Midcoast towns where lobstermen make a living also tend to be where the Affordable Care Act is reaching the most Mainers per capita, producing the highest sign-up rates for health insurance, according to an analysis of federal enrollment data.

The Kaiser Family Foundation review of enrollment figures from the U.S. Department of Health and Human Services shows that Mainers have embraced the Affordable Care Act at a higher rate than all but two states and the District of Columbia. But the sign-ups have not been evenly distributed across the state. In some areas, such as Lewiston and Livermore Falls, many have not taken advantage of the subsidized health benefits, while in other areas the ACA has gained much more traction.

Areas with the highest enrollments were mostly towns along the coast such as Vinalhaven, Deer Isle, Stonington and Friendship, where many lobstermen live. Those towns had per-capita ACA enrollment rates more than double the average Maine town, according to ZIP code-level data from DHHS.

But it’s not only lobstermen. ACA sign-ups have surged the most in areas with the highest rates of self-employment, according to a Maine Sunday Telegram analysis of ZIP code-level enrollments and U.S. Census data.

The ZIP codes with high enrollment also tend to contain a higher percentage of self-employment in the workforce, with some ZIP codes having three times as many self-employed workers or more than the state average of 11 percent self-employed.

For lobsterman John Drouin, who lives in the Washington County town of Cutler, the ACA is a mixed bag – even though he’s purchased insurance in the first two years of its existence. He said the bureaucracy and red tape he’s endured to buy benefits have been burdensome, and premiums tripled for 2015 because his income is going up and his household size is decreasing as his young adult children leave home.

But still, he’d rather have insurance than not, after 15 years of living without it.

“I’m at a certain point in my life. I’m 50 and I need insurance,” said Drouin, who had surgery last year to fix “nagging” injuries on his hand.

66,118 MAINERS ENROLLED

Overall, Mainers purchase ACA insurance at a much greater rate than most of the United States, with more than half of those who are eligible obtaining coverage.

Maine had enrolled 53 percent of those eligible for individual ACA coverage through Feb. 6, according to the Kaiser report, far above the national average of 37 percent and fourth-highest in the nation, behind Vermont, Florida and the District of Columbia.

In raw numbers, that works out to 66,118 people enrolled out of the 124,000 who are eligible to buy benefits in the marketplace, according to Kaiser. The marketplace is open to those who earn more than 100 percent of the federal poverty level, are under age 65 and cannot obtain insurance from their employer.

The open enrollment period for the second year of the Affordable Care Act ends Sunday, and Maine’s overall uninsured rate has plummeted since 2014, when subsidized coverage first became available.

Wendy Wolf, president of the Maine Health Access Foundation, which has helped to coordinate the grass-roots effort to sign people up for ACA insurance, said it’s not surprising to see the correlation with self-employment because there’s a financial incentive for such people to purchase the coverage, either because it’s less expensive or because it provides coverage they never had before.

Maine has a 10 percent rate of self-employment compared to the national average of 6.5 percent, according to the Maine Department of Labor.

“When you look at the composition of small businesses in Maine, we’re not only a state of small businesses, but we’re a state of micro small businesses,” Wolf said. “Being able to get ACA coverage is a game changer for them, because before they had no bargaining power with the insurance companies and were at the mercy of the carriers.”

Mitchell Stein, an independent health policy analyst from Cumberland, said it makes sense that areas with relatively few large employers providing health benefits are also where the most ACA sign-ups would be.

“It makes perfect sense, and it feeds right into what we would have expected and hoped for,” Stein said.

Subsidies are available to those who earn up to 400 percent of the federal poverty level, or about $95,000 per year for a family of four.

Wolf pointed to targeted efforts to sign up lobstermen for ACA coverage through the Maine Lobstermen’s Association, which obtained an $80,000 federal grant to let lobstermen know about the benefits of the ACA.

April Gilmore, who coordinates the ACA outreach efforts for the lobstermen’s association, said it was difficult to know whether its work was paying off until seeing the results this year.

“We would let people know about it, but then following them through to the finish line was really difficult,” Gilmore said. “For many people, we didn’t really know whether they took the final step.”

Gilmore said word of mouth has become a powerful tool – once friends and family members purchased insurance and found the premiums to be reasonable, people warmed to the idea of ACA coverage. Monthly premiums for those who obtain subsidies vary widely, but are typically in the $100 to $250 range.

“Nobody wants to go without insurance,” Gilmore said.

She said despite the reputation of lobstermen as rugged individualists, having coverage is important to business because every day that you’re sick and not able to go out on the water is a day of lost income.

“The work is hard physically, and being healthy and able to go out there and work is very important,” Gilmore said.

ACA ENCOURAGES MORE SELF-EMPLOYED

For Drouin, the Cutler lobsterman, the coverage in 2014 was much more affordable, with monthly premiums of just over $200. But when his income went up and his family size declined from six to three, premiums jumped to about $650 per month. The tax credit subsidies that help make insurance more affordable vary not only depending on income, but also on family size. In families with fewer dependents, the tax subsidies are less generous.

Drouin said in some ways he understands, because in the eyes of the government, he is financially supporting fewer dependents and he expects business to be better this year. But he said it’s difficult to predict income in the volatile lobster industry.

“We have 5 feet of snow on the ground and 2 more on the way,” said Drouin, who declined to say how much money he earns. “How the hell do I know how my business is going to be doing 10 months from now?”

It’s not just lobstermen who purchase ACA insurance. That’s also the case in other trades where people are their own bosses.

Kevin Lewis, CEO of Maine Community Health Options, one of the insurers in the marketplace, said the company, a cooperative, participated in many grass-roots efforts to sign people up for coverage, including at places where there would be a high percentage of self-employed, such as organic farmers at the Common Ground Country Fair in Unity.

“The marketplace is a boon for people who are self-employed and sole proprietors,” Lewis said. “We reached out to every single possible group, whether it be artists, fishermen or agricultural workers.”

Maine’s average salary is lower than the national average – $46,000 in Maine compared to $52,000 nationally – which might indicate that more self-employed individuals may qualify for the subsidies.

The ACA is expected to encourage more self-employment, according to the Washington, D.C.-based Urban Institute, freeing people from maintaining a job that they were mainly holding down for the health benefits to start their own business.

An Urban Institute study projected that 7,000 more Mainers will join the ranks of the 65,000 or so Maine residents who are currently self-employed.

While Maine has so far experienced greater success than most states in getting people to sign up for ACA insurance, the remaining 65,000 or so who would be eligible to purchase insurance may be difficult to capture.

“I would hesitate to predict a number, but there may not be many people left who are ‘gettable,’ ” said Stein, the Cumberland analyst.

STILL SPREADING THE WORD

That’s because many may have incomes below the federal poverty level – $24,000 for a family of four – and thus would be ineligible for a subsidy. The ACA assumed that those with such low incomes would be covered in a Medicaid expansion. But a 2012 U.S. Supreme Court decision ruled that states could opt out of the Medicaid expansion, and Maine is one of the states that chose not to expand the program, known here as MaineCare.

Without subsidies, the insurance would be too costly for most low-income families, Stein said. Others may not want insurance and are willing to pay a penalty. Still others may qualify for benefits, but the premiums are a big strain on their budget, so they take a chance that they won’t get sick.

And still others who qualify simply aren’t aware of the insurance but may benefit from it. Advocacy groups like the Maine Health Access Foundation and Consumers for Affordable Health Care are targeting populations, such as immigrants, who haven’t yet heard about the ACA.

On Feb. 8, Sacred Heart Catholic Church in downtown Portland hosted an enrollment event, held after a Spanish-speaking church service. Immigrants from many Latin American countries attend Sacred Heart, as do French-speaking African immigrants.

Nelida Berke, a Sacred Heart member and also a Portland official with the Office of Minority Health, spoke Spanish to people who showed up at the enrollment event, telling them how they could qualify for ACA coverage and what it meant. She identified more than 10 families who could qualify. People who are in the country illegally cannot obtain ACA coverage, but those seeking political asylum and those working here legally can.

Gilberto Rosado, from Puerto Rico, a U.S. territory, said he has worked on and off in the restaurant industry, and after consulting with one of those helping immigrants sign up for insurance, he found out he likely qualifies for subsidies.

“I can probably get Obamacare,” said a smiling Rosado, 48, who speaks limited English. He said he needs the benefits for mental health services.

Wolf said many immigrants qualify but don’t know that they do and have little or no experience with insurance.

“They’re starting with a real knowledge deficit, not understanding the system we have here. If you don’t understand, the most likely outcome is not to act,” Wolf said. “We have tapped into their community leaders and gotten them to talk about the ACA. It’s that trusted voice, and hearing the information from someone you know and think highly of.”