By Nicole Rodriguez-Robbins

Maine is a largely rural state where the major industries, fishing and logging are made up of a largely seasonal workforce. Maine was the only New England state to reject Medicaid expansion, and as result, an estimated 38,000 were excluded from Medicaid. [1] Rather than extending coverage, the Governor opted instead to shrink the state’s MaineCare program, and implement a federally-facilitated insurance marketplace.  Maine had a historically generous Medicaid program but under Governor Paul LePage seniors, the disabled, low-income parents and childless adults were dropped from coverage. In 2014, Maine Primary Care Association (MPCA), the statewide non-profit membership organization for Maine’s community health centers, received an Outreach and Enrollment grant from the RCHN Community Health Foundation to develop a comprehensive strategy focused on helping member centers enroll uninsured Maine residents in the ACA healthcare exchanges and MaineCare.  The PCA worked closely with 18 member centers to leverage Maine’s outreach network, develop highly trained staff and test new strategies and messages to improve health insurance literacy and get people enrolled and in care.

Minnie Elliott is a Certified Application Counselor at Health Access Network (HAN), which provides comprehensive primary medical, dental and behavioral health services to the rural communities of Lincoln, Millinocket, West Enfield, Lee and Medway.  The communities were previously home to a booming paper mill industry.  Over the past several years many of these paper mills have closed, leaving a large workforce without jobs. The recent closure of two paper mills, Great Northern Paper Mill and Lincoln Paper Mill in the past year, has dramatically affected the community served by the health center. Each closure means hundreds of layoffs.   While it’s not unusual for rural resident to  drive over 40 miles to a job, the high cost of gas often  means work is literally out of reach, since low-wage jobs  barely pay enough to  justify the commuting costs. . Many local residents are among the estimated 24,000 Mainers who fall into the coverage gap[2], that is, they earn too much to qualify for Medicaid, but below the lower limit for Marketplace premium tax credits. Minnie reported seeing many such families in her work. For them, the desire for insurance must be weighed against the cost of food and heating their homes in the winter.  Day-to-day necessities – food, heating, school clothes for the kids – often win out, even with the potential of a tax penalty.

Sue Mahar is a certified application counselor at St. Croix Regional Health Center in Princeton, Maine where she serves communities throughout the Washington County region. Located in the eastern-most section of the U.S., it closely borders New Brunswick, Canada and is one of Maine’s poorest counties.  Sue is a native of the area and described her personal passion for her work in the community. She formerly worked at a pharmacy where she witnessed firsthand the unmet needs of customers who came to the pharmacy unable to afford the cost of their medications.  Her manager would tell her “do not let anyone leave here with nothing.”  She learned how to navigate the system to help people apply for financial assistance, get samples from their primary care doctor or a cheaper, generic brand of a medication. She brought this passion and knowledge to her current position as an enrollment assister this past year.  A few cases illustrate her work and its many challenges. One woman in her early 60’s worked as a beautician and had lived without insurance for the past 40 years.  She couldn’t afford insurance premiums until she enrolled through the marketplace last year.  Ms. Mahar later ran into her in town and the woman recounted how she had been so sick with bronchitis that she was hospitalized.  She felt incredibly fortunate to have been insured at the time.  “I don’t know what I would have done if I didn’t have the health insurance” she told Sue, and thanked her for her help.  It is those individuals who inspire Ms. Mahar’s enrollment work amidst the complications brought on by glitches with the enrollment website, and often difficult driving conditions to the outreach sites in the winter on rural roads.  While there were many success stories, there were many more examples of those who couldn’t enroll because they didn’t meet the income level requirement to qualify for the tax credits for marketplace insurance. There are strict guidelines to qualify for Medicaid coverage in the state of Maine, making it especially difficult for those who fall below the Federal Poverty Guidelines and yet do not qualify for coverage or tax relief. Sue shares resources and helps her clients apply for the sliding fee at the FQHC and free care at local hospitals.  She reported that those she helped enroll were incredibly satisfied with their insurance and grateful for her help.

Rita Haskins works at Fish River Rural Health, the northern-most health center in Maine.  She works in the St. Johns Valley area, where much of the population is French speaking of Acadian descent. Many of the residents are middle-aged and primarily French speaking. Ms. Haskins described their primary language as “Franglais,” a Canadian French dialect with both English and Native American words mixed into the vocabulary.  Rita is a native speaker and the majority of those she enrolled preferred to speak Franglais. While the health center has developed an outreach campaign, in the intimate and informal culture of the town, many enrollment contacts are made through word of mouth.   People call Rita at St. Croix after another friend or family member has enrolled in the marketplace with her help.  In some cases, Rita makes home visits to the elderly or those who live far away and don’t have transportation to the town center. A lot of handholding is necessary in order to inform people about how the health care coverage system works.  Rita has to explain the difference between premiums, deductibles, and co-pays. She reported that some people feel most comfortable at their kitchen table, sharing one-on-one their questions and concerns and having her walk them through the application process.   A good number of older residents are illiterate and Rita is very sensitive to these applicant’s needs.  She shows patients the insignias of each insurance company so that they will be able to identify important insurance forms they receive in the mail.  Rita instructs them to call her when they get one in the mail and she will return to read the forms to them and help them fill out necessary paperwork.  The first enrollment step is often only the beginning of her relationship with applicants.

The Maine PCA’s s Outreach and Enrollment campaign is targeted at the state’s vulnerable uninsured. The campaign slogan, “Who’s Counting on You To Stay Healthy” aims to speak to the experiences and concerns of many Mainers.  Through research and focus groups, MPCA determined that being uninsured and the potential burden of medical debt was less of a concern for many CHC patients than was the potential immediate loss of income and job security if they got sick and had to miss work.  This knowledge inspired a campaign that focuses on the importance for individuals to stay healthy for their families who depend on their financial support. Jeb Murphy, MPCA’s Director of Communications and Data Collection, explained that many Mainers come from tight-knit communities where extended families and aging parents rely on their adult children for their care.  Neighbors rely on each other for information and many learned about the ACA through another trusted member of their community before they sought out assistance from a Certified Application Counselor.  To best reach these individuals,  MPCA took a grassroots approached by posting ads in local newspapers announcing the “Who’s Counting On You to Stay Healthy Campaign” along with a photo of the local Certified Application Counselor with their name and contact information.  The posters and brochures they distributed featured photos of workers in the local industry typical of each region.  For coastal areas, the outreach image is of a local lobsterman.  In central Maine, they used photos of a working logger, carpenter and waitress along with their family.  The idea is that Mainers can identify with the campaigns message and that the image will resonate with their own experience.

The Application Counselors I interviewed in many ways serve a broader role in their communities beyond enrolling individuals for healthcare coverage. Each of them has strong existing ties to the communities they are working in.  They understand firsthand the economic hardship that local Mainers struggle with.  They also understand the unique culture of these tight-knit communities where language and education are barriers to accessing insurance and other services.  In order to be successful they must establish trust among residents in small rural communities.  These application counselors provide an important bridge to services for those individuals whose needs go beyond just filling out an insurance application.  They go out of their way to identify resources and services for those who don’t quality and can’t afford the insurance but still need access to care.  Their strength lies in their existing connections to the communities they work in.  They are from the communities and understand the cultural and economic needs of the individuals they serve.  Thus, even in the constrained environment where Medicaid expansion has been thwarted, they are able to provide important support, and get Mainers into coverage and into care.