LINCOLN, Neb. (AP) — Marti Poll knows she should see a doctor. Sometimes she has a severe tightness in her chest. She also has chronic sinus and ear infections.

But she can’t afford the medical bills, so she simply waits and hopes the pain will subside.

She thought her wait might end soon after voters approved a Medicaid expansion that would allow people like her who earn too much money to qualify for the health care program but who can’t afford to buy insurance on their own. But more than seven months later, Poll and some 90,000 other Nebraska residents who could qualify are still waiting — and will be for 15 more months as Republican Gov. Pete Ricketts’ administration says it’s working to ensure the smooth implementation of an expansion that voters passed despite his objections.

“I think this would help a lot of people,” said Poll, 55, who lives outside Lincoln and works as an office assistant and janitor. “Are they just looking to do it right, or are they obfuscating? That’s the question I have.”

Some of the skepticism stems from Republicans’ long objections to expanding Medicaid under the federal health care law championed by Democratic former President Barack Obama. Medicaid, which provides health coverage for lower-income and disabled Americans, is funded jointly by states and the federal government. The 2010 Affordable Care Act encouraged states to expand Medicaid by promising that the federal government would cover most of the cost.

Nebraska was among several conservative states that declined to expand Medicaid, as first Gov. Dave Heineman and then Ricketts argued it would cost too much and overwhelm the health care system. It was one of three states with Republican-controlled legislatures where voters last year approved an expansion. In Utah, lawmakers cut nearly in half the number of people who would be covered and added spending caps and work requirements, angering advocates. Idaho lawmakers also imposed work requirements and other restrictions.

In Nebraska, Ricketts has promised to abide by voters’ wishes, and the Legislature didn’t pass any changes to the voter-approved measure. But Ricketts’ administration decided unilaterally to implement a two-tiered program: a “basic” plan available to all newly qualified recipients, and a “premium” plan available to people who are working, in school, volunteering or caring for a relative.

State Sen. John McCollister said the Nebraska Department of Health and Human Services created a needlessly complex system that he believes runs contrary to the will of voters. McCollister said a straightforward expansion likely would have been easier and allowed people to get coverage sooner.

“They’re grudgingly implementing the policy — and I think ‘grudgingly’ is the operative word,” said McCollister, a moderate Republican from Omaha.

Advocates have noted that similar expansions took less than six months in Louisiana and Virginia and less than two months in Alaska. Expansion took longer in Maine, primarily because of opposition from elected officials.

Nebraska Department of Health and Human Services officials have defended the October 2020 launch date and their two-tiered approach, calling the expansion plan a massive undertaking that shouldn’t be rushed. They note some changes still need federal approval. Other challenges include that the state needs to upgrade its computer system for processing applicants; hire more workers; and negotiate new contracts with the private, managed-care companies that will serve Medicaid recipients, officials say. They also say the state needs more doctors who accept Medicaid patients.

“We completely understand and are very sympathetic to the situation,” said Nate Watson, a deputy director for Nebraska’s Medicaid and Long-Term Care Division. “We get it. What we’re worried about is what other states have experienced. We could expand quickly and people would get a shiny new card in the mail, but if there aren’t doctors in their area or the types of doctors that they need, what good does that do anybody?”

Coverage would be available to adults ages 19 to 64 who earn up to 138% of the federal poverty level — about $16,753 per year. The federal government must pay 90% of the program’s cost in 2020 and subsequent years.

The Nebraska Hospital Association, which supported the ballot measure, has accepted the state’s timeline.

“I don’t know if they can go any faster, given what they’re trying to do,” said Andy Hale, a lobbyist for the group. “They’re trying to do what they think is best.”

However, Jordan Rasmussen, policy manager for the Nebraska-based Center for Rural Affairs, noted that the state is losing out on millions in federal funding while setting up the program.

“The delay is hurting Nebraska,” she said. “We’re missing out and our people aren’t getting the care they need.”

