A little over a year ago, things weren’t going very well for the Affordable Care Act.

For some Mainers, “hellish” might have been the right word.

The website for the federal insurance marketplace kept failing. Phone lines jammed for the popular new health insurance co-op in Lewiston. Overall, it took people longer to sign up for health insurance than it did to fly cross-country, and the process was about as frustrating.

And those were the lucky ones. Many very poor Mainers couldn’t get insurance, period.

All from health care reform that no one completely understood.

Since then, a lot has changed. And a lot has stayed the same.

More than 40,000 Mainers have gotten insurance through the marketplace, 90 percent of them with a federal subsidy to help pay for it. But the very poorest still don’t have insurance.

Hospitals, doctors and others in health care are changing the way they do business, focusing more on cost, quality and keeping people healthy. At the same time, hospitals and clinics still are having trouble paying for growing demands on charity care.

Insurance sign-ups are quicker, easier, less frustrating (Woo!). But people are still confused (Groan.).

That’s where we come in.

Last year, the Sun Journal and the Bangor Daily News joined forces to bring you ACA 101, a big look at the big law. There were tips. There were resources. There were examples featuring the characters of “Grey’s Anatomy.” (Because that’s just how we roll, yo.)

This year we bring you ACA 201, a look at how Maine has fared in the year since health insurance became mandatory for most Americans and a gander at what Mainers can expect in Year Two and beyond.

Also, more tips. More resources. And some profiles of real Mainers dealing with real insurance issues. Sorry, “Grey’s.”

First up: What’s changed. What’s not. What’s love got to do with it.

Well, that’s new

The Patient Protection and Affordable Care Act — known as the ACA or “Obamacare” — was signed by President Barack Obama in 2010. It was controversial then and is controversial now.

The law phased in sizable changes to health care, including requiring insurers to provide some preventative care for free and prohibiting them from placing lifetime caps on insurance coverage (2010), requiring insurers to spend at least 80 percent of premium dollars on medical claims rather than overhead such as office space and the corporate jet (2011), requiring that consumers be given easy-to-understand summaries about a health plan’s benefits and coverage (2012), and creating health insurance marketplaces, also known as exchanges, where people can buy their own insurance and use federal subsidies to help pay for it (2013).

One of the biggest changes came in 2014. That’s when most Americans were required to have health insurance.

Each state, plus Washington, D.C., handled the ACA a little differently. For 2014, according to the Kaiser Family Foundation, 17 created their own marketplaces while 34 relied on the federal marketplace or a federal-state partnership.

By the end of this past August, 28 states, including D.C., had expanded Medicaid to cover very poor people who wouldn’t get a federal subsidy under the program, while two states were discussing expansion. Twenty-one states didn’t expand.

Maine went with the federal marketplace and didn’t expand Medicaid.

A year or so ago, more Mainers started buying their own insurance. A lot more. Between 2013 and 2014, the number of Mainers covered by an individual insurance plan — rather than insurance from work or through the government — doubled, from about 32,000 to about 64,000.

Despite the challenges signing up this past year — the federal marketplace website all but imploded at one point — the marketplace proved a popular way for Mainers to buy that insurance, often at the urging of health care advocacy groups. Or friends.

“I think it was the folks in either Eastport or Harrington, working with the lobstering community, they were getting a lot of push back by people that didn’t like Obamacare. They finally got one of the community lead lobstermen, convinced him to sign up. And boy, when he signed up, it was just like the tipping point,” Wendy Wolf, CEO of the Maine Health Access Foundation, said. “All of a sudden people there were willing to try it because he was a trusted voice in the community.”

More than 40,000 Mainers signed up for insurance through the marketplace. The vast majority — 90 percent — got a subsidy to help pay for it.

The average subsidy: $344 a month. Average insurance cost after that subsidy: $99 a month.

“We have heard from assisters of people literally breaking into tears when they sign up and find out they have a $20-a-month premium, because for 20 years they haven’t been able to afford insurance,” Wolf said.

And many seemed to be using the insurance.

“We noticed, anecdotally in the clinic here, people showing up, saying, ‘I’ve got that new insurance and I want to get caught up (with medical care) now,’” said Mike Murnik, medical director for the Blue Hill Memorial Hospital Family Medicine Practices in Blue Hill.

Also for the first time, Mainers had a new choice for insurance: a co-op. And for the first time in a long time, the majority didn’t choose Anthem Blue Cross and Blue Shield.

Eight out of 10 Mainers who signed up for insurance through the marketplace bought a plan from Maine Community Health Options, the new co-op based in Lewiston. And 57 percent of all individual health plans in Maine, whether they were sold on or off the marketplace, went to MCHO.

The ACA did more than change insurance. With a mix of grants and penalties, it also encouraged changes in health care.

In Maine that has meant doctors, hospitals and insurers focusing more on cost, quality of care and keeping people healthy — and out of the hospital.

Mainers were more likely this past year to have their medical care overseen by a team — doctor, nurse, social worker, counselor and others — rather than a single doctor alone. Community doctors and hospitals were more likely to communicate about a shared patient, an effort to coordinate care and cut down on the number of people who ended up back in the hospital because no one was keeping tabs on them after their brain surgery or broken leg or heart attack.

Doctors also were more likely this past year to junk the old “fee-for-service” way of medicine in favor of “value-based” programs. Old way: The insurance company pays the doctor as you go, if you go. New way: Doctors and hospitals contract with insurance companies for a set amount of money to keep you healthy.

If they do a good job — you’re happy and healthier and costs are down — doctors get to keep some of that savings. If they don’t do a good job — say, a diabetic patient ends up in the hospital more this year because the doctor hasn’t been monitoring the patient well — the doctor and the hospital end up eating the extra expense.

It can be a good incentive for doctors that gets better care for patients.

“We’re concerned not only with what happens within the walls of a practice or hospital, but if somebody goes to a nursing home, somebody’s in home health, that whole gamut. You’re interested in what’s happening to the patient across the whole spectrum,” said Mike Donahue, vice president for network development and accountable care organization activity at Eastern Maine Healthcare Systems and its Beacon Health.

Beacon Health, a group started by EMHS and including more than a dozen hospitals statewide — including Central Maine Healthcare’s hospitals — started doing value-based contracts in 2012. About 12,000 patients were involved then. Today, 100,000 are involved. The number is expected to keep growing in 2015.

It hasn’t been an instant success. EMHS was hit with a $3 million penalty from the federal government in 2013 for failing to save enough money on Medicare patients.

But patients give the program high marks. And the new pay way seems to be working in other ways. Or at least helping.

At EMHS, readmission rates — the percentage of people who end up back in the hospital after they just got out — dropped from 11.5 percent in the first few months of 2012 to 1.7 percent in the first few months of 2014.

“We’ve gotten a lot of testimonials from patients that, ‘Without this program I was going to the (emergency department) 15 times a year,’” Donahue said. “Patients have said, ‘This really changed the quality of my life.’”

Same old, same old

But not everything has changed.

Although more than 44,000 people in Maine have signed up for insurance through the marketplace and the number of Mainers covered by individual policies has doubled, it’s unclear whether Maine actually has more insured people. And if it does, whether it has a lot more or just a few.

That’s because the state didn’t expand its Medicaid program, MaineCare, to cover people living below the poverty line. Experts say those people — who, if they’re living alone, made less than $11,450 this past year — can’t get federal health insurance subsidies and probably can’t afford to spend $300 a month or so to buy insurance on their own. So they likely weren’t added to the insured column.

Also, the state tightened MaineCare eligibility in recent years. And in January, it started cutting 22,000 Mainers from the insurance program altogether. Experts say those people probably can’t afford to buy insurance on their own either.

But Gov. Paul LePage, who strongly supported tightening MaineCare eligibility and not expanding MaineCare, has said the ACA itself may have caused an increase in the uninsured.

“Although the employer mandate was delayed until after the election, there have been many stories about adjustments companies are making to avoid costly mandates or penalties. These changes could have affected the 60 percent of Mainers receiving insurance through their employer,” LePage spokeswoman Adrienne Bennett said in September. “We also know that more than 10,000 private health insurance plans in Maine were canceled because of Obamacare mandates.”

Earlier this year, the U.S. Census said Maine was one of only two states to see more uninsured people between 2012 and 2013, before the ACA’s insurance mandate kicked in. A Gallup poll, however, found that between 2013 and the first half of 2014, the number of uninsured Mainers dropped, from about 16 percent to about 13 percent.

So where does Maine stand now, a year after the ACA’s insurance mandate kicked in?

Experts say 2014 Census data will be the best way to gauge, but those numbers won’t be out until next September. They predict fewer uninsured people, but not the kind of drop other states have seen.

They point to a July report from the Washington, D.C.-based Urban Institute that said the uninsured rate has dropped 37.7 percent in states that expanded Medicaid and 9 percent in the states that didn’t.

Another aspect of health care in Maine that hasn’t changed since the ACA: patient debt and hospital charity care for people without insurance.

Both continue to climb.

“We saw people roll off insurance that were Medicaid (recipients) and not see a big increase in enrollees,” said Joe Wood, who deals with finances at St. Mary’s Regional Medical Center in Lewiston. “What it’s meant to us is a struggle financially this year.”

For the first 10 months of 2013, St. Mary’s spent $18.9 million on charity care and bad debt. For the same period in 2014, it spent about $20.6 million, an increase of $1.7 million, or about 9 percent.

It has been a problem at Central Maine Healthcare, too, where bad debt and charity care are up $5 million from 2013 to 2014, a 10 percent increase.

At MaineHealth, the state’s largest health care organization, 2014 figures aren’t available yet. But based on what its hospitals have seen, “We don’t anticipate that it’s going to go down, I can say that,” said Katie Fullam Harris, MaineHealth’s senior vice president for government relations.

Also unchanged for some Mainers: uncertainty.

Will the state expand MaineCare, find some alternative that helps insure very poor people or keep the status quo? How will businesses respond when they’re required to offer health insurance — or pay the penalty — starting in 2015? Will the U.S. Supreme Court kill the whole ACA thing next summer by nixing subsidies in states that use the federal marketplace — including Maine?

Only time will tell.

“People are just waiting for the next shoe to drop,” said Patrick Marvin, policy analyst for the Maine Heritage Policy Center.

Love and hate

Four-plus years after it was signed and a year after the insurance mandate kicked in, people tend to both love and hate the law.

Love the subsidies, hate being forced to buy insurance. Love that insurance companies must cover people with pre-existing conditions, hate that their old high-deductible, limited insurance plan wasn’t acceptable under the law. Love that shots, cancer screenings and other preventative care is free, hate that it’s free only to people who have insurance.

Or they love it/hate it simply depending on the name.

“If you ask somebody if they like Obamacare they may say no. And if you ask somebody what they think of the ACA, they’ll have a positive opinion of it,” said Ray Hurd, a regional administrator for the Centers for Medicare and Medicaid Services.

It doesn’t help that the 900-plus-page law, and all the stuff that goes with it, is so confusing.

“I think we generate our own confusion. The Affordable Care Act is so complex with everything it covers that it’s hard to really understand all the pieces,” Hurd said.

Insurers have tried to help some. Anthem this year added more popular plan options, simplified its co-pay structure and tweaked plan names to put deductible and co-insurance information right up front so the names are easier to understand. It’s too soon to tell whether the new names will clear up a lot of confusion, though, since plan names have gone from “Anthem Silver Guided Access with HSA” to “Anthem Silver X HMO 3500/20.” (Anthem officials say people like the change so far.)

In general, advocacy groups, hospitals and others, including insurance companies, have focused on getting people to understand one basic piece: You need insurance. A media blitz this fall — Internet, radio, TV and print — urged Mainers to look at their insurance options and subsidy possibilities.

They say the effort has helped. So has old-fashioned word-of-mouth. They’re seeing more interest, particularly in the Lewiston-Auburn area, where sign-ups were sluggish a year ago.

But still.

“Most people are still unaware of the marketplace and really unaware of the fact that they can get financial assistance that can make health insurance affordable,” said Wolf at the Maine Health Access Foundation. “We have seen that over and over and over again, both nationally and here in Maine.”

They’re also unaware that come tax time this spring, there’s a penalty for not having had insurance in 2014. And it’s not nothing. Although $95 has been the figure most touted, it’s actually $95 per adult (and $47.50 per child) or 1 percent of household income for the year, whichever is greater. Note the “whichever is greater” part.

That penalty goes up significantly next year. And again the year after that.

Love it or hate it, you still have to deal with it.

Those who have used the marketplace say it’s working better now. Signups are taking an hour or an hour and a half compared with five or six hours or more. Renewals are taking just 30 minutes or so.

At least, experts say, those people who want to shop for insurance on the marketplace can.

“Thank God healthcare.gov is really working pretty smoothly,” Wolf said. “They’ve all said it’s just like night and day compared to last year.”