Maine residents voted decisively last fall to expand the state’s Medicaid program. But almost six months later, Gov. Paul LePage still refuses to take action as the state’s legislative session winds down, putting the Obamacare coverage program in doubt.

LePage, a tea party Republican who’s derided Medicaid expansion as a “boondoggle,” for years vetoed bills to join the program. Frustrated state lawmakers thought they finally found a way around the recalcitrant governor last November, when nearly 60 percent of Maine voters approved the first-ever ballot initiative on Medicaid expansion.


“That we have had to fight this battle time and again is discouraging,” said Andi Parkinson, an organizer with the nonprofit Kennebec Valley Organization.

The ballot initiative made Maine the 32nd state to embrace Medicaid expansion and one of the rare states to do it as the Trump administration has pushed unprecedented new restraints on the program, including work requirements for some.

Undeterred by Maine’s fight, however, health care advocates are backing similar ballot initiatives in other Republican-led states this year, hoping voters can override conservative governors and legislatures. Ballot measure campaigns are underway in Idaho, Nebraska and Utah. Meanwhile, Virginia‘s Legislature is the only statehouse where lawmakers are seriously debating Medicaid expansion this year.

POLITICO Pulse newsletter Get the latest on the health care fight, every weekday morning — in your inbox. Email Sign Up By signing up you agree to receive email newsletters or alerts from POLITICO. You can unsubscribe at any time. This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

LePage, now in his last year in office, has insisted he won’t green-light expansion, which is expected to cover 80,000 low-income Maine adults, unless state lawmakers meet his conditions for funding the program that he contends could otherwise bankrupt the state. As chances of a deal with LePage dwindle, the organizers of the Maine ballot initiative are now preparing for a legal showdown to enforce voters’ wishes.

“The law is clear,” said Robyn Merrill of Maine Equal Justice Partners, an advocacy group that spearheaded the Medicaid expansion referendum. “People will have a right [to coverage] and we will represent them in court.“

Individuals are supposed to become eligible for Medicaid coverage on July 2, according to the Maine ballot measure. The legislative stalemate leaves few options other than litigation to force LePage’s hand. Ultimately, the issue may not be resolved until after Maine elects its next governor in the fall.

Supporters say there’s no doubt the state will eventually adopt the program — it’s just a question of whether it comes after a quick legislative resolution or a protracted legal fight.

Obamacare supporters in Maine say the LePage administration has already ignored timelines mandated by the ballot initiative. Maine earlier this month skipped a deadline to file routine paperwork notifying the Centers for Medicare & Medicaid Services it would join the Obamacare expansion.

LePage’s office and the Maine Department of Health and Human Services did not respond to requests for comment.

Medicaid expansion under the Affordable Care Act covers low-income adults earning up to 138 percent of the federal poverty line — roughly $16,800 for an individual and $34,600 for a family of four. While the federal government provides the vast majority of Medicaid expansion funding, states this year must contribute 6 percent of the costs, and their share eventually rises to 10 percent.

Maine lawmakers left late last week without formally closing the session after a Medicaid expansion funding deal fell apart. Split control of the Maine Legislature has complicated the Medicaid expansion talks this year. Republicans narrowly control the Senate, but they have been more receptive to Medicaid expansion. Democrats run the state House, where Republicans remain steadfastly opposed to the program and the debate has been tied up in a battle related to taxes and a minimum wage increase.

“The Democrats are obsessed with Medicaid expansion, to the point where they’re risking our most vulnerable in the state by demanding that they be put in the spending package,” said House Minority Leader Ken Fredette, one of four Republican candidates running to replace the term-limited LePage.

LePage has argued Democrats are inviting a fiscal crisis by expanding the program, and he’s insisted that state lawmakers can’t tap into rainy day funds or raise taxes to fund the expansion. Democrats say the state already has enough money in the budget to cover Maine’s costs through May 2019.

The deal that collapsed last week would have provided the Maine health department with $3.8 million to cover administrative costs associated with expansion, including hiring new staff.

LePage and lawmakers, however, have disputed how much the state should expect to spend on health benefits for new Medicaid enrollees. LePage's health department says it will cost the state roughly $60 million for the 2019 fiscal year to provide coverage, about double the estimate from the state's independent Office of Fiscal and Program Review.

Lawmakers will eventually return for a veto session this year, but it’s unclear when or whether they’ll revisit Medicaid.

Advocates pushing for ballot measures say they’re not discouraged by the Maine dispute because they expect other states would defer to the voters if they approved the program.

“We’re confident that we can overcome any legislative or executive opposition to it,” said Jonathan Schleifer of the Fairness Project, a national group that is bankrolling the state ballot campaigns. “If there are fights after the fact, we’re ready to fight those fights.”

Last week, Obamacare supporters in Utah submitted more than 165,000 signatures to state officials to get Medicaid expansion on the ballot, well above the requirement for 113,000 valid signatures. Utah’s lieutenant governor will announce by next month whether the measure qualifies for the November ballot.