A state court in Maine has ruled that Gov. Paul LePage (R) must submit the paperwork necessary to move forward on expanding Medicaid under the Affordable Care Act to cover about 70,000 more low-income people in the state.

In her ruling, state judge Michaela Murphy slammed LePage’s health department for unilaterally blocking the expansion’s implementation since voters overwhelmingly approved it by ballot initiative last November.

“The Court concludes that the Commissioner’s complete failure to act cannot be considered substantial compliance,” she wrote, ordering the governor to submit the necessary paperwork to the federal government by June 11.

It wasn’t immediately known whether LePage planned to appeal the decision.

Maine’s state legislature has voted five times in the past five years to expand Medicaid, and LePage vetoed the effort five times. Having reached an impasse, health care advocates turned to the ballot box, gathering signatures to get the measure on the 2017 ballot and successfully campaigning for its passage. Nearly 60 percent of voters cast a ballot in favor — making the state the first in the nation to expand Medicaid by popular vote.

Under Maine’s Constitution, the governor can’t veto a law passed by citizens’ initiative, so LePage chose instead to simply refuse to move forward with its implementation, citing concerns about its cost. The lawsuit was filed after LePage blew past the April deadline to submit a simple, two-page State Plan Amendment that allows the state to draw millions in federal funding for the Medicaid expansion.

The lead group challenging LePage in court was the non-profit Maine Equal Justice Partners, whose litigation director Jack Comart told TPM that they characterized the governor’s intransigence as a veto by another name.

“We made the point that what he’s doing is essentially vetoing what the voters passed and coming up with a series of conditions and excuses for not doing it,” Comart said.

Murphy heard both sides make their arguments in Maine’s Superior Court in late May. At that hearing, an outside private attorney represented LePage, because the state’s own attorney general, a Democrat who is running to succeed LePage as governor this November, refused to defend his decision to block the Medicaid expansion.

That private lawyer, Patrick Strawbridge, argued LePage’s position that he cannot move forward with expanding Medicaid until the state legislature appropriates the money to do so — though the federal government will cover most of the cost of the program, and despite the fact that nothing in the language of the ballot initiative says the implementation is dependent on such an appropriation.

During the hearing, according to local press, Murphy slapped down Strawbridge’s argument. “The law is in effect. It’s not a suggestion,” she said. “The executive branch has a duty to enforce that.”

Governor LePage now has the option of appealing the ruling to Maine’s Supreme Court and his office told local press that they’re reviewing the judge’s decision. If he fails to implement the state’s Medicaid expansion by the date outlined in the voter-approved initiative — July 2 — Comart says he will explore additional legal challenges.

Read the Superior Court’s full ruling below: