Young demonstrators hold signs at a rally and lobby day organized by the Maine Peoples Alliance at the State House in Augusta in 2014 around the issue of Medicaid expansion.

Few issues have received as much governmental and media attention in recent years as Medicaid expansion, yet Mainers are poised to decide Question 2 on the November ballot amid confusion in the present and uncertainty about the future.

Whether Maine will expand its Medicaid program as the Obama-era Affordable Care Act intended, as a means to insuring millions of low-income people’s health, is a concept that has been rejected ad nauseam in the Legislature, ranging from numerous proposals killed in committee to six expansion plans that were supported by slim majorities in the Legislature but stopped by vetoes from Republican Gov. Paul LePage.

The arguments for and against Medicaid expansion in Maine are the same as they have been for years and they’re being made by many of the same groups and people. Despite that, health care has emerged as a crucial ideological and political issue. Mainers will head to the polls Nov. 7 amid an intense national debate about health care.

[LePage: Medicaid expansion would ‘kill’ Maine]

With health insurance premiums on the rise and insurance companies struggling to survive, particularly in the Affordable Care Act’s individual markets, President Donald Trump and most congressional Republicans support repealing the program. Though they have so far been blocked, the debate continues and the future of our national health care system is uncertain.

Question 2, which will appear on the statewide ballot, reads as follows:

“Do you want Maine to expand Medicaid to provide healthcare coverage for qualified adults under age 65 with incomes at or below 138% of the federal poverty level, which in 2017 means $16,643 for a single person and $22,412 for a family of two?”

What does expansion mean?

More adults would be covered based on their income. Currently, MaineCare covers a range of groups, such as pregnant women, parents with children younger than 18 and disabled people. Qualifying income thresholds vary. Parents and disabled adults, for example, qualify if their incomes are below 100 percent of the federal poverty level. That’s $12,060 a year for a single person, $20,421 for a family of three and $28,780 for a family of five.

Expansion would raise the threshold to 138 percent of the federal poverty level. That’s $16,643 a year for a single person, $28,180 for a family of three and $39,716 for a family of five. The initiative would also expand coverage to adults who are not disabled and don’t have children, which would be a change from current law.

Why does it matter what happens at the federal level?

It’s about the money. The 2010 Affordable Care Act encouraged states to expand their Medicaid programs, which in Maine is called MaineCare, and promised heavy subsidies to cover part of the cost of expansion — specifically, 90 percent by 2020. Without that guarantee, the cost to states would be significantly higher and probably unpalatable. So far, proposed cuts to Medicaid have helped sink attempts to repeal the Affordable Care Act. Opponents of Medicaid expansion have used uncertainty at the federal level as an argument in the past; that argument is only stronger now.

The initiative does not reference the Affordable Care Act. The referendum expands Medicaid in Maine regardless of what Congress does or doesn’t do.

The cost would be high but how high is under debate. The Legislature’s Office of Fiscal and Program Review, which puts price tags on proposed legislation, published its findings in the Maine Secretary of State’s 2017 Voter Guide. It breaks down as follows:

A $2.6 million appropriation to the Maine Department of Health and Human Services’ Office of Family Independence, which would have to hire 103 new eligibility specialist caseworkers to handle the new MaineCare enrollees. The federal government would cover 75 percent of the cost for 79 of those positions and 50 percent of the cost for the rest. Each new caseworker is predicted to have a caseload of about 700 people. It is estimated that expansion would extend coverage to approximately 70,000 more Mainers.

A $50 million appropriation to DHHS to cover medical costs for the newly eligible childless adult population. That figure represents the state’s estimated 10 percent share of the total cost. The rest would be paid by the federal government.

A $28 million appropriation to DHHS for medical costs for newly eligible parents. That figure represents 35 percent of the total cost; the federal government would pay the rest.

A $410,000 appropriation to cover medical costs for children whose families opt to join the program. That represents 2 percent of the total cost, the rest of which would be paid by the federal government.

— On the positive side of the tally sheet, OFPR estimates that existing programs would generate $27 million a year in savings, mitigating the total cost.

IN SUMMARY, expansion would require an annual state appropriation of nearly $54.5 million, and federal costs would be approximately $525 million a year. Those numbers would fluctuate, depending on whether the estimate of 70,000 new Mainers covered is high or low.

We’re being watched

Maine’s Question 2 is somewhat of a litmus test for the Affordable Care Act. As Trump and congressional Republicans persist in efforts to repeal Obamacare, constituencies for and against that concept have thrown every argument they can at the debate. Medicaid expansion by referendum is rare, which offers repeal proponents — or opponents, if the referendum fails — a rock-solid poll, of sorts, in the form of next month’s election. National media are taking notice and it’s certain Maine will garner national headlines and provide talking points in Congress following the vote.

In Maine, LePage has a lot on the line. Although term limits will force him out of office in 2019, the governor’s legacy will be shaped by whether he can convince a majority of voters that his stance on expansion is best for Maine. He has spent much of his time as governor trimming social service programs, including Medicaid, Temporary Assistance for Needy Families and food stamps, behind the argument that taxpayer resources should go to the most vulnerable and not what he repeatedly calls “able-bodied adults.”

This is likely the last time the matter will come up during LePage’s tenure, so a “no” vote will help cement his legacy of reining in the cost of public assistance programs. A “yes” vote would be a clear rebuttal of the governor’s stance but would electrify health care as an issue in the 2018 gubernatorial and legislative elections.

The vote won’t be a bookend for the debate. By January 2019, when a new Legislature and a new governor submits his or her state budget proposal, Medicaid coverage and its costs and benefits to the state will again be at center stage, regardless of what happens on Nov. 7.

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Christopher Cousins

Christopher Cousins has worked as a journalist in Maine for more than 15 years and covered state government for numerous media organizations before joining the Bangor Daily News in 2009.