A Vote Expanded Medicaid in Maine. The Governor Is Ignoring It.

https://www.nytimes.com/2018/07/24/health/maine-medicaid-expansion-lepage.html

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PORTLAND, Me. — Brandy Staples, a 39-year-old breast cancer survivor, had expected to become eligible for Medicaid coverage this month after Maine voters approved an expansion of the program last fall. Instead, she found herself in a courtroom here on Wednesday, watching the latest chapter unfold in a rancorous, drawn-out battle over whether she and thousands of other poor people in the state will get free government insurance after all.

Ignoring the binding vote, Gov. Paul LePage has refused to expand the program, blasting it as a needless, budget-busting form of welfare. He vetoed five expansion bills before the issue made the ballot, plus a spending bill this month that provided about $60 million in funding for the first year. Earlier this month he went so far as to say he would go to jail “before I put the state in red ink” by adding at least 70,000 more low-income adults to the state’s Medicaid population of 264,000.

The showdown is on the extreme end of tensions playing out this election year in a number of Republican-controlled states that have resisted expanding Medicaid under the Affordable Care Act. Following Maine’s lead, advocacy groups in Idaho, Nebraska and Utah have gathered enough signatures to get Medicaid expansion measures on their state ballots this November, although Nebraska’s have yet to be certified. Already, two prominent Republicans there, a state senator and former state senator, havechallenged the effort in court.

The waters are calmer so far in Idaho, where both candidates to replace Gov. Butch Otter have said they’ll respect the outcome, and Utah, where Gov. Gary Herbert opposes the initiative but has said he would not fight Medicaid expansion should it pass. Nevertheless, advocates of expansion, gearing up for three months of outreach to voters, are hoping the legal battle in Maine won’t dampen enthusiasm for their campaigns.

Medicaid expansion is also emerging as a potent issue in gubernatorial and congressional races in Florida, Georgia and Kansas, among others. Here in Maine, where supporters of expansion have sued the LePage administration over its failure to act, the legal conflict has spilled into the race to replace Mr. LePage, who is finishing his second term.

Janet Mills, the state’s attorney general, is also the Democratic candidate for governor. She refused to represent the administration in the court case, leaving it to a private lawyer from Boston.

Ms. Mills said in an interview last week: “If for some reason Medicaid expansion isn’t implemented in the next five and a half months, I will do it on Day 1.”

Her Republican opponent, Shawn Moody, a businessman, sides with Mr. LePage. His spokeswoman — who is Mr. LePage’s daughter, Lauren — said in an emailed statement on Thursday that if elected, Mr. Moody would “enforce the laws on the books, with appropriate funding from the legislature who under the constitution must pass all spending bills.”

A statement Ms. LePage recently shared with Maine reporters took a more colorful tone, saying in part, “Shawn will not risk the fiscal health of the state to expand welfare for nondisabled individuals, and will not support funding welfare by raising taxes, raiding the rainy-day fund, or using one-time budget gimmicks.”

On June 4, A Maine Superior Court judge last month ordered the LePage administration to submit a plan within a week for expanding Medicaid, chastising its “complete failure to act.” Unsurprisingly, the administration appealed, and the state’s highest court, the Maine Supreme Judicial Court, heard arguments Wednesday about whether the lower court’s order should be kept on hold, as Mr. LePage wants, until his appeal is resolved.

The question of how to pay for Medicaid expansion kept coming up, with the justices appearing reluctant to get involved.

Patrick Strawbridge, the lawyer representing the LePage administration, said the lower court had been wrong to order Mr. LePage to submit a plan binding his administration to pay its share for Medicaid expansion when the legislature hadn’t appropriated “a single penny” for it.

That led James Kilbreth, a lawyer for the plaintiffs, to point out the legislature’s allocation last month of $60 million, using one-time surplus and tobacco settlement funds, to cover the first year of Medicaid expansion costs.

“You can’t have a circumstance in which the governor, after the legislature appropriates funds, is free to veto and veto and veto appropriations to fund the act,” Mr. Kilbreth said.

The legislature failed to override Mr. LePage’s veto of the spending bill because a bloc of House Republicans refused to join in. Mr. LePage has said he will not approve spending that raises taxes or relies on the state’s rainy day fund or “one-time funding mechanisms or budget gimmicks.” He recently suggested increasing a tax on hospitals to cover the state’s share of expansion costs — a funding stream that a number of other states that expanded Medicaid are using — but legislative leaders say they need to see a formal plan before deciding whether to support the idea.

Mr. LePage often points back to earlier state decisions to expand Medicaid, over a decade ago. Afterward, Maine struggled with budget shortfalls and fell behind on Medicaid payments to hospitals. After Mr. LePage took office, he paid the hospitals more than $200 million that they were still owed and reduced Medicaid eligibility. The new expansion would be different in that the federal government would pay significantly more of the cost.

Ms. Staples, the breast-cancer survivor who attended the oral arguments, works part time in food service at Bowdoin College. She pays $75 a month for subsidized private coverage through the Obamacare marketplace, plus a deductible, but is poor enough to qualify for Medicaid if it were expanded, she said. She gathered hundreds of signatures to help get Medicaid expansion on the ballot last year, then knocked on hundreds of doors to get out the vote as a member of the Maine People’s Alliance, a nonprofit organizing group. It was the first time voters anywhere got to decide the issue, and they approved it 59 percent to 41 percent.

“We shouldn’t have to be fighting this right now,” Ms. Staples said outside the marble-lined courtroom as throngs of summer tourists, oblivious to conflict, wandered the Old Port neighborhood outside. “We have 70,000 lives on the line here.”

Her friend Lynnea Hawkins, 38, said she relished the prospect of Mr. LePage going to jail over Medicaid expansion, however unlikely that might be. She has only a volunteer job, with the Maine People’s Alliance, where she and Ms. Staples both serve on the board. She qualifies for Medicaid now as the mother of a dependent child, but without the expansion, she will lose it next spring when her son turns 18.

“I want to be outside the jail with a nice chair and some popcorn, waving to him — ‘Bye, have fun!’” said Ms. Hawkins, who lives in Lewiston.

Robyn Merrill, the executive director of Maine Equal Justice Partners, the advocacy group leading the lawsuit, said, “We don’t have an objective indication that anybody is going to have to go to jail.” But she added that if the Supreme Judicial Court ultimately enforced the lower court’s order and Mr. LePage still refused to budge, the plaintiffs would ask the court to find his administration in contempt.

Donna Wall, 61, a plaintiff in the lawsuit, is uninsured. She racked up $60,000 in debt after shattering her ankle when she fell on an icy sidewalk in Lewiston last December while delivering newspapers in the middle of the night, a job that paid her $150 a week.

A GoFundMe.com campaign raised more than $10,000 to help her. But Ms. Wall, who cares full time for her 20-year-old autistic twins and donates blood plasma for extra income, is eager for the security of Medicaid coverage. She applied for it on July 3, a day after the state was supposed to start covering the newly eligible population under the law.

“The governor has this preconceived notion that we’re lazy,” Ms. Wall said on Tuesday. “I would love for him to come and live with me a couple weeks, see what it’s like to take care of the boys.”

The expansion would cover anyone earning up to 138 percent of the federal poverty level, which equals about $16,700 a year for a single person and $34,600 for a family of four. Many health clinics that treat the poor are telling their patients to apply for Medicaid now even though they may not get coverage any time soon.

“We’re telling them to let us know if or when they get denied,” said Lori Dwyer, the president and chief executive of Penobscot County Health Care, which runs nonprofit clinics in the Bangor area and treats 65,000 patients a year, about 17 percent of whom are uninsured.

“Though I’m an incredibly optimistic person and always hold out hope,” Ms. Dwyer said, “I’m extremely discouraged.”