S8E3 Maine Healthcare: What Reduced Health Insurance Subsidies Could Mean in Maine
In this episode, we discuss the high-stakes expiration of the Enhanced Premium Tax Credits (ePTCs)—a pandemic-era policy that is set to sunset at the end of 2025 with Hilary Schneider, Jordan Rhodes, and Hilary Schneider, Jordan Rhodes, and Meg Garrat-Reed. While the Affordable Care Act (ACA) laid the groundwork for subsidized health insurance in 2010, the 2021 American Rescue Plan significantly boosted these savings, making coverage affordable for thousands who previously sat just outside the eligibility line.
Transcript
S8E3 Maine Healthcare: What Reduced Health Insurance Subsidies Could Mean in Maine
[00:00:00] Eric Miller: Hello and welcome back to Maine Policy Matters, the official podcast of the Margaret Chase Smith Policy Center at the University of Maine, where we discuss the policy matters that are most important to Maine’s people and why Maine policy matters at the local, state, and national levels. My name is Eric Miller, and I’ll be your host.
[00:00:23] Today we’ll be interviewing Hilary Schneider, Jordan Rhodes, and Meg Garrett Reed on the potential expiration of enhanced tax credits established by the American Rescue Plan and the resulting impact on health insurance markets and public health in Maine. So I’m going to briefly interrupt myself there just to set the context of when we had this conversation.
[00:00:46] We recorded this panel after the government reopened, but before we knew whether or not the premium tax credits of discussion were going to be extended by Congress and it seems like the premium tax credits will expire at this moment, and we’ll just have to wait until 2026 to see if the enhanced tax credits or some form of replacement passes the House and Senate.
[00:01:12] And with that, we’ll continue with the episode. Hilary Schneider is the director of the Maine Department of Health and Human Services Office of the Health Insurance Marketplace, which operates Maine state based marketplace. Schneider has two decades of health policy experience, primarily in government relations and consumer advocacy. She has also worked in marketing, economic and management consulting and program evaluation.
[00:01:36] Jordan Rhodes is the Director of Research and Policy Analysis within the Commissioner’s Office at the Maine Department of Health and Human Services. His research centers around policies and interventions that improve access to care, affordability, and health outcomes among Mainers.
[00:01:50] Meg Garrett Reed was appointed as the first executive director of the Maine Office of Affordable Healthcare on February 28th, 2023. She previously spent four years serving in the Maine Department of Health and Human Services, first as senior advisor for coverage and affordability, and later as the founding director of Maine’s Health Insurance Marketplace, CoverME.gov.
[00:02:12] Prior to her return to Maine, Meg was Director of Policy and Partnerships at United States of Care, a national nonpartisan nonprofit focused on supporting state level efforts to expand quality affordable healthcare. Earlier in her career, she served as special assistant to the chief of staff and director of delivery system reform at the Centers for Medicare and Medicaid Services. Before her appointment to the Centers for Medicare and Medicaid Services, she worked for more than five years in the offices of Congresswoman Chellie Pingree, most recently as legislative assistant for a portfolio of issues including healthcare and human services. Meg is an alumna of Wellesley College and holds an MA in public management from Johns Hopkins University.
[00:03:02] In 2010, the Patient Protection and Affordable Care Act commonly referred to as just the Affordable Care Act or ACA, was passed into law and expanded health insurance coverage, established premium tax credits, which subsidized healthcare plan premiums and provided protections for people with preexisting conditions.
[00:03:20] Then, while the world was continuing to grapple with the COVID-19 pandemic in 2021, the United States Congress passed the American Risk Plan Act, which expanded the eligibility and subsidy amount of these premium tax credits. However, these expanded premium tax credits are set to expire at the end of 2025.
[00:03:39] This matter of expiring tax credits became a significant item of discussion during the recent government shutdown. Healthcare policy experts have known that these enhanced subsidies will expire unless Congress intervenes, and some have dug into the numbers to estimate how much health insurance costs will increase for healthcare marketplace consumers if these premium tax credits are not extended.
[00:04:02] Jordan Rhodes and Hilary Schneider published an article that looked into these potential cost increases in Maine and the demographic breakdown of who is most economically vulnerable. They are joining us today to discuss their article along with Meg Garrett Reed, to cover the healthcare affordability landscape and how it looks today, and how that may change in the near future. And now, onto our panel.
[00:04:30] Hi all. Thanks so much for joining us today. So I’d like to start with our conversation today with Jordan and Hilary. Would you mind describing how your paper came together this year, and key takeaways from your analysis.
[00:04:43] Hilary Schneider: I can start with talking about how this came about. So I joined as the director of Office of the Health Insurance Marketplace which oversees the state-based health insurance marketplace in the state. I joined about a little over two years ago. As soon as I came in as director, one of the biggest things that directors across, of marketplaces across the country were talking about was, looking forward to December 31st, 2025 of when the enhanced, this enhanced level of federal tax credits that were helping folks afford coverage was going to expire if Congress didn’t take action.
[00:05:25] And so a lot of conversations about that because what we had seen which we’ll talk about more in more detail, is the benefit had given to the residents in our state. And so we really wanted to look at what the impact was gonna be from a number of fronts as we knew it was gonna become a pretty important conversation in Congress and wanted to be able to have data and stories to shed some light to help educate our policymakers as to what the impact would be.
[00:05:58] And I can let Jordan talk a little bit more about that too.
[00:06:02] Jordan Rhodes: I can talk through the study analysis and findings. So we took 2025 open enrollment data in Maine. So that’s the period when individuals generally enroll in a plan through CoverME.gov. Right now, the 2026 open enrollment period is underway.
[00:06:16] And we examined monthly premiums with and without the enhanced tax credit. So in, in 2025, the enhanced tax credits were in effect. So we essentially calculated, what premiums would’ve been this year had those enhanced tax credits not been in effect. And we compared those two outcomes. We did this for all households with marketplace coverage in Maine and given Maine’s really large rural population, we also looked at the change in premiums across rural areas of the state.
[00:06:44] So there were three significant findings from our analysis. So first the enhanced tax credits have a significant impact on lowering marketplace premiums across the state. So we found that without the enhanced tax credits, average household monthly premiums would’ve been $165 or about 59% higher statewide.
[00:07:04] So significant impact. However, we found a more pronounced effect in rural areas of the state, and in particular, we found really big impacts in isolated rural areas of the state, which just by definition are more remote and more sparsely populated. So average household premiums in these isolated rural areas would’ve been $175 or 59%, or excuse me, 63% higher without the enhanced tax credits.
[00:07:29] On an annual consumer basis, this amounts to an additional $1,400 in premium costs among individuals in those more remote areas of the state. And then in addition, without the enhanced tax credits households in rural areas would’ve spent about 10%. Of their household income on premium costs on average in 2025.
[00:07:52] So to summarize again that first finding we see that the enhanced tax credits had a really sizable impact on lowering premiums among CoverME.gov consumers, and in particular in rural areas.
[00:08:04] Our second finding is that, areas of the state that would’ve seen the largest premium increases without the enhanced credit, so those isolated rural areas, tend to have higher shares of consumers over the age of 60 and consumers who live in fishing and lobstering communities. So we viewed this as a really significant finding because these populations may be particularly vulnerable to the expiration of the enhanced tax credits and higher premiums that would result.
[00:08:29] So older individuals often have greater healthcare needs. They may face, higher rates of chronic conditions, yet they may be more financially strained or constrained given that they’re approaching retirement age. And then self-employed individuals in the fishing and lobstering industries, for example, may have limited access to alternate forms of coverage.
[00:08:49] So to summarize that second finding, we found that the enhanced tax credits play a really significant role in lowering premiums for older individuals and in communities that have higher shares of employment in Maine’s legacy industries of fishing and lobstering.
[00:09:05] Then third, we saw that rates of marketplace coverage are actually highest in rural areas as well. So while statewide, just under 5% of Mainers selected marketplace coverage during the 2025 open enrollment period, the share was higher in rural areas of this state. And in those isolated rural areas, which I’ve mentioned a couple times previously that share actually exceeded 6% of the population. So this is a relatively high share of the commercial health insurance market in Maine, and likely even higher in those rural areas, which we know tend to have higher rates of MaineCare and Medicare enrollment.
[00:09:39] So given that there are relatively higher percentage of individuals with marketplace coverage in these rural areas the impacts of allowing enhanced task credits to expire could be felt on a more communal basis if, for example, uninsured or underinsured rates increase as a result of the higher premiums. So again, just to summarize our findings more broadly we see impacts of the enhanced tax credits across the state, and in particular in rural areas of the state that may be more vulnerable to these premium increases.
[00:10:09] Eric Miller: Really interesting. And with that sun setting of the tax credits coming up at the end of the year here. Hilary, you have known about the possibility that these enhanced tax credits could expire unless Congress steps in at the end of 2025. How has your office been preparing for those tax credits, either be extended or allowed to expire?
[00:10:30] Hilary Schneider: Yeah, so we’ve, we, as I said, we’ve known about ’em for a while and we’ve been doing a lot of work to prepare for that. So we have a small but mighty team. This analysis really started some of the planning, which really we could drill into looking at the populations that would be most impacted. I just, I can’t not say that these also come about with a increased number of changes to health insurance marketplaces across the country that were handed down from the federal government through H.R.1, a law that was passed and put into law on July 4th of this year, as well as a new federal rule for marketplaces. And so we are dealing with kind of an unprecedented number of changes to the marketplace operationally in addition to these the loss of these additional tax credits.
[00:11:21] So one of the things that we thought was really important to do is to make sure that consumers on our marketplace knew about these changes coming down the road as soon as possible. If we’re talking about premium increases in some cases of a hundred, 200%, we know that’s gonna be quite a shock to households and that they’re going to stay in coverage. There’s likely gonna have to be some planning around where in their budgets they’re gonna be able to scale back or what other options they might be able to find for health coverage if they don’t think they can afford it through the marketplace any longer.
[00:11:59] And so over the summer we did a multi-part communication series to our members that included emails and postcards to those that we didn’t have permission to mail to. And each of those communications also contained a link to a short video that I was in where I would describe the high points. So for folks who don’t learn as well through reading that they could listen to me talk about what the high points were and we saw quite a lot of views of those videos. So we know that people were paying attention and we did hear from members that appreciated knowing what was coming down the road.
[00:12:40] We also gave them some tips about things that they could think about. The other thing we have to had to do is prepare operationally. And that means that we are essentially a web-based platform and so we have a system vendor that we work with where we had to change kind of the formulas of eligibility within the system.
[00:13:02] We have to put those into place. Like any tech operation, we have to test those and make sure they’re working so that when we launch the change, there’s not any bugs in it. And so when we looked at doing that, knowing that this debate was going on in Congress, knowing that it could extend beyond when open enrollment started, which was November 1st, and which is indeed the case we’re finding ourselves in, we tried to make that change in the platform. So it was almost a flip of a switch. So if the tax credits get extended by Congress with the same formula that we can flip that switch back.
[00:13:39] The other impacts is just really preparing our call center and all of our stakeholders and the people who help folks enroll in coverage, making sure that they all understand what’s happening and can answer the questions of consumers. And indeed, our call center has been really busy since open enrollment started, and a lot of the questions have been: Why are my premiums going up? Is this because of the stuff I’m reading about in the newspapers and also people, there a lot of misinformation, a lot of people worried that all financial assistance is going away, which is not the case.
[00:14:14] And also worried, are the numbers that I’m seeing in the system while I’m enrolling now; Is it gonna get even worse? So we’ve been really busy answering a lot of questions and also unfortunately, this is an instance where healthcare has been highly politicized.
[00:14:31] Eric Miller: Yeah. I admire the effort of trying to reach out to so many people and communicate this nuanced and complicated system that doesn’t necessarily come intuitively to people.
[00:14:45] And while we’ve been discussing a lot of the end of these tax credits, the context at which these tax credits, the premium tax credits were set into law was toward the “ender” end of the first phase of COVID, or is somewhere in there at the end. And so, what did these enhanced tax credits mean to people and from the context which the premium was applied to, to now?
[00:15:11] Hilary Schneider: Yeah. They mean a lot to people. I think that while they were put into place as part of a COVID relief effort and the underlying premise was that the federal government wanted to make sure that Americans had coverage when they were faced with a significant health event like COVID and making sure that, knowing that coverage provides people access to prevention, provides people access to vaccines, and provides people access to treatment when they get diagnosed with a condition that can be serious.
[00:15:42] And has access to primary care office visits. We know that people who are insured are more likely to go to their doctor, to have a regular relationship with a doctor. Having access to health coverage is linked to so many positive health outcomes. And not just, a lot of people like to talk about it can increase usage of unnecessary care, but really what we know is that access to healthcare increases usage of necessary care and prevention.
[00:16:09] And that’s so important. And while that was at a heightened state during the COVID-19 pandemic, it’s true. It’s true always right? It’s true always. And we never know when we could have an accident or be faced with a health condition. So what this has meant to Mainers is it has meant that they can afford coverage that previously was out of reach for them.
[00:16:33] And these, it also reinforces one of the primary reasons behind the establishment of marketplaces was making it so coverage isn’t so connected to your employer. What that looks like in Maine is, we’ve covered tens of thousands of more people. We were at record enrollment of adults through the marketplace since we expanded Medicaid in the state.
[00:16:59] And so we know that the impact was more people had coverage. And those are people who are self-employed. Those are people like Jordan talked about in our heritage industries like the fishing and lobstering industry who don’t have access to job-based coverage. These are people who left corporate jobs to explore passions or things that allowed them to have more flexibility to take care of loved ones.
[00:17:22] Like I can think of a hairdresser that we, cover that has shared her story with us. Her mom moved in with her and she needed to take care of her, help take care of her mother because she had healthcare needs. And so not only did she lose her job in, in a healthcare facility that had closed, but she went back to hairdressing because it was something she could do to make a living. But also it was something that allowed her the flexibility in her hours to also take care of her mother. And so, and she could only do that because she had access to coverage through CoverME.gov that, that had financial assistance.
[00:17:59] I also say one of the things, as Jordan said, we looked at is the impact on rural economies. Because we know as manufacturing has declined and as mills closed in some of these rural towns. And there are towns, that don’t have any large employers, but also towns where, if your employment is based on one large employer and that employer closes, you’re left with rural economies where there aren’t a lot of jobs in the area and not a lot of job-based coverage as a result.
[00:18:28] And so those communities are building back their economies on the creative economy, on gig work, on remote work, and on freelancers and self-employed individuals. And those are the people that we cover. We also cover hospitality workers, hourly wage workers who are sometimes have multiple hourly wage jobs. And that’s the only way that they’re gonna get coverage. And these are the people who take care of us, who cut our hair or our plumbers, our electricians, and also are the people who take care of our family members, like our home care workers who don’t have access to job-based coverage. The impact is definitely on people’s lives, on people’s livelihoods, on people’s health, but also on our economy and our rural economies.
[00:19:20] Eric Miller: It is incredible how the cost isn’t just felt that a premium increase it permeates the rest of one’s life and just the broader healthcare apparatus which we’re gonna dig into more throughout the rest of this conversation. And I’m excited to hear from Meg next about how her office works on affordability issues broadly, and what other trends in healthcare affordability that you are noticing that impacts consumers.
[00:19:47] Meg Garratt-Reed: Yeah, I would say it’s important to note that this change is coming at a time when there are especially significant challenges in affordability for consumers more broadly. We’re seeing right now going into 2026, the underlying premium cost, what you can think of as a sticker price for health insurance premiums growing at pretty unprecedented rates, at least in recent times.
[00:20:09] That’s true across all markets, but especially acute in the, in individual market because it’s compounded by some of these policy changes. So those sticker prices are gonna be rising in going into 2026 by an average of 23.9%. Really significant jump. While policy is impacting that it’s really being driven primarily, again, across all markets by some factors and trends that we’ve been seeing for several years now.
[00:20:34] And really the most significant component is just the increasing cost of the care that people are using through their insurance. In particular, there’s a couple factors that in recent years have been the most significant: prescription drugs, that’s probably not a surprise to folks. We’re seeing more utilization of prescription drugs and also introduction of new medications that come in at very high price points that can really quickly drive up spending.
[00:20:57] But also outpatient hospital services are an area that we’ve identified in our data and analysis as a place where prices have been rising quite a bit in recent years here in Maine. So those components again are driving up premium costs across health insurance markets and different providers and even for employers who are playing claims themselves.
[00:21:15] And the enhanced premium tax credits, I think are a critical part of helping to protect consumers from that trend. But, I would just call it out as an area where I think policymakers either at the federal or the state level who are concerned about affordability in the long term and looking for ways to make healthcare more affordable in a way that’s sustainable really also need to get serious about tackling these underlying costs of care in the long term to change the trajectory of where costs are going.
[00:21:43] Eric Miller: Yeah, that’s, it’s really amazing that pre-COVID, please correct me if I’m wrong, but it seemed like we were seeing a lot of these trends. Then COVID ratcheted up a lot of this where hospital operational costs, federal government was helping provide funds to maintain their operations. And then also the federal government was helping fund more affordable healthcare.
[00:22:07] And so the pullback of both of those seemingly at the same time is leading to a change in the landscape that is interesting to navigate. So these knock-on effects that we’ve been talking about and the lowering of these tax credits and higher premiums on policy holders, is it safe to assume that rates of uninsured and underinsured individuals across the state would increase?
[00:22:31] Jordan Rhodes: I can speak a bit to that ’cause we did look at that in our study. So in our analysis we did not explicitly model out how many individuals will lose health insurance coverage, but the higher tax credits. However, we did use national estimates of coverage losses without these tax credits and we applied these towards Maine. And based on that approach, what we saw was that an additional 13,000 individuals would’ve been uninsured in 2025 had the enhanced tax credits not been in effect.
[00:22:59] We have seen other estimates in the range of, 8,000, 10,000 additional uninsured. So our estimate might be a little bit on the higher end. But I think there’s pretty general consensus that the uninsured rate will go up without these higher tax credits, both in Maine and nationally. So, and then in addition to a higher uninsured rate, we do expect that lower tax credits will lead to a greater number of uninsured individuals. And by that we generally mean individuals who select coverage with greater cost sharing or higher deductibles than they would have selected with the tax credits in effect.
[00:23:34] Again, this is not something that we explicitly modeled. However, we believe that the magnitude of the premium increases will almost certainly impact rates of uninsured and underinsured. Almost any time the price of a good goes up by 60%, there are impacts on the amount purchased or consumed, and health insurance is no exception to that.
[00:23:53] But I can turn it over to Hilary for a bit more discussion on kind of the spillover and knock-on effects into other parts of our economy.
[00:24:00] Hilary Schneider: Yeah. And one of the things I can just say is we’re witnessing some of this in real time right now. I think you said at the top, this is a timely discussion in our open enrollment for plan year 2026, started on November 1st, and it runs through January 15th. And during this time I look at, as did Meg, when she was the former director, looks at the data regularly during open enrollment to see how we’re doing. And we just released on our website on CoverME.gov, our first biweekly snapshot. We released data every two weeks of how open enrollment is going, and we just released the first biweekly snapshot.
[00:24:41] What that snapshot shows you is that we are in fact, seeing declining enrollment and two weeks into an open enrollment period is usually when we’re seeing increases in enrollment. Typically the highest point of enrollment during the year, because our enrollment changes on a minute to minute basis based on people coming in and out of the marketplace.
[00:25:03] But the highest enrollment point is typically right after open enrollment ends on January 15th, and so you have attrition throughout the year as people get access to other types of coverage, especially when we’re filling gaps, becoming eligible for Medicare or other types of coverage. And so during open enrollment, we see our enrollment grow.
[00:25:26] And in the first two weeks we have seen our enrollment decline. And so that’s quite disheartening. But it’s, it just is a testament to the impact of the expiration of the enhanced premium tax credits. And in fact, at this point in time, we have the lowest enrollment that we’ve seen since we started a state-based marketplace.
[00:25:47] And that’s not because the population has declined that needs our coverage. It’s directly attributable to the loss of the enhanced premium tax credits. And we’ve actually had over 2000 consumers cancel coverage for their, for 2026, since the start of open enrollment and nearly, and we ask people the reason why they’re canceling, and nearly 700 of those folks have said they can no longer afford coverage. And that’s a direct testament to this issue. We see cases every day of folks who are going from an annual premium of about $700 a year to they could pay $40,000 a year. And so that’s a dramatic increase and obviously something that people can’t, cannot shoulder and more likely, more common, we’re seeing increases from 1000 to $2,000 a month. Definitely some significant increases.
[00:26:48] The other piece I can say that we’re seeing in real time is people are also, in a sense downgrading their coverage. And while all of our plans are comprehensive, they are classified as different metal levels. And the metal levels are can, are attributable to how much you would pay at a cost. So you the bronze plans have some of the higher deductibles would pay the most out of pocket, but you have a lower monthly cost and then the gold plan, silver and gold plans, the deductibles decrease and your out-of-pocket cost decrease, but your monthly premium increases and we’re seeing a lot of movement between silver to bronze plans.
[00:27:29] A lot of people are moving into bronze plans, and that gives us concerns that there could be people who can’t afford those deductibles who are buying those plans, and then they are in a, in sense, underinsured and then they’re delaying getting care. And that’s a concern to us for, from health outcome standpoint, but also when people show up in, in hospitals or in provider offices needing care and they can’t pay for it, those costs get shifted onto everybody who buys health insurance coverage.
[00:28:00] So there’s pretty big ramifications.
[00:28:05] Eric Miller: Yeah, absolutely. I’m reminded of my own story in my mid-twenties and I enrolled in the marketplace and I am fortunate enough to have, I’m a low healthcare consumer. I do consume it to, for physicals and checkups and stuff, but I went with a catastrophic insurance option because I felt confident that I would not experience something that would be detrimental to my financial situation. But I am very fortunate that I was in that position to feel confident in that choice, whereas I can’t even imagine having a chronic or frequently experiencing healthcare emergencies that would require a lot more interaction with a healthcare system. Do you see where there’s been some discussion about the rural metro and isolated rural context earlier from Jordan, and I’m curious if there have been geographic trends throughout that the marketplace has been open, especially with the implementation of the extended tax credits that your office has noticed, Hilary.
[00:29:07] Hilary Schneider: Yeah, so when we look at enrollment by geography, some of the trends are not surprising, which is that the largest number of consumers we have are in the most populated counties, and that’s just driven by population.
[00:29:22] So the largest number of consumers we have are in Cumberland and York County, and that just because Cumberland and York County have the most people that live in them. But when we do look at enrollment per capita, and our highest per capita enrollment is in Knox County, followed by Lincoln, Hancock and then Cumberland.
[00:29:42] And some of that I think is attributable to the niche that we play in the coverage landscape as I talked about. So, one of the big populations we see is early retirees or somebody who may lose their job in their fifties or early sixties, and we know that unfortunately it can become more difficult to find employment when you get to be that age.
[00:30:04] And so we fill that niche for when people have lost their job-based coverage or when they early retire. And so you look at some of those coastal counties and you see greater percentages of early retirees, but then also those are counties where you see more tourism industry or hospitality industry and people who don’t have access to job-based coverage.
[00:30:26] They’re the people who clean rooms in our lodgings and also these heritage industries like the fishing and lobstering industry where you’re not working for corporations or have job-based coverage. And so that, I think is, those are the trends why we see the greatest per capita. We do see areas where we have opportunity where, we don’t have as much enrollment as we would like in communities that have people who are likely eligible for coverage through us, but for some reason are not coming in.
[00:30:56] And those are in northwest Maine of Oxford, Somerset, and Franklin Counties, but also some of those coastal counties where we do have high per capita enrollment. But we could be doing even better. And I think part of that is that, it’s amazing to me, but I shared with you those sobering statistics earlier, but one of the more promising numbers that we’re seeing right now is we do have new consumers coming in.
[00:31:24] And so right now we have enrolled as of yesterday over 1200 new consumers. And a lot of those people are people who are just finding out about us. They didn’t know about us or they thought that they couldn’t afford it, or they had heard some rumor and they’re coming in now. And so, the good news is that there are lots of areas where we can still be serving folks. And so we work really hard all year, but especially this time of year to get the word out about our coverage and the availability coverage and just encourage people to come in to CoverME.gov and check it out. And you don’t have to set up an account, one of the only places you can go and actually see what your health insurance would cost you without setting up an account. I was on some of the insurers’ websites earlier this week, and often you have to put in all of your kind of contact information before you can even see what the prices would be. So there’s definitely demographic trends and we’re definitely concerned. We’re concerned about, as Jordan had said about the impacts on rural Maine and on our older Mainers.
[00:32:26] The other thing I think is important to point out is that you, that premiums, health insurance premiums vary based on where you live geographically. And so that’s also why we see some of the bigger impacts in rural areas because it also has to do, as Meg said, with underlying healthcare costs. And when you have less competition in areas and you have older populations and populations with higher rates of chronic illness, then you have higher underlying healthcare costs. And then those people in those areas pay more for health insurance. And when you add age onto that, where you also can be charged more, it’s like a double triple whammy.
[00:33:08] Eric Miller: All that intuitively makes so much sense. Especially those three populations that are higher, make up a higher utilization percentage of the marketplace consumers on the coast.
[00:33:20] Jordan, do you have anything to add to the geographic observations that you all made?
[00:33:24] Jordan Rhodes: Think Hilary summarized it really well. So for related analysis, we did look at how the expiration of enhanced tax credits would impact consumers across Maine county. So i n the analysis that I described earlier in our discussion, that was by different tiers of virality. We looked at it by counties. We also looked at it by some household characteristics. The findings from this analysis largely aligned with our study results. So across counties, consumers in more rural counties, including Aroostook County, Washington County, and Franklin County would’ve seen average premium increases of in the range of 70% had the enhanced tax credits not been in effect in 2025, or aligning with the findings from our study households in fishing and lobstering communities, as well as households with older enrollees. So again, enrollees aged 60 and older would’ve experienced steeper increases in monthly premiums without the tax credits.
[00:34:17] So. Again we’ve done a lot of analysis on this. We really wanted to get a sense of how this is gonna impact Maine consumers. We’ve cut the data a number of different ways, and the findings are definitely consistent regardless of what methodology or what geographic stratum we apply to get at the root of this issue.
[00:34:32] Eric Miller: Yeah. And to turn a little bit to hospital operational costs, if these expanded tax credits expire what do we expect to happen to hospital operational costs? I know it’s been in the news quite a bit for the past couple years. Do we expect these costs to resemble pre-COVID-19 levels, or are we in a new territory here?
[00:34:54] Meg Garratt-Reed: It’s a great question. I would say I wouldn’t necessarily expect there to be operational cost impacts from a change like this. I think you noted some of the impacts of COVID earlier on. I think we’ve seen stabilization in some of those trends. For example, a lot of reliance for a while on travel nurses where that was a major kind of cost driver for hospitals.
[00:35:14] And I think health systems and hospitals have been doing work to move away from that model. And I don’t necessarily see that changing. I don’t think that these changes are as sudden or as disruptive to the whole kind of health system delivery system as the pandemic was. That being said, I do think the issue of uninsurance and underinsurance can have some knock-on effects in particular when it comes to hospital operations.
[00:35:36] One thing that comes to mind for me is inappropriate use of emergency departments. Folks who either don’t have insurance or are really concerned about their exposure and out-of-pocket costs might be less likely to seek care early on in kind of some lower cost settings and get on top of a problem and may be holding out, hoping to save money while a problem intensifies and gets worse and may land them in the hospital eventually.
[00:35:59] So that’s one place where I could see impacts. And I’ll just note there, one other important kind of piece of broader context, I think to call out is when we talk about changes in uninsurance resulting from the expiration of these enhanced premium tax credits. Those are also coming at a time when changes in federal policy around Medicaid, we’re expecting impacts to UN insurance from those policy changes as well. That’ll be coming a little bit in the longer term. But essentially there are new laws making it more difficult to get enrolled in Medicaid and to stay enrolled in Medicaid known as MaineCare here in Maine. So hospitals are gonna be facing both of those challenges at once.
[00:36:33] And so the main thing that I’d consider in terms of hospital impacts, I think is probably changes to revenue that they’re going to have to adjust to when seeing more uninsured patients or underinsured patients who may not follow up and pay a bill that they have and needing to adjust to that.
[00:36:48] So I think that’s especially challenging and frustrating from my perspective as someone who’s thinking about affordability and thinking about ways to save money in the health system. But this is a really blunt in instrument to do that, rather than looking at efficiency, for example, and ways that we can make care more efficient or ways that we can adjust payment to get away from a fee for service model and do a better job paying for quality.
[00:37:09] Instead, we’re just removing people based on pretty insignificant sort of administrative or cost concerns in ways that are gonna have variable impacts on hospitals too. So hearing Jordan and Hilary’s analysis, more impacts in rural areas, for example, that might impact rural hospitals much more than larger hospitals in the southern or coastal part of the state. So I think that’s a significant concern and one in our office that we’re keeping an eye on because I think we might expect hospitals to respond to that by turning around and raising prices for commercial health insurance.
[00:37:40] But then we’re in a position where it’s already becoming unaffordable for folks to enroll. And I think it could become a really challenging cycle where, insurance becomes less affordable, less people enroll and it’s really not a trajectory that’s gonna be sustainable or solve problems in the long term.
[00:37:54] So I think that’s gonna be a really important trend to watch for and try to think about how we prepare and respond to that.
[00:38:02] Eric Miller: Yeah. And reading Jordan and Hilary’s paper I came across some notes about, riskier health insurance pool, hospitals navigating reinsurance rates that maybe are less predictable. And so, like the hospital’s risk itself is also increasing. And if people would like to read more about or hospital operational costs in Maine, Jordan actually published a paper in Maine Policy Review last year talking about Medicaid expansion and hospital operational costs. I don’t know if you would like to say a couple words about that, Jordan.
[00:38:34] Jordan Rhodes: Well, this might be a nice plug that we actually have an another study coming out in Maine Policy Review for the special rural edition on the horizon, but it does, I think, connect to both of these issues a lot. So in that study we looked at how coverage rates, access to care, financial barriers, and non-financial barriers to care have changed in Maine since 2018. So in particular from 2018 to 2023, and we found the largest coverage gains in some of the largest utilization gains in more isolated rural areas of the state. That timing overlaps with Medicaid expansion in Maine, which, per the earlier study, we know had a significant impact on reducing uncompensated care costs across Maine hospitals, especially during the pandemic.
[00:39:10] That timing also overlaps directly with the enhanced premium tax credits. And coupled with the analysis that we did in this study, we know that those tax credits had a significant impact in isolated rural areas. So just further evidence of what we’ve seen in recent years in terms of the coverage gains, but also per a lot of Meg’s points, like what’s at risk going forward, if these enhanced tax credits go away.
[00:39:31] If some of the gains in coverage, the Medicaid expansion are undone through some of the provisions that might be introduced in the future or that will be introduced in the future. So definitely a lot of overlap across these studies, but I also think it speaks to the transformational changes in coverage that we’ve seen since 2019, again, through expansion, through the continuous coverage provision and through the enhanced premium tax credits.
[00:39:53] Eric Miller: Fascinating. Thank you so much for your contributions to Maine Policy Review and looking forward to the upcoming piece that will be published in the rural Special Edition. So as we come to a close here, do you all have anything to add to the close of our conversation that we haven’t really discussed quite yet?
[00:40:10] Hilary Schneider: I’ll just put in a plug that if anybody’s listening doesn’t have access to health coverage, they really should check out CoverME.gov and do it now because our deadline for coverage starts January 1st, is December 15th, and then January 15th for February 1st coverage. And as we’ve talked about CoverME.gov is the only place that Mainers can go to get access to federal tax credits, which is what we’re talking about.
[00:40:36] And while there is this enhanced level that is set to expire on December 31st, seven out of 10 of our members still qualify for savings and for some, and for a lot of folks still making coverage the only affordable option is through our marketplace. A couple other comments I’ll say is, I’ve been doing health policy work for a few decades now, and if people think there’s a silver bullet solution, Jordan, Megan, I and everybody else who does this work would have put that forward and made it happen. So if you hear, things that are easy and oh yeah, that’s such an easy solution, it’s probably not the solution and it’s probably not gonna work. And one of the things I can say is that I’ve been reading a lot of comments about how well, this just shows how the Affordable Care Act is not affordable and really everybody that was involved in the Affordable Care Act passing and watching that knew that underlying healthcare costs was not a big piece that was addressed in the Affordable Care Act. The affordable piece was indeed giving people access to tax credits that lowered the cost of health insurance. And there was hope that by covering more people with health coverage, that there would be downstream effects where health coverage would become more affordable. And we did see that for a number of years. But there are other factors that are contributing to why healthcare is expensive and the healthcare system in America, it’s very complicated. So a number of factors go into it, but indeed the, these tax credits are actually proving for why the Affordable Care Act works.
[00:42:23] And one of the things we also see in the marketplace is when you give people, when you make coverage affordable, people buy policies that are better for them. So you have people who have lower incomes who are buying low deductible policies. Policies that are not gonna mean that they have thousands of dollars of debt even being insured because you make those policies accessible. And this is a system that is a sliding scale system that, and the people we cover by definition are mostly working and they’re working hard. And this is giving them an opportunity to level the playing field where they don’t have to work for a large employer but can still get coverage.
[00:43:08] And then the final point I would make is if you’re young and healthy and you think this doesn’t impact you, the mom of two young, healthy boys or younger men, I would say that I often think about the health coverage landscape and the opportunity it gives them, because it’s hard to find a job these days and you can dream big, you can go start your own business, you can go try something out and you can get health coverage through the marketplace. And also you’re only young and healthy for so long and even young and healthy, you can break your elbow skateboarding like my college son did a few weeks ago and end up racking up medical bills, but also, what do you want the healthcare system to look like when you have a health condition or when you’re older or when you’re a pre-retiree? And that’s the concept of health coverage, is that we all pay into a system so that it’s there when we need it.
[00:44:06] Eric Miller: Excellent points to close on.
[00:44:08] Thank you so much you all for being here today. We really appreciate you coming on the podcast to discuss something that affects so many people and is as complicated as health insurance is. I think that you all presented in such a way that is more digestible. So really appreciate that and for taking the time.
[00:44:29] If you enjoyed this episode and the previous discussions we’ve had on this podcast, please consider donating to the Maine Policy Review by visiting the journal’s website linked in the description. Our team includes Barbara Harrity and Joyce Rumery, co-editors of Maine Policy Review, and Jonathan Rubin, director of the Policy Center.
[00:44:46] Special thanks to professional writing consultant Kathryn Swacha, technical writer Nicole LeBlanc, and podcast producer, editor, and writer Jayson Heim. Our podcast music is composed by Nathanael Batson. Visit MCSlibrary.org to learn about Margaret Chase Smith, the library, and our work in public policy and education.
[00:45:07] Find episode materials, the full transcript and resources in the description of this episode, and on the Maine Policy Matters website. Share your topic ideas via the form on our website and follow us on Facebook, LinkedIn, and Instagram. You can find all of our episodes wherever you find your podcast. And thank you for listening.