About seven million people signed up for insurance last year through the Affordable Care Act. But there were two to four million more who were essentially locked out due to something called the "family glitch."
It happens when a spouse gets affordable coverage through work, but it's not extended to family members. Those family members also become ineligible for subsidies. The result is that some moderate- to low-income Mainers continue to struggle for access to health care.
If anyone was anticipating signing up for health care coverage last year, it was Kami, a stay-at-home mom in Washington County, who doesn't want her last name used. Her husband is a store manager. And while he has health insurance through his employer, to add Kami, it would cost more than twice as much. "Because what it would be for him and I would be approximately 30 percent of his income," she says.
But Kami needs coverage. She's considered high risk for breast cancer. She has anxiety and depression. So, she eagerly looked forward to enrolling through the ACA's online marketplace. "So one of the questions is, 'Does your employer provide affordable heath care?' I had checked, 'No,' Because looking at what my husband's employer offers, we couldn't afford it," she says.
But it turns out that her husband's insurance is considered affordable because it costs less than 9.5 percent of his income. And under the ACA, if insurance is affordable for one family member, it's deemed affordable for all family members. That means Kami didn't qualify for subsidies to buy coverage for herself. She fell into the family glitch. "To find out we don't qualify, I'm like, 'OK - now what do I do?' It was stressful. It's stressful."
"It's not something we think was intended when the law was drafted and passed," says Mitchell Stein, an independent health policy consultant in the Portland area. "But if you recall, the way the law was passed, there was no kind of clean up of the bill. There was no conference committee. Because of the politics at the time, it was passed as is."
And now an estimated two to four million people fall into the family glitch, including Tia Knapp. She's a certified marketplace assister at a health center in western Maine. As an individual, she says she has affordable health coverage through her employer. "What I do have as single parent is a college-bound gal, who is required to have insurance in order to complete her enrollment," she says.
Adding her daughter to her employer-based health plan is not affordable, so neither is the marketplace. For the past two years, Knapp has taken out a loan of about $1,800 to buy a major medical plan offered through her daughter's college. It only covers her daughter while she's in school. "So, we did the best we could do with our budget to make it affordable. But the thing that gets me is she's not covered all year."
It's a problem that Deb Shields, an application counselor at Eastport Health Center, says she wrestles with on a regular basis. "I think it's the one thing all of us assisters really fight with every day - is how the heck are we gonna help these families?" she says. "The thing is, they rarely qualify for a sliding fee at our health centers. That's supposed to be the stop gap - to help people falling through the cracks."
Kami - the mom from Washington County - says at least her kids get coverage through MaineCare. Finding care for herself is a struggle. "We'd be willing to pay more than whatever minimum - but we just cannot afford $600 to $700 a month. It is impossible."
Mitchell Stein says one stop gap that does soften the blow of the family glitch help is CHIP - the Children's Health Insurance Program. But that funding expires next September, unless Congress extends it.
As for the glitch itself, Stein says it will take an act of Congress to fix it. Democratic Sen. Al Franken, of Minnesota, introduced a bill in June to do just that. But the chance of it passing, says Stein, is anybody's guess.