According to U.S. Census Bureau data released last week, Maine is the only state in the nation where the number of uninsured children has increased significantly since 2010.
It comes during a time when there are more insurance options available than ever under the Affordable Care Act. Advocates have identified possible reasons behind the rise, and what changes they say would increase kids' access to health care.
In 2010, 4 percent of Maine kids were uninsured. By 2014, that number climbed to more than 6 percent. That's an increase of 5,000 kids, for a grand total of about 16,000 uninsured, says Garrett Martin, executive director of the Maine Center for Economic Policy, which evaluated the census data.
"We've gone from being one of the best states in the country, and being significantly below the national level of children below without insurance, to now having higher levels of kids without insurance," he says.
It's a change that pediatrician Deborah Hagler, medical director of Martin's Point Pediatrics in Brunswick, says she has been witnessing as more and more of the practice's patients are self-pay. Many of the children, she says, have complex health issues.
"The families in this situation — there's no insurance and physicians are recommending studies or tests that they can't afford," she says. "The stress on the parent, it's tremendous."
The increase in uninsured children coincides with the passage of the Affordable Care Act, under which families presumably have more options to get health coverage. So, why is this happening in Maine?
"Nobody knows the exact answer to that question," Martin says. "But I think there is very clear and credible evidence that shows that when parents lose access to health insurance, that it is less likely that their children get insurance as well."
Both the Kaiser Family Foundation and the Health Policy Institute at Georgetown University have published reports that find when parents are insured, children have better access to care. But in Maine, more than 28,000 parents have lost MaineCare coverage since 2012 due to changes in eligibility requirements that eliminated coverage for those who earn between 100 percent and 200 percent of the federal poverty level.
Claire Berkowitz of the Maine Children's Alliance says kids in those families are actually still eligible for coverage.
"But if parents at that income level aren't eligible, there can be confusion especially at the time the parent is told they're no longer eligible for insurance," she says. "And the communications may not be as clear about, 'but don't worry, your kids are still eligible.' It's not a very clear process."
"On our helpline, we frequently hear from families who don't have health coverage," says Emily Brostek, executive director of the advocacy group Consumers for Affordable Health Care. "And either don't know that MaineCare might be an option for their kids, or have applied and have been told they're ineligible when they actually are. So there are a lot of issues with families trying to get coverage through that system not getting the care they actually qualify for."
She says Maine's Department of Health and Human Services needs to do a better job communicating with families to let them know their children may be eligible for MaineCare.
A spokesman at DHHS declined to comment for this story.
Beyond better communication, Robyn Merrill of Maine Equal Justice Partners says the state would substantially increase health coverage by expanding Medicaid under the Affordable Care Act.
"There's federal money that's available." she says. "We're just not taking the funds there to provide insurance, and create jobs, and bring in money to the state that we so desperately need."
The federal government covers 100 percent of the cost to expand Medicaid through 2016, then lowers to 90 percent of the cost by 2020. Gov. Paul LePage has vetoed several bills that would have expanded Medicaid because he says Maine can't afford it.
Hagler says she sees families that can't afford care and ultimately take their kids to hospital emergency rooms.
"Sometimes that's their entry into getting help, but by that point the problem has either progressed to a point of severity that it didn't need to, or potentially the problem is so severe that the consequences of the problem may not be manageable in an easy way," she says.
Hagler says her office is now asking a staff social worker who normally helps patients with behavioral issues to also help families find insurance coverage. But navigating what she says is a piecemeal system can be challenging in a typical office visit.