Mainers will see at the polls on Nov. 7 a citizens’ initiative to expand Medicaid (MaineCare) by a certain formula. It appears on the state ballot as Question 2, and asks: Do you want Maine to expand Medicaid to provide healthcare coverage for qualified adults under age 65 with incomes at or below 138 percent of the federal poverty level, which in 2017 means $16,643 for a single person and $22,412 for a family of two?

Supporters of the campaign, which required the effort of gathering signatures statewide, include several of Maine’s social justice nonprofits, such as the Maine Center for Economic Policy, Maine, Equal Justice Partners, Maine People's Alliance, Maine Voices Network and Planned Parenthood of Northern New England Maine Action Fund.

The bill requires Maine to provide federally approved Medicaid services through MaineCare to qualifying persons under 65 years of age with income equal to or below 133 percent percent, plus 5 percent of the nonfarm income official poverty line.

Dollarwise, that meant that in 2017, those eligible for receiving Medicaid (MaineCare) services would be earning annually $16,643 or less as an individual, or $33,948 or less for a household of four.

Medicaid, which is called MaineCare in Maine, provides medical insurance to groups of low-income people and individuals with disabilities. Under the Affordable Care Act (ACA, or “Obamacare,” Medicaid was expanded o cover all individuals earning incomes up to 138 percent of the federal poverty level. But states could choose whether they wanted to expand Medicaid, and the federal government had committed to paying up to 94 percent of that expansion cost in 2018, with the federal share declining to 90 percent in 2020 and beyond.  

According to ballotpedia, “As of October 2017, 19 states, including Maine, had chosen not to expand Medicaid. Governor Paul LePage vetoed legislation to expand Medicaid under the ACA five times.”

Opponents, including the Welfare to Work political action committee, which includes state representatives Deborah J, Sanderson, Heather W Sirocki, Richard Bennett and Gov. LePage, have said
that Maine taxpayers would have to pay up to $100 million annually for Medicaid expansion. They based their arguments on a Maine Heritage Policy Center report. The Maine Heritage Policy Center is a conservative nonprofit focused on shaping Maine public policy.

Proponents, including the Maine Center for Economic Policy, maintain that the expansion will expand health coverage to 70,000 low-income Mainers and create 6,000 jobs. The Maine Center for Economic Policy, according to its self-description, is a nonpartisan, policy research organization committed to helping Maine people prosper in a strong, fair and sustainable economy.

Increasing access to health coverage will prevent family illness or health problems from turning into bankruptcy, loss of a home, and destitution, according to proponents of the measure to expand Medicaid.

Opponents said the measure will bloat the existing MaineCare system and translate to fewer resources for Maine's most vulnerable citizens. 

According to the Maine Secretary of State’s Citizen’s Guide to the Nov. 7, 2017 election: “In summary, when fully implemented, this initiative is anticipated to require net annual appropriations from the General Fund of $54,495,000. Federal costs would be around $525,000,000 annually. If approved by the voters, additional implementing legislation will be required to provide the additional appropriations and allocations.”

The Maine Office of the Attorney General said that to qualify for MaineCare under existing law, an adult must be a Maine resident and a U.S. citizen, or a permanent resident or legal alien (subject to some restrictions), who is in need of health care assistance. In addition, the adult must be one of the following:

• pregnant
• a parent or caretaker relative of a dependent child or children under age 18
• blind
• disabled, or
• 65 years of age or older
and must have income and assets below a certain level, which is defined differently in the law for each of the above categories of individuals and varies according to household size. For example, parents or caretaker relatives with one or more dependent children and disabled adults must have family incomes at or below 100% of the federal poverty level to qualify for MaineCare currently.

To be considered "disabled" under existing law, an adult must be found unable to engage in "any substantial gainful activity" (as defined in the Social Security Act) by reason of a physical or mental impairment that is medically determined and can be expected to result in death or to last for a continuous period of at least 12 months.

The initiated bill would expand coverage to include qualified adults (meeting existing residency and citizenship criteria) who are under the age of 65, not otherwise eligible for this assistance under existing law, and have family incomes at or below 138% of the federal poverty level. Thus, the initiative would extend MaineCare coverage of healthcare costs to:

• parents or caretaker relatives with one or more dependent children who have family incomes between 101% and 138% of the federal poverty level;

• adults with disabilities who have incomes between 101% and 138% of the federal poverty level; and

• adults with family incomes at or below 138% of the federal poverty level who do not have dependent children and are not "disabled" as that term is defined in the Social Security Act described above.

The federal poverty level is adjusted every year. In 2017, 138% of the federal poverty level means:
$16,643 for a single person
$22,412 for a family of two
$28,180 for a family of three
$33,948 for a family of four, and so on up to $57,022 for a family of eight

Under the terms of the federal Affordable Care Act, by 2020, federal matching funds would cover 90% of the healthcare costs for the qualified adults under age 65 without dependent children who would be newly eligible under this expansion, while the State would cover the balance of 10%. Federal funds would cover 65% of the healthcare costs for parents or caretaker relatives with one or more dependent children who have household incomes between 101% and 138% of the federal poverty level. Additional information on the cost of implementing this initiative is provided in the fiscal note prepared by the Office of Fiscal and Program Review and published in this Citizen's Guide.

If approved, this citizen initiated legislation would take effect 30 days after the Governor proclaims the official results of the election.
A "YES" vote is to enact the initiated legislation.
A "NO" vote opposes the initiated legislation.

If passed, according to the state’s fiscal analysis:

The initiative will require annual General Fund appropriations of $2,578,609 for the Office of Family Independence - District program in the Department of Health and Human Services (DHHS) for the state share of the costs of 103 new positions to administer the MaineCare eligibility expansion. Funding for the new positions reflects a 75 percent federal match for the 79 Eligibility Specialist positions and a 50 percent  federal match for the other 24 new positions. The funding for the Eligibility Specialist positions assumes a 700 person caseload for each new position.

The initiative will require annual General Fund appropriations of $50,366,696 to the DHHS for medical costs for the newly eligible childless adult population. This amount represents 10 percent of the total cost, with federal matching funds used for the remaining 90 percent.

The initiative will require annual General Fund appropriations of $28,139,957 to the DHHS for medical costs for the parent's population between 101 percent to 138 percent of the federal poverty level. This amount represents 35 percent of the total cost, with federal matching funds used for the remaining 65 percent.

The initiative will require annual General Fund appropriations of $409,745 to the DHHS for medical costs for the children who have not had MaineCare in the past, but whose family will opt for MaineCare coverage after expansion. This amount represents 2 percent of the total cost, with federal matching funds used for the remaining 98 percent.

Although overall costs will increase under this initiative, some programs will achieve savings that will mitigate the additional expenditures. The savings that are generated within existing programs are estimated to be $27,000,000 annually and are already taken into account in the summary of costs and revenues in this fiscal impact statement.

Additional costs for the Legislature's Office of Fiscal and Program Review for certain review and reporting functions can be absorbed within existing budgeted resources.
In summary, when fully implemented, this initiative is anticipated to require net annual appropriations from the General Fund of $54,495,000. Federal costs would be around $525,000,000 annually. If approved by the voters, additional implementing legislation will be required to provide the additional appropriations and allocations.