AUGUSTA — Just hours after a Medicaid expansion was endorsed by nearly 60 percent of Maine voters, Gov. Paul LePage and his Republican allies vowed to delay, if not derail, the citizen-initiated law that would provide health care to as many as 70,000 low-income residents of the state.

As supporters of the first-in-the-nation law were declaring victory, LePage and conservatives in the Legislature – who say the expansion will bust the state’s budget – were girding for a political battle that is likely to dominate the State House when lawmakers return in January, and could spill into the courts.

This year the Legislature repealed or significantly altered four citizen-initiated measures dealing with the voting process, additional taxes to fund public schools, marijuana legalization and the minimum wage. Those moves angered not only supporters of the measures, but also some lawmakers, who said the will of the people and their rights under the Maine constitution were being violated.

A total of 343,838 ballots were cast Tuesday on Question 2, a higher-than-expected turnout, and the measure passed by 202,616 to 141,222, or 59 percent to 41 percent.

But in a defiant statement early Wednesday, LePage promised to reject the expansion unless the Legislature, without raising taxes or tapping into surplus revenues, finds a way to pay for it. The federal government would reimburse Maine for 90 percent of the costs of insuring the population covered under expansion. Based on projected total costs, the state would have to spend roughly $54 million annually to receive about $525 million a year in matching federal funds under the Affordable Care Act.

DEFY VOTERS, OR STAND WITH THEM?

Throughout the day Wednesday, leaders from both parties issued statement after statement either praising or criticizing Tuesday’s results, making it clear that the path forward for Medicaid expansion will be a rocky one.

Top State House Democrats, some of whom worked with Republicans to repeal or alter other recent ballot-box laws, vowed to stand with voters and defend their decision on Medicaid.

“Any attempts to illegally delay or subvert this law will not be tolerated and will be fought with every recourse at our disposal,” said Speaker of the House Sara Gideon, D-Freeport. “Mainers demanded affordable access to health care yesterday, and that is exactly what we intend to deliver.”

Senate Minority Leader Troy Jackson, D-Allagash, likewise said there was no room for negotiation.

“When Gov. LePage and his allies tried to defeat Medicaid expansion at the ballot box, Mainers turned out at the ballot box to reject his lies. And we won,” Jackson said. “And when, inevitably, Gov. LePage and Rep. Fredette conspire this year to overturn the voters’ will and take health care away from 80,000 Mainers, we will rise up to resist them. And we will win.”

Jackson was referring to House Minority Leader Ken Fredette, R-Newport, who has kept the House minority caucus in lockstep with LePage to sustain most of the governor’s vetoes and accomplish other policy objectives. Fredette said there could only be an expansion of Medicaid if it came without imposing new taxes or drawing down surplus revenues.

“I acknowledge the passing of the referendum dealing with the expansion of Medicaid,” Fredette said. “However, I do not believe House Republicans will support any tax increase or the raiding of the rainy day fund to pay for an ever-expanding state government due to the out-of-control referendum process.”

VARIETY OF LEGISLATIVE OPTIONS

Sen. Eric Brakey, chairman of the Legislature’s Health and Human Services Committee, framed Medicaid expansion as a move that would inevitably drain resources from other state programs.

“I will not vote to spend a penny on Medicaid expansion for able-bodied adults while our seniors and intellectually disabled adults go without basic services,” said Brakey, R-Auburn, who had chastised his colleagues for not accepting the recreational marijuana law approved at the ballot box last year.

When the Legislature convenes in January, it will have to take procedural steps to make Medicaid expansion fit within existing state statutes, as well as provide funding for it. Lawmakers could do that through standalone legislation or as part of a broader supplemental budget bill that adjusts state spending in response to changing revenues.

Beyond that, it’s unclear what might occur come January. The Legislature could amend the ballot-box law, but any legislative bill to expand Medicaid would need two-thirds support to overcome a LePage veto. Without that, the underlying ballot-box law will remain in place. Lawmakers also could amend the ballot measure to delay its implementation date. That would push the fight over Medicaid to the next governor and the next Legislature, which will be seated in January 2019.

Adding to the uncertainty at the state level is the murky future of the Affordable Care Act, which encourages Medicaid expansion, but surely will be under siege again as long as Republicans control Congress and the White House.

LePage, who has vetoed Medicaid expansion legislation five times, offered no details Wednesday on what steps he might take to hinder expansion. He could direct the state Department of Health and Human Services to delay the rulemaking that will be needed to implement the fine print in the ballot measure. But such a move likely would spark a battle in the Legislature, which is split, with Democrats controlling the House of Representatives and Republicans holding the Senate.

LePage also reached back in time Wednesday to blame former independent governor Angus King, now a U.S. senator, for a state health care debt that LePage said had reached nearly a billion dollars by 2013.

“The last time Maine experimented with Medicaid expansion in 2002 under then-Gov. Angus King, it created a $750 million debt to hospitals, resulted in massive budget shortfalls every year, did not reduce emergency room use, did not reduce the number of uninsured Mainers and took resources away from our most vulnerable residents – the elderly and the intellectually and physically disabled,” LePage said.

LePage signed a bill in 2013 that directed revenue from the state’s wholesale liquor business to pay off a $183.5 million state debt to Maine’s 39 hospitals for unreimbursed care under Medicaid. The state payment drew down an additional $307 million in federal matching funds.

ISSUE MAY BE SETTLED IN COURTS

The Medicaid expansion vote Tuesday extends Medicaid eligibility to people making up to 138 percent of the federal poverty level – or just under $17,000 a year for a single person – with the federal government paying 90 percent of the cost of expansion.

Backers of the ballot measure, including David Farmer, a spokesman for the Mainers for Health Care committee that ran the campaign to pass expansion, said LePage couldn’t “unilaterally” block the will of the voters.

“More than 70,000 Mainers have already waited too long for health care,” Farmer said. “They shouldn’t have to wait any longer. The governor cannot ignore the law or the constitution of Maine. Simply put, the governor does not have veto power of citizens initiatives and he cannot ignore the law.”

Others also said the issue could be settled by the courts if LePage and Republicans continue to resist expansion.

Robyn Merrill, executive director of Maine Equal Justice Partners, a nonprofit advocacy group that launched the referendum effort, noted that by statute, the ballot measure becomes law within 45 days after the Legislature convenes early next year, and then the administration has 180 days to implement expansion.

“If they fail to do that, there would be legal recourses,” Merrill said, adding that her organization could go to court to force implementation of the law.

“It’s the law now. The administration needs to implement it,” she said.

‘WE ARE IN UNCHARTED TERRITORY’

Mitchell Stein, a Maine-based health policy consultant, said that “anything is possible” if the LePage administration balks at putting expansion into effect.

“We are in uncharted territory,” Stein said. “I wouldn’t be surprised if we ended up in court.”

He noted that nothing in the ACA itself mandates implementation in a certain time frame, because when the ACA became law in 2010, it was intended that Medicaid expansion be mandatory. Two years later the U.S. Supreme Court struck down that requirement and ruled that Medicaid expansion must be voluntary for states.

Maine is not only the first state to approve expansion by ballot referendum, it’s also the first to approve it with an executive branch that’s openly hostile, Stein said. In all other expansion states, governors were supportive.

Staff Writer Joe Lawlor contributed to this report.

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