Expanding Medicaid a hot issue on Tuesday's ballot

If the Medicaid expansion referendum on Tuesday’s ballot is approved by voters, at least 70,000 low-income Mainers would likely enroll in the federal program to secure health care coverage that many of them lack.

For proponents, Question 2 is a way to boost the economy and save lives, paid for mostly by the federal government, which would cover at least 90 percent of the tab for their care.

“This is a good deal for Maine,” said Dr. Charles Pattavina, president of the Maine Medical Association. “It’s the right thing to do for the health of our patients and it will be an important boost for Maine hospitals, physician practices and other clinicians who care for all of us.”

The Legislature’s fiscal staff figured this year that the change would require the state to spend an additional $54 million a year, with the federal government kicking in $525 million more each year to fund the remaining cost of the expansion.

For former U.S. Sen. George Mitchell, a Democrat who spoke up on the issue during the campaign, the ballot question is straightforward.

“Voters have a chance to make the Maine health care system fairer and to strengthen the state’s economy,” he said.

“We should all be working together to build a system that will provide insurance for the maximum number of Maine people as possible,” Mitchell said. “Expanding Medicaid makes sense and would be a good decision for Maine.”

Critics balk, saying it’s free health care for the undeserving.

“Don’t believe the hype about Medicaid expansion,” Gov. Paul LePage warned in a recent radio address. “It is not for children or the elderly. It is just ‘free’ health care for people who should be working — and you will pay the price.”

Health care system experts, however, say most of those in the new group eligible for coverage are working — in jobs that don’t provide coverage, often in food service, construction or retail. Many live in rural areas, where one in four Mainers doesn’t have health care coverage.

If voters approve the Medicaid expansion, most of the Mainers who would become eligible are able-bodied, childless adults. Recipients would also include some families whose incomes are a little too high for the existing threshold of 105 percent of the federal poverty line.

With the federal government paying 90 cents of every $1 for those covered by the expansion, the change will clearly help seniors, children and low-income workers, said Sen. Nate Libby, D-Lewiston, who has repeatedly voted in favor of the plan only to see LePage veto it.

Republican gubernatorial hopeful Mary Mayhew, former Health and Human Services commissioner, said passing the ballot measure “would be incredibly unfortunate.”

Mayhew said supporters make Medicaid expansion “appear like motherhood and apple pie” by providing health care to hardworking Mainers, but they won’t say that the state’s cost of adding “able-bodied adults” to the rolls will cripple the state’s ability to provide much-needed help to the elderly, those with intellectual disabilities and others who can’t provide for themselves.

State legislators have approved the expansion five times, with LePage each time blocking the move with vetoes the Legislature couldn’t overcome. That’s why advocates turned to the referendum process, collecting signatures during the 2016 election that earned the measure a spot on this year’s ballot.

If voters approve it, Maine would become the 32nd state to expand its Medicaid rolls. It would offer Medicaid to people with incomes up to 138 percent of the federal poverty line, providing coverage for a family of four making nearly $34,000 or $16,643 for a single person

The medical community backs the proposal. In addition to the doctors’ association, it has been endorsed by the Maine Hospital Association, the Maine Primary Care Association, the Maine Chapter of the American College of Physicians, the Maine Academy of Family Physicians and Maine Providers Standing Up for Healthcare.

“Increasing the number of Mainers with health insurance by expanding Medicaid would improve quality of life, increase workplace productivity and save lives,” Dr. Sam Zager of the Maine Academy of Family Physicians said.

Most of the opposition comes from GOP leaders.

State Sen. Eric Brakey, an Auburn Republican who is taking on independent incumbent Angus King in next year’s U.S. Senate election, said the proposed expansion “would cannibalize” critical government spending on education and other broadly backed programs by putting “able-bodied adults” who don’t have children “at the front of the line” for government help.

Democrat Libby questions that contention, saying the state is running a budget surplus that exceeds the extra cost to Maine taxpayers to add more people to Medicaid’s rolls.

But critics remain wary.

Mayhew, who estimated at least 100,000 Mainers would sign up for an expanded Medicaid, said the Legislature’s bipartisan staff’s cost analysis understates the number of participants. As a result, she said, the program will cost the state more than $100 million annually, twice the staff’s estimates.

To cover that “pretty hefty price tag,” she insists the state would have to cut education, slice other crucial programs or rely on “dramatically increased taxes.”

Nearly all of the money spent because of a Medicaid expansion would flow directly into Maine’s economy through the health care providers who are paid for the services they provide to patients enrolled in the program. The Maine Center for Economic Policy estimates the Medicaid expansion would create 3,000 jobs and stimulate an extra $500 million in economic activity each year.

Advocates said that offering more coverage, creating new jobs and spurring the economy is well-worth the extra expense, particularly given the additional help it provides for struggling hospitals. They also insist it will help combat the opioid epidemic by opening the door for many addicts to receive health care.

In criticizing the expansion, the governor said this summer that hospitals want the Medicaid expansion “because it’s free money” for them, given “they’re going to serve the people anyway” as part of the required charity care they offer in return for nonprofit status.

Another way to look at it is that hospitals will get an additional $188 million annually for care that’s currently not compensated, according to the economic policy center. Those charges wind up being paid by other patients and their insurance companies, which contributes to more costly premiums.

Many of the state’s smaller hospitals are struggling to keep their doors open. Expanding Medicaid, they said, will ease their financial plight.

Mayhew sees another downside to the expansion in the future. The federal government will reimburse 90 percent of the Medicaid cost for those added to the rolls if the ballot issue passes, much more than the 65 percent it reimburses for those on traditional Medicaid. The state pays the rest.

Therefore, she said, it’s not hard to see which group will see cuts if there’s not enough state money, she said.

However, states are required to provide Medicaid services to every eligible person who enrolls in the program, without exception. It can’t pick and choose among them. If the state makes cuts elsewhere to come up with the additional Medicaid funding, it has to be in areas not covered by Medicaid.

She said history shows that expanding Medicaid in Maine won’t help.

Between 2000 and 2010, a period when the program was more broad, the percentage of Mainers without insurance remained steady despite adding tens of thousands of people to Medicaid. She said that’s because many people dropped employer-based coverage for Medicaid, shifting the cost of their care onto the taxpayers.

That will happen again, she warned. “This will set us back,” she said, and prove “a devastating blow to our state.”

“We already lived through the disaster of Medicaid expansion,” LePage said in this week’s radio address. “The promises did not pan out. It did not create savings, reduce charity care or decrease the number of uninsured Mainers.”

Libby said, however, that the federal government’s reimbursement rate is much higher now than it was the first time the state expanded coverage, lessening the burden on state taxpayers. “The equation is much different” now, he said.

Mayhew said she’s also worried the federal government, which is more than $20 trillion in debt, won’t be able to pay its share down the road.

She said she has “zero confidence” that Washington will follow through on its promised reimbursements. “I do not want to be beholden to the federal government,” Mayhew said.

scollins@sunjournal.com