When Maine Democrats passed their first Medicaid expansion bill four years ago, they wanted to make sure reporters and television cameras were there to see it. Republican Gov. Paul LePage wanted a similar audience - to witness the bill’s inevitable failure.
Democrats had called a press conference in the State House Hall of Flags. Reporters were there, as were the cameras.
And so was LePage, who arrived first.
As Democrats descended the stairs to the hall, they watched as LePage and his staff hastily arranged a folding table and a chair in front of the cameras. Two dozen Republican lawmakers joined the governor as he read a veto message, pulled out a pen and symbolically guillotined the bill.
The veto was the first of a half dozen by LePage to kill Medicaid expansion, an issue that has dominated Maine politics ever since the U.S. Supreme Court shifted the political front lines of the Affordable Care Act to the states in 2012.
The fight over Medicaid isn’t unique to Maine. Dozens of state legislatures engaged in similar debates over whether to expand the healthcare program for low-income residents through incentives offered in the ACA.
Maine is one of 19 states that have rejected expansion. But on Nov. 7, it could be the first to approve it at the ballot box.
Question 2 asks Maine voters if they want to provide roughly 70,000 Mainers with healthcare coverage by expanding eligibility of Medicaid - known here as MaineCare.
Shifting Fronts Of The ACA
The national battle over Medicaid expansion began with a 2012 U.S. Supreme Court decision that conservatives originally hoped would hobble the Affordable Care Act, President Obama’s signature legislative achievement.
But instead of repealing the law’s individual mandate requiring that most Americans obtain health insurance, the court upheld it. The court then struck down a provision requiring all states to expand eligibility of Medicaid.
That surprise 2012 court ruling shifted the political battle. While the GOP-led U.S. House of Representatives would go on to take over 50 symbolic ACA repeal votes, progressive and conservative activists descended on state legislatures to fight over Medicaid expansion.
The intensity of those battles illustrated the importance of Medicaid expansion as a component of the ACA. Not only is the program designed to lower the uninsured rate, but it’s arguably made repealing the health care law harder. Gutting the ACA likely means cutting Medicaid or rolling back expansion, which in either case means purging the Medicaid rolls.
Medicaid cuts were the primary reason that U.S. Sen. Susan Collins broke ranks with most of the GOP to oppose two ACA repeal bills.
“First, both proposals make sweeping changes and cuts in the Medicaid program. Expert projections show that more than $1 trillion would be taken out of the Medicaid program between the years 2020 and 2036,” she said in September. “This would have a devastating impact to a program that has been on the books for 50 years and provides health care to our most vulnerable citizens, including disabled children and low-income seniors.”
Collins has also cited the impact on Maine’s rural hospitals, which are heavily dependent on Medicaid reimbursement payments.
Effects On The Uninsured
Architects of the healthcare law sought to lower the country’s uninsured rate several ways.
One was requiring most Americans to have health insurance and providing subsidies to encourage them to buy it.
Another was expanding Medicaid, a federal program run by the states and funded with a mix of state and federal money.
The Maine program is about $2.6 billion, with two-thirds coming from the feds.
According to data released by U.S. Centers for Disease Control and Prevention earlier this year, the percentage of uninsured adults dropped from 18.4 percent to 8.6 percent in the 31 states and the District of Columbia that expanded Medicaid.
The CDC says the uninsured rate among adults is less dramatic among the states that didn’t expand Medicaid, 23 percent in 2013 to 18.4 percent during the first three months this year.
Maine’s uninsured rate mirrors the trend in non-expansion states, dropping from 16 percent in 2013 to 9 percent in 2016.
Meanwhile, Medicaid enrollment has been dropping. The LePage administration has moved aggressively to cut eligibility. And the enrollment numbers show it.
In 2012, there were 345,000 Mainers receiving Medicaid. There were 268,000 through June of of this year, according the Department of Health and Human Services.
Meanwhile, roughly 70,000 Mainers have fallen into what’s known nationally as the ACA coverage gap. The gap occurs in the 19 states that did not expand Medicaid.
The ACA originally conceived Medicaid expansion as a bridge between low-income adults already eligible for Medicaid coverage and those who could qualify for subsidies to purchase their own individual plans.
But without expansion, thousands of Mainers neither qualify for subsidies nor Medicaid.
If Question 2 passes, most of the 70,000 people who would gain coverage earn between 0 and 138 percent of the federal poverty level -- that’s about $16,000 dollars for an individual and $34,000 for a family of four.
For And Against
Conservative and progressive activists have engaged in a pitched fight over Medicaid expansion for four years.
The arguments for and against expansion haven’t changed much, and neither have the methods of persuasion.
Conservatives repeatedly note that Maine was an early expander of Medicaid between 2002-2003.
They claim that the state’s uninsured rate was unaffected by increasing eligibility and that the program became a budget buster, creating deficits when state revenues declined during the economic downturn.
Progressives counter that early expansion helped keep Maine’s uninsured rate steady while other states saw a surge. Additionally, they argue that the higher federal reimbursement rate offered through the ACA protects the state.
If expansion passes, the federal government will initially cover 94 percent of the cost. That ratchets down to 90 percent by 2020 and stays at that level - unless Congress cuts reimbursement.
But Brent Littlefield, with the anti-expansion Welfare to Work PAC, says there’s still a cost to Maine taxpayers.
“The current plan would have state taxpayers paying between $50 million-$100 million per year,” he says.
The expansion debate has been marked by its soaring rhetoric. Opponents have repeatedly called would-be recipients “able bodied,” while calling the proposal “welfare expansion” - descriptions designed to tap sharply divided public perceptions of people receiving public assistance.
Proponents, meanwhile, have been stressing the human impact, focusing on personal stories of those who would benefit from the program.
Question 2 has been billed by some as a final resolution to the expansion debate that has raged for years.
It could also be a litmus test for public sentiment about the Affordable Care Act. GOP repeal efforts have not polled well. While the ACA has not been a centerpiece of the proponents’ arguments for expansion, an affirmative expansion vote on Nov. 7 could be spun as a tacit public endorsement for the health care law because Medicaid is such a key component.
That’s one reason why Question 2 has intrigued the national media. The other is that Maine would be the first state to expand via the ballot box.
Locally, the political stakes are high. LePage has been a leading critic of expansion and he’s taking an active role in opposing Question 2.
Defeating Question 2 could validate the governor’s reticence. Conversely, an affirmative vote could deal a blow to the governor’s full-court press against the law.
Nonetheless, a victory for progressive activists could be fleeting if Democrats are unable to fill the Legislature with enough Democrats to protect and implement Question 2 if it passes.
After all, lawmakers changed, delayed or attempted to repeal all four of the ballot initiatives that voters approved last year.