“I go to work every day to earn a living and to support my family, but I still can’t afford health insurance,” Kathleen Phelps, a hairdresser from Waterville, Maine, told a press conference last year. She was there to speak in favor of a since-successful initiative to put Medicaid expansion on the ballot in the state. “This initiative could save my life,” she said.
Maine voters on November 7 will weigh in on Question 2, the ballot measure to determine whether the state will expand access to health insurance for those with low incomes through Medicaid.
Phelps appeared again in support of these efforts in a September advertisement for Mainers for Health Care, the ballot committee behind it.
“I have [chronic obstructive pulmonary disease] and I need oxygen,” she said. “I don’t qualify for Medicaid, too young for Medicare, and I can’t afford insurance on my own.
“So it’s a choice between oxygen and paying my bills. I worry every day that there will come a day where I just won’t be able to breathe at all,” Phelps concluded.
In Maine, 106,000 people were uninsured in 2016, according to recently released Census data. About 70,000 more people could be insured should voters opt for Medicaid expansion, supporters of the efforts say.
“People Without Health Insurance Die Unnecessarily”
The citizen-initiated effort was approved for referendum in February after the “Act to Enhance Access to Affordable Health Care” garnered 66,000 verified signatures from registered voters. It would make those under 65 years of age with incomes at or below 138 percent of the federal poverty line eligible for Medicaid.
David Farmer, the communications director for Mainers for Health Care, told Rewire that those who would benefit from Medicaid expansion “are folks that range from working mothers, veterans, small business owners, older Mainers who don’t yet qualify for Medicare, and people really all over the state.”
Mainers for Health Care consists of a coalition “of organizations dedicated to ensuring Maine families have access to quality, affordable health care.” Its steering committee includes the Maine Center for Economic Policy, Maine Equal Justice Partners, Maine People’s Alliance, Maine Voices Network, and Planned Parenthood of Northern New England Maine Action Fund.
Farmer also explained that the ballot committee was engaging in multiple efforts to turn out the vote in their favor, including canvassing door-to-door around the state and setting up booths at community events.
When asked what is at stake when it comes to expansion, he noted that “people without health insurance die unnecessarily,” adding that “we know from experience in other states and experience right here in Maine that when people have access to health care they live longer, happier lives, they are more productive members of the workforce, and they are more secure.”
Further, expanding Medicaid in the state would create 3,000 more jobs, according to the ballot committee. Mainers for Health Care claims in a fact sheet on the initiative’s economic impact that not only would the expansion bring in “more than $500 million in new federal funds” each year, it would also save the state millions “through decreased state funded health care spending and savings to our criminal justice system.”
According to a February 2017 issue brief from the nonpartisan Kaiser Family Foundation analyzing multiple studies in regards to the effect of Medicaid expansion, “National, multi-state, and single state studies show that states expanding Medicaid under the ACA have realized budget savings, revenue gains, and overall economic growth.” Overall, Kaiser found that “the large body of research on the effects of Medicaid expansion under the ACA suggests that expansion has had largely positive impacts on coverage; access to care, utilization, and affordability; and economic outcomes, including impacts on state budgets, uncompensated care costs for hospitals and clinics, and employment and the labor market.”
And that expanded access to care could be the crux of the matter for many supporters. Ann Woloson, policy analyst at Maine Equal Justice Partners, one of the organizations in the Mainers for Health Care coalition, told Rewire in an interview that her organization had gotten behind the efforts because it “represent[s] the interests of low income people in the legislature and the courts and of course state agencies—and many of the folks that we work with day-to-day are in need of health insurance coverage.”
Access to care is especially critical in a state ravaged by the opioid crisis. According to an analysis conducted for the Maine Office of the Attorney General, 376 people fell victim to “drug-induced deaths” in the state in 2016, a 38 percent increase from the previous year. The vast majority of these deaths were related to the use of at least one opioid.
Medicaid expansion is a “tool that states are using to address the drug crisis in a very real way,” Woloson told Rewire. “They’re using the Medicaid dollars to fund drug court treatment services, something our state has struggled to do,” she explained. “And they’re also using Medicaid expansion to provide treatment to people in jail or prison, and that’s helping to reduce re-entry into the criminal justice system.”
The Economics of Expansion
Putting Medicaid expansion in the hands of voters is especially notable given the efforts to stop it at the top levels of state government. Maine’s governor, Republican Paul LePage, has continuously blocked efforts to expand Medicaid. Since he took office in 2011, he has vetoed five measures that would have done so. In August, LePage reportedly spoke out against the ballot measure during a radio interview, claiming, according to the Bangor Daily News, that it would financially “kill the state.” It was seemingly a reference to the debt that accumulated prior to the passage of the Affordable Care Act (ACA) under his predecessors, who in 2002 expanded Medicaid in Maine. LePage rolled back expansion after taking office. He made a similar argument on Wednesday in his weekly state address.
When asked whether there was validity to LePage’s argument against Medicaid expansion, Farmer told Rewire that “there is great distance between what [LePage] says and the truth of what happened,” last time the state moved to expand Medicaid.
Though the ACA expanded Medicaid to include most low-income people at or below 138 percent of the federal poverty line, the U.S. Supreme Court ruled in 2012 that states could opt-out of expanding. For those states that did choose to expand, the federal government promised to “finance 100 percent of the costs of those made newly eligible for Medicaid from 2014 to 2016 and then the federal contribution phases down to 90 percent by 2020 and beyond,” as an analysis from the Kaiser Family Foundation noted.
“The majority of people who would gain access to health-care coverage with this expansion would be covered by the enhanced federal match rate of no less than 90 cents on the dollar,” said Farmer. “That was not the case in previous expansions.” He continued that although those who oppose expansion “say that the uninsured rate was relatively flat in Maine” after previous efforts, “they don’t recognize the context of what was happening in the world when a major global recession was driving rates up everywhere else and Maine was able to hold its own.”
Woloson also explained that it was “economic downturns” that had caused fiscal problems in the state, not Medicaid expansion. “People were losing their jobs, there was less tax revenues, there were all kinds of problems with the economy that created problems,” she said.
Should Maine choose to expand the program, the state would join 31 states and the District of Columbia in doing so and would be able to receive federal matching for newly eligible populations. Still, it would need to invest some money in financing it, and that, state administrators argue, would put it into debt.
A fiscal note from the state legislature’s Office of Fiscal and Program Review found that expanding Medicaid would cost the state nearly $54.5 million annually when fully implemented. The note says that though “overall costs will increase under this initiative, some programs will achieve savings that will mitigate the additional expenditures,” though it did already factor in “savings that are generated within existing programs,” which would total over $27 million annually, in its summary.
When it comes to those savings, Woloson said that there “will probably be more than that” given that the state’s estimate “does not include the tax revenue that would be generated from the over 3,000 jobs” she said would be created by the move.
Despite the purported economic and health benefits that could result from expansion efforts, some Maine Republicans have nevertheless already attempted to undermine the citizen-initiated push to expand access to health care in the state, losing a battle in early September to frame the initiative as “welfare” on the ballot.
Instead, voters will see the following question:
Do you want Maine to expand Medicaid to provide health care coverage for qualified adults under age 65 with incomes at or below 138 percent of the federal poverty level, which in 2017 means $16,643 for a single person and $22,412 for a family of two?
The state’s constitution specifies that the “veto power of the Governor shall not extend to any measure approved by vote of the people,” but that hasn’t stopped LePage’s efforts to halt the initiative’s success. In late August, the Welfare to Work PAC registered with the state’s Commission on Governmental Ethics and Election Practices in opposition to the ballot measure.
LePage is listed as a fundraiser for the political action committee on their registration form. The Welfare to Work PAC did not reply to questions sent by Rewire by the time of publication about how the governor was involved with its efforts.
If Medicaid expansion is favored by voters at the polls in November, it will become law but it will still be “a law like any other one,” Farmer said, “and what that means is that the legislature can always change laws on the books.” However, he noted that the state lawmakers on both sides of the aisle have already voted in favor of such an effort on multiple occasions.
“I think they will make sure it is appropriately implemented once voters say yes,” he said.
CORRECTION: This article has been updated to correct the date of the Maine election.