted: “Nobody knew that health care could be so complicated.”