Gov. Janet Mills speaks at a news conference in the State House, Wednesday, Feb. 6, 2019, in Augusta, Maine. Mills is accompanied by officials including Department of Health and Human Services Commissioner Jeanne Lambrew at right. Lambrew’s department is enrolling Mainers in Medicaid expansion at a slower-than-expected rate, with advocates counting access and a lack of education among the biggest barriers to signing people up. Credit: Robert F. Bukaty | AP

AUGUSTA, Maine — It has been nearly a year since Maine expanded Medicaid under the Affordable Care Act, with enrollment on track to fall below projections once the mark is reached in early 2020.

Nearly 43,000 people were enrolled in MaineCare expansion earlier this month after Gov. Janet Mills, a Democrat, opened the voter-approved program in January. That’s just 60 percent of the population that the state expected to be covered by the end of this year.

People who work with MaineCare-eligible populations say access and a lack of education are among the biggest barriers to signing people up. A provision in federal Medicaid rules may be causing older people to stay away. Health officials say they’re closer to their goal than the numbers reflect but acknowledged barriers still exist.

Health officials say the number of people currently enrolled does not reflect everyone MaineCare has covered this year. Jeanne Lambrew, the commissioner of Maine’s Department of Health and Human Services, said about 55,000 people have been covered by MaineCare’s expansion at some point this year but some have left for one reason or another.

In November, Lambrew told the Legislature’s joint appropriations and financial affairs committee that those numbers do not account for the lag time between when someone is covered and when they are approved, and that enrollee estimates — which Lambrew estimated would be 70,000 by December, according to the Associated Press — included reaching people who were previously eligible but did not sign up. A Manatt Health study earlier this year projected Maine would have 50,000 enrollees a year into expansion.

Lambrew said she feels good about where the state is on expansion and that it may be closer to its goal than it realizes. She said her department has seen 60 percent more applications for MaineCare during open enrollment than last year as of last week, a factor she attributed in part to a state campaign to raise awareness around coverage options.

Barriers such as education, access and wait times may be preventing people from getting coverage. Mary Schneckenburger, an education and outreach manager for Consumers for Affordable Health Care, said their hotline gets back 40 calls a day on a range of insurance-related issues.

When it comes to MaineCare, those issues can be as simple as not knowing how to sign up or whether they’re eligible. Many learn they could be covered under MaineCare when they try to sign up for coverage on the Affordable Care Act exchange, Schneckenburger said. Other times, misunderstandings about coverage occur — like a woman who thought she had MaineCare after getting a letter from DHHS explaining medical privacy rights.

System problems can also be a challenge, Schneckenburger said. People sometimes get incorrectly denied and don’t know it, or face hourslong waits when trying to connect with a state eligibility assistant. When that happens, people often give up, she said. Ann Woloson, the executive director for Consumers for Affordable Health Care, said rural access issues, such as not having internet or a telephone, could also be prohibiting people from signing up.

Lambrew said her department faced many systematic problems earlier this year and has worked to improve its application processing and wait times, pointing to the call center DHHS opened in Wilton. She said application processing had reached a “record high” before the department started its advertising campaign around ACA open enrollment — which started Nov. 1 and ends Sunday — and MaineCare in early October, which has led to an influx of MaineCare applications.

“We appreciate that sometimes people have to wait a long time, and we are always trying to see what are the next improvements we can make to improve our customer service,” she said.

A federal requirement may be causing older residents to shy away from MaineCare. Elderly populations were projected to make up almost 50 percent of the MaineCare expansion’s population by the Muskie School of Public Service at the University of Southern Maine, but the age group continues to lag behind young enrollees, DHHS data shows.

Providers who work with enrollment say that may be due to the state’s estate recovery program, which states are required to have in order to receive federal Medicaid dollars. The process allows states to seek reimbursement for Medicaid benefits from the estate after a person who received Medicaid benefits after age 55 dies.

There are several rules governing recovery, including that the state has to wait until the person who received benefits no longer has a spouse or any children under the age of 21 or who is blind or disabled. Things like “reasonable” funeral expenses and attorneys’ fees are not subject to recovery. There are also hardship and caregiver waivers.

Mickayla Gammon, a sales manager for the Senior Planning Center, said that provision makes many MaineCare-eligible people between ages 60 and 64 afraid they’ll lose their homes. But because they no longer qualify for marketplace coverage, “they end up kind of stuck,” she said.

She said residents either seek cost-sharing plans — which usually do not cover preventive care or prescriptions — get MaineCare coverage but then do not use it, or forego insurance altogether.

“We really just try to educate them and steer them towards their best coverage option,” Gammon said. “If you’re someone who has diabetes or a chronic condition, you need to have health insurance.”

Lambrew said estate recovery is rare in Maine and that it might be a “perceived barrier,” but the concern is prevalent enough that advocacy group Maine Equal Justice Partners backs a bill that will be before the Legislature in 2020 to direct the state to only collect on federally mandated services, including nursing facility services, home and community-based services, and related hospital and prescription drug services.