Prior to last month’s elections, no polling had been done on Maine’s first-of-its-kind ballot initiative to expand Medicaid. Considering how controversial the health-care debate in Congress has been all year and the fact that the state elected a Republican governor, health policy experts were expecting a nailbiter.
But to their pleasant surprise, the vote was quickly called in their favor.
Sixty percent of Maine voters chose to expand Medicaid, which is one of the key provisions of the Affordable Care Act (ACA), otherwise known as Obamacare. That means more low-income people in Maine should soon be eligible for Medicaid, the government-run health insurance program. (The governor, however, has vowed to implement it only under certain conditions.)
The victory in Maine has re-energized Obamacare advocates hoping to replicate that success in other states.
A 2012 U.S. Supreme Court ruling made Medicaid expansion optional for states. Since then, 33 have expanded. The holdout states are largely run by Republicans. In many cases, GOP governors support Medicaid expansion but can't convince their GOP legislatures to approve it.
In Maine's case, though, it was just the opposite: Gov. Paul LePage vetoed five expansion bills passed by the legislature over the course of five years.
In Nebraska, state Sen. Adam Morfeld, a Democrat, said he plans on pushing a Medicaid expansion bill that didn’t get a vote this year again in 2018.
"[Maine's vote] reshapes the debate. My district is one of the top five in the state where people fall in that coverage gap, so I’m constantly hearing about the need for more affordable health care,” says Morfeld.
Morfeld said he's noticed his Republican colleagues warming to the idea, but even if the legislature were to pass something, the challenge would be getting GOP Gov. Pete Ricketts to sign off on it. Ricketts is opposed to Medicaid expansion, calling it a “risky proposition for taxpayers ... because we cannot trust the federal government’s long-term financial commitment to state programs.”
Under the ACA, the federal government pays 100 percent of the costs of expanding Medicaid and then gradually drops its contribution to 90 percent over the course of several years. The state then picks up the rest of the tab. In several of the bills introduced in Congress to repeal and replace Obamacare this year, though, that funding provision was removed or drastically reduced.
Regardless, if Ricketts vetoes a Medicaid expansion bill, Morfeld says he will follow in Maine's steps and take the issue to the ballot box.
At least three other states have ongoing attempts to place Medicaid expansion on the ballot.
In Idaho, advocates filed paperwork in October to let voters weigh in on Medicaid expansion in November 2018. Idaho Attorney General Scott Keim says he has concerns about the language of the measure, primarily around costs to the state if the federal government stops paying for the program. If the AG allows the proposal to proceed, they'll need 48,000 signatures to qualify for the ballot.
Advocates in Utah are also waiting on a decision from their state about whether they can start collecting signatures for a Medicaid expansion initiative. The federal government approved a waiver in November for Utah to expand Medicaid to 6,000 people who are either chronically homeless, in the criminal justice system or in need of substance abuse treatment. But state Sen. Brian Shiozawa, a Republican sponsoring the initiative, says it's time for the state to fully embrace Medicaid expansion.
"The ACA is the law of the land, whether we like it or not. If our tax dollars are going to D.C. anyway, let's get some of it back to help out the taxpayers," Shiozawa says. "I'm an emergency room doctor, so I know we have very real need."
In Missouri, the fight to expand Medicaid is largely up to one man, and it's an uphill battle. Gary Peterson, a 76-year-old former truck driver, has to collect 100,000 signatures for his initiative to make the ballot. But even the state's Democratic Party hasn't taken a position on Peterson's efforts.
Another state has a shot of expanding Medicaid soon -- but not through the popular vote.
In Virginia, outgoing Democratic Gov. Terry McAuliffe tried to expand Medicaid for most of his four-year term. Standing in his way was the GOP-led legislature. But in the elections last month, Democrats gained more seats in the state House than they have in any single cycle since the 19th century. Depending on the final election results (which have yet to be certified), Democrats may flip control of the chamber over to them. Either way, Democrat Ralph Northam was elected governor and is committed to pushing Medicaid expansion.
The ballot initiative was given a cut-and-dry timeline: The approved measure becomes law 45 days after the legislature reconvenes on Jan. 3. After that, the state Department of Health then has to file a plan with the U.S. Department of Health and Human Services within 90 days and officially expand services in 180 days.
But within days of the vote, LePage said he wouldn't implement Medicaid expansion unless the state legislature maps out how it will fund it. The state's Department of Health and Human Services estimates that expansion would cost the state $63 million for fiscal year 2019. To put that into perspective, total government spending in Maine totaled $8 billion in 2016.
Medicaid expansion “will cost taxpayers hundreds of millions of dollars to give ‘free’ health care to working-age, able-bodied adults, most of whom do not have dependents," says LePage.
Though LePage will likely try to stop or at least slow expansion, lawmakers on both sides of the aisle don't think he has the authority to do so.
"The results of [the] election are clear. It is now the job of the legislature to once again find a path forward," Maine Senate President Michael Thibodeau, a Republican who is also running for governor, told Politico.
It remains to be seen if the legislature will follow LePage's request to show how they'll fund it when they reconvene for regular session in January.
LePage is also in his final year in office, limiting the amount of time he has to win a legal fight. Still, advocates of Medicaid expansion are prepared for one. David Farmer, spokesperson for Mainers for Health Care, which supported the ballot measure, says his organization will take LePage to court if he halts the implementation process.
"What the governor says he will do and what he can actually do are two different things," he says.