Maine health care providers are grappling with how to prepare for more patients without insurance. 

As premiums rose and tax credits expired, the number of people enrolled in the state’s health insurance marketplace dropped by thousands from 2025 to 2026. Now, thousands more Mainers are expected to lose their Medicaid coverage when a new federal law takes effect.

But no one knows exactly who will lose their Medicaid coverage or where they live, making it difficult for providers to predict what could happen when the new eligibility rules start rolling out in three months.

“It’s really a perfect storm,” said Kate Ende, policy director for Consumers for Affordable Health Care, a nonprofit that helps people navigate access to health care. “Whether you’re losing Medicaid — MaineCare — or you’re losing coverage because you simply can’t afford it anymore because premiums have just skyrocketed, in both situations you’re losing access, and you’re less likely to seek preventive and routine care.”

With rates for private health insurance estimated to rise again, it is likely that more Mainers will voluntarily drop their insurance. Maine insurers have proposed an average increase of about 15 percent for individual plan premiums, which the Maine Bureau of Insurance will review and finalize in mid-August. Last year, rates increased an average of 24 percent for the individual market.

Insurers said higher rates are necessary due to the increasing cost of medical care, higher use of medical services, higher prescription costs, the expiration of the enhanced premium tax credit, and worsening health of insured people in the individual and small-group market, said Tim Schott, acting superintendent of the Maine Bureau of Insurance. The enhanced premium tax credit lowered monthly health insurance payments for eligible individuals and families, and was not extended by Congress in 2025.

More people tend to go without, or switch to catastrophic plans, when prices rise. As of February, there was a nearly 10 percent decline in enrollments on the state-based marketplace for private insurance compared with last year, according to the state. Plan cancellations were especially high among younger people and Mainers who previously received a health insurance tax credit.

On top of this turmoil, changes to Medicaid are starting to take effect this fall. Last summer, Republican lawmakers in Congress passed the One Big Beautiful Bill, which will cut Medicaid spending by an estimated $911 billion over the next decade. The law includes new work requirements for some Medicaid recipients and changes to eligibility for some immigrants.

Beginning on Oct. 1, more than 600 immigrants, including refugees and asylum seekers who have not yet received a green card, likely will no longer be eligible for full benefits under MaineCare, the state’s version of Medicaid, according to the state. Children and pregnant people will be exempt.

On Jan. 1, new work requirements will take effect for people who qualified for Medicaid after the state opted to expand coverage to them in 2019. There are an estimated 86,000 members in the state’s expansion group who will now have to show they are working, volunteering or attending school for 80 hours a month to keep their coverage. 

The state has previously estimated that 31,000 of those people would lose their coverage because they no longer qualify or because the additional paperwork will be too much of a barrier.

Ende, with Consumers for Affordable Health Care, said people who are still eligible may find the new requirements confusing or more difficult because they will have to report every six months instead of once a year and will have to do more to prove they are working or are too sick to work.

“People have busy lives, and they’re already juggling a lot,” Ende said. “People are moving, and they may not be at the same physical address they were. They may have unstable housing. There’s a lot of reasons why these overly burdensome paperwork requirements can cause somebody who is eligible to lose coverage.”

Providers are struggling to anticipate exactly how many in their service area could lose coverage, but they are budgeting for rising costs from uninsured patients.

MaineGeneral Health, the health system that serves central Maine and has MaineGeneral Medical Center as its flagship hospital in Augusta, estimated that 3,000 people in its service area could lose coverage. The health system is budgeting for an increase in charity care in the current fiscal year, which began July 1, according to Terry Brann, MaineGeneral’s chief financial officer. Some of that predicted increase is due to a state law passed last year that expands who is eligible for charity care.

Charity care, which hospitals are required to provide when patients come to the emergency department but can’t pay their bills, was already high. Maine hospitals provided nearly $60 million in charity care in 2023, according to a previous Maine Monitor analysis of data from the Maine Health Data Organization.

Brann said rising rates of uninsured people in Maine will have long-term consequences for MaineGeneral’s financial stability.

“We have seen impacts to access across the state for OB/GYN services, primary and specialty care services. These changes will continue to impact us and others across the state — making it even harder for patients to access timely care,” Brann said. “We’ve had to make difficult decisions about what programs and services we can provide long-term.”

But predicting which parts of Maine will see the most people lose their Medicaid coverage is difficult. Brann said MaineGeneral has no breakdown of where the state could be hit hardest.

On one hand, there are more people on Medicaid in northern Maine. About 34 percent of Mainers in the 2nd Congressional District are on Medicaid, compared with about 23 percent in the 1st Congressional District, according to KFF, a health policy organization.

However the new work requirements are only required for select people with Medicaid — those in the Medicaid expansion population — and it’s not clear how many of them live in the 2nd District.

The new law also carves out exemptions to the new work requirements for certain people, such as those who are caregivers, or have substance use disorders or chronic conditions. These exemptions make it challenging to predict exactly which parts of the state will see the most people lose coverage, said Trevor Putnoky, president and CEO of the Healthcare Purchaser Alliance of Maine.

“It’s almost impossible to tell,” Putnoky said. “You would have to have really detailed demographic workforce data to be able to model out how this is going to impact people.”

John Porter, a MaineHealth spokesperson, said it is “not knowable” how the new work requirements and additional paperwork will impact MaineCare coverage.

“One factor is what steps, if any, will the state take to ease the administrative burden on the eligible Medicaid population,” he said. “Another factor is what the final rules will be with regard to exemptions from the work requirements.”

The Medicaid cuts will come after MaineHealth lost $48.7 million as of June 30, against a budget that called for a financial gain of $64 million in the same period, he said. This excludes one-time COVID relief payments.

There are other reasons why northern Maine is likely to be hit harder by health insurance upheaval as a whole, however, Putnoky said. There are more small-group employers in northern Maine who have a harder time weathering rising health insurance costs. These employers may have to end coverage or instead offer employees a stipend to buy their own plans on the marketplace where premiums are much higher. The 2nd District also has more seasonal workers who could find it difficult to complete additional paperwork to meet work requirements.

What’s more, northern Maine has an older population with more chronic diseases, said Lisa Harvey-McPherson, vice president of government affairs for Northern Light Health, based in Brewer. People who don’t have coverage often delay their care and then go to the emergency department when their needs are more complex and more acute. As a result, the cost for the patient is higher, she said. In comparison, southern Maine has more commercial payers, so it’s a more stable market.

Northern Light Health has previously estimated it will lose about $27 million in the first year of Medicaid cuts. The losses will come at a precarious time for the health system, which recorded about $26 million in bad debt in 2024 and $12.1 million in charity care.

There are health disparities between northern and southern Maine. The 1st District met or performed better than the national average on all but one of 42 health outcomes measured by Congressional District Health dashboard. The 2nd District was worse than the national average on six metrics: firearm suicides, frequent mental distress, frequent physical distress, independent living difficulty, opioid overdose deaths and smoking.

A recent national report from a coalition of nine civil rights and health care advocacy groups estimated that 60 percent of people who lose coverage will be from communities of color. 

Disparities grow when sicker people have less access to health care, Putnoky said. Ending up in the hospital is expensive and can lead to medical debt, bankruptcy or charity care covered by the hospital, which must absorb the expenses by cutting or raising costs elsewhere.

“They don’t have insurance, and they’re going to get saddled with enormous amounts of medical debt,” Putnoky said. “Somebody’s going to pay for it, right? Either they’re on the hook for it, and it’s going to put them in a really difficult position, or the hospital is going to be on the hook for it, and they’ll see their charity care percentage tick up.”

This story was originally published by The Maine Monitor, a nonprofit civic news organization. To get regular coverage from The Monitor, sign up for a free Monitor newsletter here.