Supporters of Medicaid expansion celebrate their victory, Tuesday, Nov. 7, 2017, in Portland. Credit: Robert F. Bukaty | AP

On Tuesday, as thousands of Mainers supported expanding health care to an estimated 7 0 ,000 residents through Medicaid, the federal government signaled support for conservative measures that would likely constrict that access and give states greater control over the program.

The federal Centers for Medicaid and Medicare Services, or CMS, now aims to make it easier for states to customize their Medicaid plans, including changes such as monthly premiums and work requirements that some analysts say could drive down enrollments. Coming against a backdrop of conservative opposition to the Affordable Care Act and the provision that supports and funds the Medicaid expansion, the CMS announcement lends further uncertainty to the future of the voter-approved expansion in Maine.

In a speech Tuesday morning to state Medicaid directors gathered in Arlington, Va., CMS Administrator Seema Verma announced the agency’s commitment to working closely with states that seek to require more from “working-age, able-bodied Medicaid enrollees.” The change comes in response to the program’s growth in recent years, she said, and the need to “reset the federal-state relationship.”

Medicaid, known in Maine as MaineCare, is jointly run and funded by the state and the federal governments, providing health insurance to low-income residents.

Verma also said CMS would streamline the processing of state waiver applications designed to give states more flexibility in designing their Medicaid programs.

That’s good news for the LePage administration, which in August submitted its application proposing a monthly MaineCare premium of up to $40, $10 copays for some medical services, a 20-hour-per-week work requirement, and other measures. The application now awaits approval from CMS.

The Maine Department of Health and Human Services said in a statement on Tuesday afternoon that it was “encouraged” by Verma’s announcement.

“Through this waiver, it was the department’s intention to prioritize our limited resources for the Mainers who need them most, while promoting responsibility for one’s individual health and the cost of healthcare,” the statement read, in part. “We look forward to working with the administration to fulfill our shared objective of creating a sustainable Medicaid program through the promotion of individual accountability. “

But Mitchell Stein, an independent health policy consultant who advocates for policies expanding access to health care, said Wednesday that efforts to encumber MaineCare enrollees with work requirements, monthly premiums and other disincentives are intended to discourage enrollment and limit the provision of health services to vulnerable, low-income people.

“Most people on Medicaid who are able to work are already working,” he said. Nationwide, only 13 percent of adults included in the expansion population are able-bodied and not working, in school, or seeking work, Stein said, and of those, three-quarters are either actively looking for work or caring for family members.

“So, the idea that all these people are just sitting around not working is simply not true,” he said.

For the working poor, even a small monthly premium or copay can pose an impossible barrier to staying in the program, Stein said. Some states that instituted monthly premiums in their Medicaid programs reported spending far more trying to collect the payments than the payments generated, he said. Meanwhile, people who desperately need health care and other services drop out or are disenrolled for non-payment.

At Maine Equal Justice Partners, an Augusta-based nonprofit that advocates for Mainers living in poverty, attorney Jack Comart said Tuesday’s comfortable win for Question 2 demonstrates widespread support for expanding MaineCare, despite uncertainties related to the ACA and how the program is administered.

“This isn’t just a Portland thing or a southern Maine thing,” he said. “It won in rural towns and across the first and second districts. People want access to health care and they want their neighbors to have access to health care.”

Comart said LePage’s opposition is not unexpected and may result in unnecessary delays in rolling out the expansion. “It’s unfortunate that he continues to ignore the will of the people,” he said, “but ultimately, this will happen.”

As of 2016, upwards of 15 million Americans had enrolled in Medicaid as a result of the 2014 ACA expansion, out of a total enrollment of about 76 million, according to data from the Kaiser Family Foundation. An estimated 275,000 Mainers are currently enrolled in MaineCare — a number that could rise to 345,000 if the expansion, endorsed by 59 percent of Maine voters on Tuesday, is fully implemented.

Meg Haskell

Meg Haskell is a curious second-career journalist with two grown sons, a background in health care and a penchant for new experiences. She lives in Stockton Springs. Email her at