Maine is first in nation to expand Medicaid by ballot initiative

Maine Medicaid Expansion: What’s Next (We did it!) 

On Nov. 7, Mainers passed Question 2 with an overwhelming 59% of the vote. Voters sent a clear and strong message: They want more affordable health care, not less. 

More than 70,000 Mainers cannot afford to wait any longer for the health care they need to be and stay well. The magnitude of the victory that we achieved - thanks to years of work by many of you - cannot be over-emphasized in terms of its impact on people’s lives. Thanks to the initiative, more than 70,000 Mainers will gain access to long-overdue, life-saving health insurance coverage.

In fact, the implications for Maine and beyond are significant.

“Voters in Maine approved a measure allowing them to expand Medicaid under the Affordable Care Act (ACA).

It was the first time since the law took effect that the question of expansion had been up to U.S. voters. 

The issue affected many people in Maine, a rural state that has the nation's oldest population and the region's lowest wages.” 

Associated Press ~https://www.apnews.com/cf007502a8dc421990c4d8dfcde19235

PORTLAND, Maine (AP) — Residents in this rural state grappling with a heroin epidemic and an aging population voted Tuesday to deliver a rebuke to Republican Gov. Paul LePage and join 31 other states that have expanded Medicaid under former President Barack Obama’s health care law (The Affordable Care Act ~ ACA).

The referendum represents the first time since the law took effect that the question of expansion had been put in front of U.S. voters.

Some 11 million people in the country have gotten coverage through the expansion of Medicaid, a health insurance program for low income people.

Maine became the 32nd state to expand Medicaid…Voters approved the initiative by a gaping 18-point margin, with support from many conservative, rural areas in the north of the state where expansion will have a significant impact. 

The "Question 2" victory means more than 70,000 Mainers will gain insurance coverage.” 

A clear and resounding message was sent to the Governor by voters. Nevertheless, Gov. LePage issued a statement saying he would not implement expansion if the Legislature didn’t fund it at twice the amount estimated in the bill’s fiscal note from the nonpartisan Office of Program and Fiscal Review ie OPLA. 

Governor LePage's statement caused some to worry about the future of Medicaid expansion here in Maine. 

Maine Equal Justice Partners in Augusta, an independent voice for Medicaid said, "We can assure you. This victory will stand. We will be working together over the coming months to ensure that people get healthcare coverage and the will of Maine voters is upheld. Get the facts on implementation of Medicaid expansion. We would like to answer some of the post-election questions that have come up to help clear up any confusion."

When will newly eligible Mainers get their healthcare coverage? 

The law the voters passed requires the administration to provide health coverage to people within 180 days of the effective date of the law. The administration is therefore required to provide coverage to people who are eligible no later than July 2, 2018. 

Here is the timeline for the implementation

• Nov. 7, 2017 - Ballot measure passed with a strong majority (59% of Maine voters).

• Dec. 4, 2017 – Governor made public proclamation of the election results. • Jan. 3, 2018 - Legislature convenes. Thirty days have passed since the governor’s proclamation and the law becomes effective on this day. 

• Feb. 17, 2018 - While the law is effective on January 3rd, it becomes operative 45 days after the Legislature convenes.

• April 3, 2018 – This is 90 days after the effective date, and DHHS must submit a State Plan Amendment to the federal government by this day.

• July 2, 2018 (state fiscal year ’19) – No later than 180 days after the effective date, people become newly eligible under the law.

Can the governor block this law and prevent people from getting health coverage?

No. The governor cannot veto a ballot initiative. Medicaid expansion is now the law of the land. The Legislature is the only governmental body that can change the law and there is no reason to expect them to repeal it (see Q&A #4). The governor, just like all of us, must follow the law. 

What if the Legislature repeals the new law? 

Even though the Legislature has the authority to repeal or change the law, this is incredibly unlikely. The majority of the Legislature has already passed Medicaid expansion five times. Now, the voters have weighed in and passed it with a strong majority. Legislative champions have already made it clear that this is now the law and the will of the voters will stand. 

What is the actual cost of Medicaid expansion? 

Expanding Medicaid through the ACA is an incredible bargain. Initially, the federal government will pay 93.5% of the cost of coverage for most who would become newly eligible and no less than 90% beginning in state fiscal year 2021. The state’s share is relatively small considering the return on investment of $9 from the federal government for every $1 Maine invests. The official fiscal note from the nonpartisan Legislative Office of Fiscal and Program (OPLA) Review estimated that the state cost of Medicaid expansion once fully implemented at the 90/10 match rate in 2021 will be approximately $55 million a year, bringing in $525 million in federal matching funds. 

The cost of expansion for the first couple years with the enhanced match rate is still to be determined by the Legislature working with OFPR with input from DHHS. 

OFPR has initially estimated that the state’s cost for fiscal years 2018 and 2019 combined would be $45.5 million. This number is too high, however, as it is premised on the assumption that people will gain coverage in January of 2018. The Legislature and OFPR will therefore need to work through the actual cost for this biennium over the coming months. 

Will the Legislature need to cut other programs and services to fund the state’s share for Medicaid expansion? 

No. Medicaid expansion does not involve taking funding from one group to pay for another. It is about taking advantage of an unprecedented, cost effective opportunity available from the federal government to provide health insurance coverage to low income Mainers who can’t access Medicaid now. Providing coverage to more people will help to stabilize our health care system overall. Other states that have expanded their Medicaid programs have not been forced to make cuts to other programs. 

It's wrong for opponents to claim that expansion threatens people on wait lists for home care services. This myth has been debunked throughout the nation. Maine is not facing a budget shortfall, the revenue picture shows an actual surplus, and there are funds available to the legislature to pay for expansion over the next biennium without harming others that need services. 

What if the Legislature does not fund Medicaid expansion during this legislative session? Or what if the Legislature funds it but the Governor vetoes the funding bill? 

Medicaid expansion is the law and people will become eligible for coverage on July 2, 2018 regardless of whether the Legislature has passed a funding mechanism and regardless of whether the governor delays or resists implementation. Once eligible for coverage, people will have legal recourse if they are improperly denied coverage, meaning they will have a legal claim in court. Hopefully, it will not come to that and the Legislature will act swiftly to fund the state’s share and the governor will act swiftly to respect and implement the will of the voters, but regardless, people will become eligible under the law. 

I understand that the federal government must approve Maine’s State Plan Amendment to implement expansion. 

What if the federal government does not cooperate? 

The state administration must submit a State Plan Amendment (SPA) within 90 days of the effective date, according to the new law. The federal government must approve Maine’s State Plan to implement Medicaid expansion, but that should be a routine process that is anticipated by the legislative timeline. 

Usually, this approval takes on average about 82 days. If the federal government delays giving its approval in an obvious effort to thwart implementation, it will be subject to legal challenge. 

How can I get involved to help ensure the law gets implemented and people get coverage as soon as possible? 

The Mainers for Health Care campaign was successful because it was a grassroots, collaborate effort. A Leadership Team of people who would be impacted by the policy were at the heart of the campaign, sharing their stories, recruiting volunteers and knocking on doors. More than 80 state and local organizations endorsed the campaign and helped make it happen. Health care providers, faith leaders, nurses, advocates and concerned citizens joined forces to make this happen for Maine. In that spirit, we will work together to finish the job and get health coverage to people as soon as possible. 

If you would like to join in these efforts and are not already connected to the Mainers for Health Care campaign, please contact Kate Brennan at kbrennan@mejp.org or 1-866-626-7059, ext. 204. 

If you have questions about the policy or the law that we have not answered here, please contact Ann Woloson at awoloson@mejp.org or 1-866-626-7059, ext. 210.