Medicaid Expansion in Maine Moves from the Legislature to the Courts

Maine statehouse dome in AugustaA successful citizens referendum to expand Medicaid stalled in the state Legislature and moved to the courts this week.

Over the past five years, the Maine Legislature has passed several bills to expand the state’s Medicaid program – MaineCare – under the provisions of the Affordable Care Act to cover a greater number of low-income residents. Every year, Maine Governor Paul LePage vetoed the legislation, and the Legislature was unable to muster enough votes to override his veto.

In November 2017, Maine voters approved Medicaid expansion in a referendum with 59 percent of the vote. Under Maine’s constitution, the governor cannot veto a referendum passed by citizens’ initiative, and the referendum became law in early January of this year.

The expansion law lays out a series of actions Maine’s Department of Health and Human Services must take to implement the expansion of coverage to people earning up to 138 percent of the federal poverty level. Specifically, the law directs the department to submit a state plan amendment (SPA) to the Centers for Medicare & Medicaid Services (CMS) no later than 90 days following the effective date of the law, which was April 3, 2018. It also directs the state to adopt any necessary rules required to make certain that people who are eligible for coverage under the expansion are enrolled by July 2, 2019.

In the most recent legislative session, Maine lawmakers reviewed the Medicaid expansion referendum language and debated how much should be appropriated to fund the expansion. Two weeks ago, the legislature adjourned without addressing or funding the expansion.

Governor LePage contends he cannot implement the expansion until it is funded. The law does not link implementation of the expansion to CMS approval of Maine’s SPA, nor does it require the identification of specific funding to underwrite any costs associated with the expansion. It simply compels the state to implement the law in the stated timeline.

To date, the Maine has not filed the SPA required by the language of the law and this week a group of advocates and individuals who would be eligible for Medicaid coverage under the expansion filed a lawsuit in state court to compel the state to file the SPA.

The lawsuit is the first salvo in what promises to be the judicial phase of the protracted struggle over Medicaid expansion in Maine. Frustrated advocates in a number of other states, where expansion has not yet been adopted, are considering mounting a referendum campaign similar to Maine’s. Advocates in Utah and Idaho have collected enough signatures to put an expansion referendum on the ballot, and advocates continue to collect signatures in Nebraska and Montana.