Hildegard Tenney has lived nearly all her life without health insurance. A meat cutter at a supermarket in Washington County, 51-year-old Tenney could never afford coverage, so she visited the doctor only as a last resort, when she could scrape up enough cash to pay out of pocket for the visit.

“There were times where I probably should have gone to the doctor’s, but I didn’t have the money,” she said.

She signed up for MaineCare while she was pregnant with her children but later dropped the coverage for herself. Tenney of Jonesboro believes she’d still qualify for the health insurance program for low-income Mainers, but she considers herself a proud person who can make do on her own.

“I make enough money to survive,” she said. “I don’t want to take anything away from anybody else that needs it.”

Until recently, Tenney was among the 13 percent of Washington County residents who lacked health insurance, one of the highest rates in the state. She just received her insurance card for the new plan she selected under the Affordable Care Act.

Tenney joins the ranks of the roughly 44,000 Mainers who signed up for private coverage under the federal health reform law. About 80 percent of them chose a plan offered by Maine Community Health Options, a startup insurer based in Lewiston that captured most of the market, despite competition from the exponentially larger and well-established Anthem Blue Cross and Blue Shield.

New county-by-county data released by MCHO reveals the member-run insurer made inroads in rural Maine, where outreach efforts prove more challenging but necessary to reach significant populations of uninsured residents.

MCHO enrolled 1,147 people in Washington County — not nearly as many as in populous counties such as Cumberland and York, but the number represents nearly 4 percent of the population. In neighboring Hancock County, which has the highest uninsured rate at 15 percent, MCHO enrolled 5.3 percent of the population. Knox County represented the insurer’s largest share at 5.6 percent.

“It’s nice to see both strength in numbers where we expected them but then also a strong showing in less populated counties,” said Kevin Lewis, CEO of MCHO.

Anthem hasn’t released county-level enrollment data.

During the open enrollment period, which began in October 2013 and officially wrapped up March 31, MCHO signed up 35,608 Maine residents through Healthcare.gov. Another 3,700 signed up for one of its plans another way, such as through an insurance broker or directly with the company.

About a quarter of MCHO’s enrollees earn between the federal poverty level and 1.5 times that amount, or between $23,500 and $35,325 annually for a family of four. Insurers know which consumers fall within that income bracket, because those individuals qualify for financial help to cover some of their out-of-pocket costs.

Some of those consumers may have opted to enroll in MaineCare, if the state expanded the program under the health reform law. Precisely how many remains unclear, but the topic has sparked plenty of debate in Augusta.

Republicans argue low-income Mainers, who would have qualified for expanded MaineCare, can sign up instead for private coverage through Healthcare.gov, saving the state money. Democrats contend that tens of thousands of residents who don’t qualify for subsidies through the health insurance marketplace can’t afford that, robbing them of coverage.

An expansion to MaineCare, the state’s name for the federally subsidized Medicaid program, would have covered residents who earn up to 138 percent of the poverty level, or $32,500 for a family of four. But the federal government hasn’t released detailed income breakdowns on enrollees — to the public or to insurers — making it tough to pin down how many new MCHO and Anthem customers would have qualified for expanded MaineCare.

Mitchell Stein, a Cumberland health policy consultant, pegs the figure between 8,000 and 10,000, based on new county figures released by MCHO. That’s a rough “back of the envelope” estimate that assumes incomes are evenly distributed within the 100 to 150 percent of poverty band, he said.

Still, a significant number of Mainers living in the poorest parts of the state now have health coverage through MCHO, Stein said. While enrolling 4 or 5 percent of the population might sound modest, the potential pool was limited to begin with, he said. Most Mainers had health insurance through work or public programs and didn’t need to change their coverage. Healthcare.gov was geared toward the relatively small proportion of Mainers who buy their own insurance, such as the self-employed.

“One of the myths of the ACA was that everyone was going into some government-controlled program,” Stein said. “Much the opposite, the ACA was meant to work within the existing system. For many people the existing system is working.”

Some of MCHO’s new customers may have had insurance previously through another carrier, Stein noted.

Several factors likely play into MCHO’s success enrolling rural Mainers, including the political leanings and quality of outreach in each region, he said.

“Maine’s outreach as a whole was very successful, compared to some of the other states,” Stein said.

Susie Beal, an outreach coordinator at the Harrington Family Health Center who helped Tenney to enroll, said she did her best to keep politics out of her discussions with local residents. While the Affordable Care Act often touches a nerve — particularly its requirement that most Americans sign up for health insurance or pay a penalty — she focused on walking people through their health insurance options and helping them sort through misinformation, she said.

“They were very passionate about their beliefs, and I respect that,” Beal said. “But this is the law. In order to be compliant with the law, this is what we had to do.”

Beal spent the last six months traveling throughout Washington and Hancock counties, hosting presentations in town offices, libraries, small businesses and elsewhere. She personally helped more than 350 people enroll in health coverage, from an elderly woman with diabetes who “couldn’t stop hugging me” to a well-known lobsterman she recruited to spread the word among his friends.

Like Tenney, about 300 of those enrollees had no insurance, and all qualified for financial subsidies to help make their coverage more affordable, Beal said.

“Most of the time, people’s primary concern first was how much was it going to cost,” she said.

Tenney enrolled in a plan that costs her $88.46 a month, with a $10 co-pay for doctor visits. She’s planning to schedule her first checkup in years.

“I always skipped them,” she said. “Given my age, I probably shouldn’t be skipping them anymore.”

Jackie Farwell

I'm the health editor for the Bangor Daily News, a Bangor native, a UMaine grad, and a weekend crossword warrior. I never get sick of writing about Maine people, geeking out over health care data, and...