Maine Question 2, Medicaid Expansion Initiative (2017)

Maine Question 2
Election date November 7, 2017
Topic Healthcare and Welfare
Status a Approved
Type State statute	Origin Citizens

2017 measures
June 13, 2017
Maine Question 1
November 7, 2017
Maine Question 1
Maine Question 2
Maine Question 4
Maine Question 3

Maine Question 2, the Medicaid Expansion Initiative, was on the ballot in Maine as an indirect initiated state statute on November 7, 2017. It was approved.

A "yes" vote supported this initiative to require the state to provide Medicaid through MaineCare for persons under the age of 65 and with incomes equal to or below 138 percent of the federal poverty line.

A "no" vote opposed this initiative to require the state to provide Medicaid through MaineCare for persons under the age of 65 and with incomes equal to or below 138 percent of the federal poverty line.

Aftermath

On January 3, 2019, Maine Gov. Janet Mills (D) signed an order to expand Medicaid, known as MaineCare in Maine, citing the approval of Question 2, a ballot initiative, in 2017. Question 2 was the first citizen-initiated measure to expand Medicaid via Obamacare. The state's plan for expanded coverage required approval from U.S. Centers for Medicare and Medicaid Services (CMS). On April 3, 2019, Gov. Mills announced that CMS had approved the state's plan, which included expanded Medicaid coverage retroactively from July 2, 2018.

Gov. Mills’ predecessor, Paul LePage (R), said his administration would not file an application with the federal government to expand Medicaid unless the legislature could fund expansion without tax increases or one-time funding mechanisms. In April 2018, several organizations that supported Question 2 sued the governor’s administration in a case that ended up going before the Maine Supreme Judicial Court. The state Supreme Judicial Court ordered Gov. LePage to submit an expansion plan to the federal government in June 2018. In August, Gov. LePage wrote a letter to U.S. Health and Human Services asking officials to reject the plan that Maine filed to expand Medicaid. In November 2018, the issue was back in court, with a superior court judge ruling that the governor’s actions went against the initiative’s objectives. The judge extended the deadline for implementation to February 1, 2018.

Post-2017 initiative plans for Medicaid expansion

Following the approval of Question 2, Jonathan Schleifer, Executive Director of The Fairness Project, noted that similar initiatives to expand Medicaid had been filed in other states, such as Utah, Idaho, and Nebraska, for 2018. Schleifer said, "We need to end the conversation around repealing Obamacare and make it very clear, as we did last night, that folks want to expand it. We’re not waiting until 2020, we’re going to get as much of this done in 2018 as we can."

Implementing Question 2

On November 8, 2017, Gov. Paul LePage (R), who vetoed legislation to expand Medicaid five times, released a statement following the vote on Question 2, which said, "Credit agencies are predicting that this fiscally irresponsible Medicaid expansion will be ruinous to Maine’s budget. Therefore, my administration will not implement Medicaid expansion until it has been fully funded by the Legislature at the levels DHHS [Department of Health and Human Services] has calculated, and I will not support increasing taxes on Maine families, raiding the rainy day fund or reducing services to our elderly or disabled.”

The Maine Office of Fiscal and Program Review estimated that the state's portion of the cost would be about $54.5 million per year, while Gov. LePage said the cost would be closer to $100 million.

On December 11, 2017, Gov. LePage laid out the criteria that he wanted to be met to fund Medicaid expansion before he ordered the DHHS to implement Question 2. He listed the following:

• no tax increases for families or businesses;
• no use of the Budget Stabilization Fund;
• no one-time funding mechanisms; and
• full funding of Section 21 and 29 waitlists (healthcare services for people with developmental disabilities) and no reduction in healthcare services for seniors and people with disabilities.

Gov. LePage explained his criteria, stating, "I refuse to raise your taxes. Maine is a poor state. We cannot count on our economy to generate new revenues to cover expansion." House Speaker Sara Gideon (D-48) criticized the governor's letter, saying, "It must be hard to be a person who simply says no and looks for ways to make sure that others don’t have health care, don’t have access to a doctor, to make sure the state doesn’t receive a half billion dollars injected into the economy that comes when this Medicaid expansion happens."

The Maine Appropriations and Financial Affairs Committee began discussions on funding and implementing Question 2 on December 13, 2017. Rep. Drew Gattine (D-34), following the discussions on December 13, stated, "We’re a ways away from figuring out how much money we’re going to need and when we’re going to need it."

In Maine, initiatives go into effect 30 days after the official proclamation of election results. An initiative requiring spending beyond available funds, however, and that does not provide a funding mechanism, can be delayed until 45 days into the following legislative session. Question 2 was written to give the Department of Health and Human Services (DHHS) 90 days after the effective date to submit a plan to the federal government and 180 days to begin expanded coverage.

On April 3, 2018, the state missed the deadline to file an application for Medicaid expansion with the federal government in order to secure funding by July 2018, as required by Question 2.

Attorney General Janet Mills (D) called on Gov. LePage to implement Question 2 in April 2018. She said, "The law is the law. Medicaid expansion has been enacted into law by the people. There is really, in my view, no legal way to get around that. And the funds are available to get us through the biennium."

Maine Equal Justice Partners et al. v. Hamilton

  

Lawsuit overview
Issue: Implementation—whether the Maine Department of Health & Human Services is required to submit a plan for Medicaid expansion
Court: Kennebec County Superior Court and Maine Supreme Judicial Court
Ruling: Ruled in favor of plaintiffs, requiring the state to file a plan to expand Medicaid
Plaintiff(s): Maine Equal Justice Partners, Consumers for Affordable Health Care, Maine Primary Care Association, Cassie Steimlosk, Donna Wall, Charles McDaniel, Ann Avery, Gina Zamello, and Penobscot Community Health Care	Defendant(s): Ricker Hamilton, Commissioner of Maine Department of Health & Human Services
Plaintiff argument: The Maine Department of Health & Human Services is required, per Question 2, to submit a plan for Medicaid expansion	Defendant argument: Courts cannot require expenditures, as that would violate the separation of powers between courts and the legislature.

  Source: Kennebec County Superior Court

On April 30, 2018, Maine Equal Justice Partners, along with three other organizations and five individuals, filed litigation against the state to implement Question 2. Ricker Hamilton, a commissioner of the Maine Department of Health & Human Services (DHHS) who oversees MaineCare, was named as the defendant. The plaintiffs asked the Kennebec County Superior Court to declare that Commissioner Hamilton is obliged, per Question 2, to submit a state plan for Medicaid expansion to the U.S. Department of Health and Human Services. Plaintiffs said there was no lawful reason for the commissioner to not submit a plan.

On April 30, Gov. LePage's office said he was unable to comment on active litigation. However, the governor did release a statement, which said, "While I remain adamantly opposed to the policy of expanding Medicaid because it threatens our state's financial stability, the legislature is allowing it to become the law. You, the Legislature now must do your job to fund it as quickly as possible so the Executive branch can do its job: execute the law. But I will not implement it without adequate funding." Commissioner Hamilton stated that courts cannot require expenditures, as that would violate the separation of powers between courts and the legislature.

On June 4, 2018, Judge Michaela Murphy ordered the state to file a plan with the federal government to expand Medicaid by June 11. Judge Murphy said that she was “not persuaded that the executive branch is excused from clear statutory obligations by the legislature’s failure to follow through with legislative obligations — as defined by the executive branch.”

On June 7, 2018, the governor's administration appealed the ruling to the Maine Supreme Judicial Court. On August 23, the state Supreme Judicial Court, in a six-to-one ruling, upheld the lower court's order for Gov. LePage's administration to submit an expansion plan to the federal government.

Expansion plan filed

On August 31, 2018, Gov. LePage wrote a letter to U.S. Health and Human Services Secretary Alex Azar and U.S. Centers for Medicare and Medicaid Services administrator Seema Verma, asking them to reject the plan that the Maine DHHS filed to expand Medicaid. He wrote, "I strongly encourage CMS (U.S. Centers for Medicare and Medicaid Services) to reject the State Plan Amendment that may soon be submitted by the Maine Department of Health and Human Services pursuant to court order. ... If accepted, the [State Plan Amendment] would commit Maine to expanding the Medicaid program to an additional 70,000 to 90,000 individuals. However, not one dime of the hundreds of millions of dollars that will be needed to pay for the state’s share of the expansion has been appropriated."

Review of department action

Plaintiffs, including Maine Equal Justice Partners (MEJP), asked the court to review the DHHS's expansion plan and Gov. LePage's actions. On November 21, 2018, Judge Michaela Murphy ordered the DHHS to begin expanding Medicaid on December 5, 2018, with a retroactive application date of July 2, 2018.

Judge Murphy said, "Although the Governor may believe implementation to be unwise and disagree with the [expansion initiative] as a matter of policy, he may not ignore the will of the people and refuse to take any action toward accomplishing the policy objectives of the [initiative]." She also said the DHHS commissioner had access to existing appropriations to expand Medicaid.

On November 26, 2018, the DHHS appealed the case, saying that expansion would "prompt a fiscal crisis by requiring the expenditure of funds needed to provide care for the even poorer population that currently receives (Medicaid) services." On December 5, 2018, Judge Murphy defined the DHHS' appeal but extended the deadline for implementation to February 1, 2018.

Gov. Janet Mills

On January 2, 2019, Janet Mills (D) was sworn in as the state's governor, succeeding Paul LePage (R). On January 3, 2019, Gov. Mills ordered the DHHS to begin expanding Medicaid under Question 2. The state's plan for expanded coverage approved by Gov. Mills required approval from U.S. Centers for Medicare and Medicaid Services (CMS). On April 3, 2019, Gov. Mills announced that CMS had approved the state's plan, which included expanded Medicaid coverage retroactively from July 2, 2018.

Overview

Obamacare and Medicaid in Maine

Medicaid is a government program that provides medical insurance to groups of low-income people and individuals with disabilities. Maine's Medicaid program is known as MaineCare. The Affordable Care Act (ACA), also known as Obamacare, provided for the expansion of Medicaid to cover all individuals earning incomes up to 138 percent of the federal poverty level. In 2012, the U.S. Supreme Court ruled in NFIB v. Sebelius that the federal government could not withhold funds from states that refused to expand Medicaid. The ruling had the practical effect of making Medicaid expansion optional for states. In 2018, the federal government financed 94 percent of the costs of state Medicaid expansion. For 2020 and subsequent years, the federal government was set to cover 90 percent of the costs. As of October 2017, 19 states, including Maine, had chosen not to expand Medicaid. Governor Paul LePage (R) vetoed legislation to expand Medicaid under the ACA five times. Maine Question 2 was the first instance in the country of Medicaid expansion through a citizen initiative.

Initiative design

Question 2 was designed to require the state government to provide Medicaid through MaineCare for persons under the age of 65 and with incomes equal to or below 138 percent of the official poverty line. In 2017, this amounted to annual income of $16,643 or less for an individual and $33,948 or less for a household of four. According to the Portland Press Herald, the initiative could expand Medicaid coverage to around 70,000 additional people. Other analyses estimated that it would affect about 80,000 residents. The Maine Department of Health and Human Services (MDHHS) was required by the initiative present a plan to the U.S. Department of Health and Human Services for approval within 90 days of the measure taking effect. MDHHS was allotted 180 days following the measure's effective date to adopt rules to ensure that people eligible for Medicaid under the expansion have access to services. In Maine, initiatives normally go into effect 30 days after the official proclamation of election results. If the initiative requires spending beyond available state funds, however, and does not provide a funding mechanism, the effective date of the initiative can be delayed until 45 days into the following legislative session. The 2018 legislative session started on January 3, 2018.

State of the ballot measure campaigns

Mainers for Health Care, the support campaign, and other supporting PACs had raised $2.67 million. The largest contributor to the campaign was The Fairness Project, which donated $1.05 million. Opponents organized as the Welfare to Work PAC, which received $427,785. The largest contributors to the opposition were two individuals who each donated $50,000—George Schott and Paul Coulombe.

Election results

Question 2
Result		Votes	Percentage
a Yes		203,080	58.95%
No		141,436	41.05%

Election results from Portland Press Herald

Vote in Pivot Counties

See also: Pivot Counties: The counties that voted Obama-Obama-Trump from 2008-2016 and Pivot Counties in Maine

Voters in Maine passed Question 2, with 58.95 percent voting to enact the initiative. Voters in Maine’s eight Pivot Counties were divided on Question 2, an initiative designed to expand Medicaid under the Affordable Care Act, also known as Obamacare. Pivot Counties are counties that voted for Donald Trump (R) in 2016 after voting for Barack Obama (D) in 2008 and 2012. Trump campaigned on repealing the ACA, and Republicans in Congress sponsored bills to repeal and replace the healthcare law in 2017.

The total combined “yes” vote of electors in Maine’s eight Pivot Counties on Question 2 was 51.43 percent, 6.37 percentage points more than in Maine’s one Republican county and 13.24 percentage points less than in Maine’s seven Democratic counties. The following scatterplot illustrates how the state's 16 counties voted on Question 2 relative to how the counties voted in the 2016 presidential election.

Somerset and Aroostook counties, located along the state’s northern border with Canada, voted within a percentage point of Piscataquis County, and they were the only counties where a majority of electors voted against question 2. In 2016, Trump relied on the state’s northern counties to win the 2nd Congressional District and split the state’s electoral votes with Hillary Clinton.

The remaining six Pivot Counties voted to pass Question 2, with “yes” vote totals falling between 50.89 percent in Washington County and 56.00 percent in Kennebec County. The average countywide vote to approve the initiative in the Pivot Counties was 50.63 percent.

Click "Show" on the table below to view the election results data for Question 2.

Vote on Question 2 (2016) in Maine Pivot, Democratic, and Republican Counties
County	Type	Trump Margin in 2016	Percent "Yes" on Question 2	Percent "No" on Question 2
Androscoggin	Pivot	9.39%	51.56%	48.44%
Aroostook	Pivot	17.19%	45.77%	54.23%
Cumberland	Democratic	-26.35%	69.14%	30.86%
Franklin	Pivot	5.47%	52.57%	47.43%
Hancock	Democratic	-7.51%	61.89%	38.11%
Kennebec	Pivot	3.58%	56.00%	44.00%
Knox	Democratic	-14.24%	65.44%	34.56%
Lincoln	Democratic	-2.39%	59.46%	40.54%
Oxford	Pivot	12.94%	51.54%	48.46%
Penobscot	Pivot	10.91%	51.28%	48.72%
Piscataquis	Republican	25.14%	45.06%	54.94%
Sagadahoc	Democratic	-6.29%	61.90%	38.10%
Somerset	Pivot	22.67%	45.42%	54.58%
Sagadahoc	Democratic	-0.28%	59.05%	40.95%
Washington	Pivot	18.44%	50.89%	49.11%
York	Democratic	-4.76%	60.78%	39.22%
Aggregate Pivot Counties Vote		11.07% (36,275 vote margin)	51.43% (74,040 votes)	48.57% (69,923 votes)
Average Pivot Counties Vote		12.57%	50.63%	49.37%

Text of measure

Ballot question

The official ballot question was as follows:

“

Do you want Maine to expand Medicaid to provide healthcare coverage for qualified adults under age 65 with incomes at or below 138% of the federal poverty level, which in 2017 means $16,643 for a single person and $22,412 for a family of two?

”

Ballot summary

The ballot summary for the initiative was as follows:

“

This initiated bill requires the State to provide federally approved Medicaid services through MaineCare to qualifying persons under 65 years of age with income equal to or below 133% plus 5% of the nonfarm income official poverty line. The initiated bill requires the Department of Health and Human Services to prepare and submit to the Federal Government any state plan amendments, no later than 90 days after the effective date of the initiated bill, necessary to implement the provisions of the initiated bill. The initiated bill requires monthly reporting by the department to the appropriate joint standing committees of the Legislature on the status of a state plan amendment submission until such an amendment is approved and reporting on the status of implementation of the expanded coverage under MaineCare and on the status of implementation and savings generated to state-funded programs as a result of the expanded coverage. It requires the Department of Administrative and Financial Services, Maine Revenue Services to report on revenues generated as a result of expanded coverage. It requires any savings to be transferred to the MaineCare Stabilization Fund prior to the end of fiscal year 2018-19. It requires the Office of Fiscal and Program Review to independently review these reports and report its findings to the appropriate joint standing committees of the Legislature.

”

Full text

The following is the full text of the measure. The underlined text was be added, and struck-through text was be deleted from existing statute:

PART A Sec. A-1. 22 MRSA §3174-G, sub-§1, ¶F, as amended by PL 2011, c. 380, Pt. KK, §2, is further amended to read: F. A person 20 to 64 years of age who is not otherwise covered under paragraphs A to E when the person's family income is below or equal to 125% of the nonfarm income official poverty line, provided that as long as the commissioner shall adjust adjusts the maximum eligibility level in accordance with the requirements of the paragraph. (2) If the commissioner reasonably anticipates the cost of the program to exceed the budget of the population described in this paragraph, the commissioner shall lower the maximum eligibility level to the extent necessary to provide coverage to as many persons as possible within the program budget. (3) The commissioner shall give at least 30 days' notice of the proposed change in maximum eligibility level to the joint standing committee of the Legislature having jurisdiction over appropriations and financial affairs and the joint standing committee of the Legislature having jurisdiction over health and human services matters; and Sec. A-2. 22 MRSA §3174-G, sub-§1, ¶G, as enacted by PL 2011, c. 380, Pt. KK, §3, is amended to read: G. A person who is a noncitizen legally admitted to the United States to the extent that coverage is allowable by federal law if the person is: (1) A woman during her pregnancy and up to 60 days following delivery; or (2) A child under 21 years of age.; and Sec. A-3. 22 MRSA §3174-G, sub-§1, ¶H is enacted to read: H. No later than 180 days after the effective date of this paragraph, a person under 65 years of age who is not otherwise eligible for assistance under this chapter and who qualifies for medical assistance pursuant to 42 United States Code, Section 1396a(a)(10)(A)(i)(VIII) when the person's income is at or below 133% plus 5% of the nonfarm income official poverty line for the applicable family size. The department shall provide such a person, at a minimum, the same scope of medical assistance as is provided to a person described in paragraph E. Cost sharing, including copayments, for coverage established under this paragraph may not exceed the maximum allowable amounts authorized under section 3173C, subsection 7. No later than 90 days after the effective date of this paragraph, the department shall submit a state plan amendment to the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services ensuring MaineCare eligibility for people under 65 years of age who qualify for medical assistance pursuant to 42 United States Code, Section 1396a(a)(10)(A)(i)(VIII). The department shall adopt rules, including emergency rules pursuant to Title 5, section 8054 if necessary, to implement this paragraph in a timely manner to ensure that the persons described in this paragraph are enrolled for and eligible to receive services no later than 180 days after the effective date of this paragraph. Rules adopted pursuant to this paragraph are routine technical rules as defined by Title 5, chapter 375, subchapter 2A. Sec. A-4. Interim reporting. Between the effective date of the Maine Revised Statutes, Title 22, section 3174G, subsection 1, paragraph H and the dates of approval of the state plan amendment by the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services necessary for implementation of Title 22, section 3174G, subsection 1, paragraph H, the Department of Health and Human Services shall provide monthly reports to the joint standing committee of the Legislature having jurisdiction over health and human services matters and to the joint standing committee of the Legislature having jurisdiction over appropriations and financial affairs on the progress of implementation of that paragraph, any issues that might delay implementation or act as barriers to implementation and any possible solutions to those issues and barriers. Sec. A-5. Reporting on implementation status. No later than one year after the effective date of the Maine Revised Statutes, Title 22, section 3174G, subsection 1, paragraph H, the Commissioner of Health and Human Services shall report to the joint standing committee of the Legislature having jurisdiction over health and human services matters and to the joint standing committee of the Legislature having jurisdiction over appropriations and financial affairs on the status of implementation of Title 22, section 3174G, subsection 1, paragraph H, including information on enrollment, costs, revenues generated from the Federal Government and other revenues, anticipated state savings and other issues pertinent to implementation. PART B Sec. B-1. Calculation and transfer of savings. The Commissioner of Health and Human Services, the Commissioner of Corrections and any state agency that recognizes savings as a result of implementation of the Maine Revised Statutes, Title 22, section 3174G, subsection 1, paragraph H shall report within 60 days prior to the end of the first 12 months of enrollment under the Maine Revised Statutes, Title 22, section 3174G, subsection 1, paragraph H to the joint standing committee of the Legislature having jurisdiction over health and human services matters, the joint standing committee of the Legislature having jurisdiction over appropriations and financial affairs and the joint standing committee of the Legislature having jurisdiction over criminal justice and public safety matters on the amount of General Fund savings and other savings resulting from coverage provided under that paragraph, including but not limited to savings to substance abuse and mental health programs; medical services provided to persons in the care and custody of, or upon release by, the Department of Corrections or a county jail or regional jail; reimbursement to cities and towns for general assistance provided under Title 22, chapter 1161; services provided for individuals 21 years of age or older and under 64 years of age who are currently eligible for the MaineCare program under medically needy, spend-down criteria; services provided under the MaineCare program, Section 1115 Health Care Reform Demonstration for Individuals with HIV/AIDS; services provided for parents participating in family reunification activities under Title 22, chapter 1071; an estimate of savings for services provided to individuals who previously would have pursued a disability determination to qualify for coverage; services provided to individuals awaiting a MaineCare program disability determination for whom the applications are subsequently granted; services provided under the State's breast and cervical cancer treatment program; and other programs in which savings are achieved. The report must include the amount of savings realized during the preceding fiscal year by service area or program and the amount of savings projected to be achieved during the remainder of that fiscal year and during the next fiscal year by service area or program. Sec. B-2. Reporting of revenue. The Department of Administrative and Financial Services, Maine Revenue Services shall report to the joint standing committee of the Legislature having jurisdiction over appropriations and financial affairs no later than 60 days following the end of the first 12 months of enrollment under the Maine Revised Statutes, Title 22, section 3174G, subsection 1, paragraph H regarding any new revenues, including any increase in federal medical assistance payments resulting from coverage provided under Title 22, section 3174G, subsection 1, paragraph H. Prior to the end of state fiscal year 2018-19, the State Controller shall transfer any savings amounts identified under this section to the MaineCare Stabilization Fund established under Title 22, section 3174KK. Sec. B-3. Evaluation by legislative office. Within 90 days after the end of the first 12 months of enrollment under the Maine Revised Statutes, Title 22, section 3174G, subsection 1, paragraph H, the Office of Fiscal and Program Review shall independently review reports required pursuant to sections 1 and 2 of this Part and report to the joint standing committee of the Legislature having jurisdiction over appropriations and financial affairs and the joint standing committee of the Legislature having jurisdiction over health and human services matters on its determination of the savings and new revenue, if any, resulting from implementation of Title 22, section 3174G, subsection 1, paragraph H. This report must also include information about the amount of federal funds received by the State as a result of coverage authorized under that paragraph.

Readability score

See also: Ballot measure readability scores, 2017

Using the Flesch-Kincaid Grade Level (FKGL and Flesch Reading Ease (FRE) formulas, Ballotpedia scored the readability of the ballot title and summary for this measure. Readability scores are designed to indicate the reading difficulty of text. The Flesch-Kincaid formulas account for the number of words, syllables, and sentences in a text; they do not account for the difficulty of the ideas in the text. The Maine secretary of state wrote the ballot language for this measure. The FKGL for the ballot title is grade level 16, and the FRE is 50. The word count for the ballot title is 39, and the estimated reading time is 10 seconds.

Support

Mainers for Health Care, also known as Yes on 2, led the campaign in support of the initiative.

Supporters

Committee

The support campaign's steering committee included the following organizations:

• Maine Center for Economic Policy
• Maine Equal Justice Partners
• Maine People's Alliance
• Maine Voices Network
• Planned Parenthood of Northern New England Maine Action Fund

Officials

• Attorney General Janet Mills (D)
• U.S. Rep. Chellie Pingree (D-1)

Former officials

• U.S. Sen. George Mitchell (D)

Organizations

• American Association of University Women (AAUW) Maine Chapter
• American College of Physicians - Maine Chapter
• Alliance for Addiction and Mental Health Services
• Alliance for Maine Women
• Bangor Area Homeless Shelter
• Coastal Enterprises, Inc. (CEI)
• Community Concepts
• Congolese Community of Maine
• Congregation Bet Ha'am
• Consumers for Affordable Health Care
• Daily Kos
• Eastern Maine Labor Council
• Equality Maine
• First Parish Portland Unitarian Universalist
• Food AND Medicine
• Frannie Peabody Center
• Friends (Quakers) Committee on Maine Public Policy
• Furniture Friends
• Greater Lovell Indivisible
• Indivisible Belfast
• Kennebec Valley Community Action Program
• Kennebec Valley Organization
• League of Women Voters of Maine
• Local Berniecrats Maine
• Mabel Wadsworth Center
• Maine AFL-CIO
• Maine All Care
• Maine Association of Interdependent Neighborhoods
• Maine Children's Alliance
• Maine Coalition to End Domestic Violence
• Maine Community Action Association
• Maine Council of Churches
• Maine Dental Hygienists Association
• Maine Family Planning
• Maine Hospital Association
• Maine Medical Association
• Maine Nurse Practitioner Association
• Maine Primary Care Association (MEPCA)
• Maine Providers Standing Up for Healthcare
• Maine Public Health Association
• Maine Small Business Coalition
• Maine State Nurses Association
• Maine Women's Lobby
• Maranacook Family Health Care
• MSEA-SEIU Local 198
• National Alliance on Mental Illness (NAMI) Maine
• National Association of Social Workers (NASW) Maine Chapter
• National Multiple Sclerosis Society, Greater New England Chapter
• New Mainers Public Health Initiative
• Northeast Occupational Exchange
• Pathways
• Penquis Community Action Program
• Preble Street
• Rising Tide Brewing Company
• Shalom House, Inc.
• Southern Maine Democratic Socialists of America
• Take Action Bethel
• The Bingham Program
• The Opportunity Alliance
• The Resistance Seacoast
• United Way of Greater Portland
• Waldo Community Action Partners
• YWCA Central Maine

Arguments

Mainers for Health Care, the campaign in support of Question 2, stated the following:

“

Federal funds were earmarked for Maine 3 years ago that would provide health insurance to 70,000 Mainers by expanding Medicaid coverage. The Maine Legislature passed legislation five times to put these federal funds to work for Maine. The Governor has vetoed each bill without having a true understanding of the implications. No one should be blocked from accessing affordable health insurance, especially when so many need care or medicine and there are simple ways to improve the system. Expanding access to Medicaid is a common sense move that will improve health, create 3000 jobs throughout the State, and help preserve Maine’s community hospitals and health centers that so many of us depend on. Increasing access to health coverage will prevent family illness or health problems from turning into bankruptcy, loss of a home, and destitution. Increasing access to treatment will help us address Maine’s drug crisis which is hurting our communities. We need to invest in treatment options so our family, friends, and neighbors who are battling addiction can get the help they need. During these uncertain times, it is more important than ever that we stand together, united for more affordable health care, not less!

”

Other arguments in support of the initiative included:

• Kathy Phelps, an initiative petition circulator and self-employed hairdresser, said, “My needs are simple so that I can live within my means. But I can’t afford the high cost of health insurance or health care on my own. At 59 years old, I still have 6 years to go before I qualify for Medicare. I know the voters in Maine want more health care, not less and will vote for this ballot initiative in November.”
• James Myall, a policy analyst for the Maine Center for Economic Policy, said, "Across the United States, Medicaid is playing a crucial role in responding to the fight against the opioid crisis—except in Maine—where one person per day is dying from a drug-related overdose, most of which are caused by opioid use."

Opposition

Welfare to Work, also known as Vote No on 2, led the campaign in opposition to Question 2.

Opponents

Officials

• Gov. Paul LePage (R)
• Rep. Heather Sirocki (R-28)
• Rep. Karen Vachon (R-29)

Organizations

• National Federation of Independent Business in Maine

Arguments

Welfare to Work, the committee in opposition to Question 2, stated the following:

“

Special interests pushing Medicaid expansion say it’s practically free, as federal taxpayers help cover some cost. That’s not true. Maine State taxpayers, right here in Maine, must pay up to $100 Million per year for welfare Medicaid expansion according to a detailed study from the Maine Heritage Policy Center. The Maine Legislature’s own budget analysis office says the cost is guaranteed to be at least $50+ million per year. This money must be paid by the State Legislature and comes directly from the State of Maine. Those pushing Question 2 won’t say where it will come from… but we know from history what will likely happen. None of it is good.

”

Other arguments in opposition to the initiative include:

• The Maine Republican Party issued a statement in response to the initiative, noting that the Affordable Care Act was likely to be repealed or changed by Congress and President Donald Trump (R). Released in January 2017, the statement said, "We are likely witnessing the introduction of a referendum that would have no effect other than misguided demands that Maine taxpayers would be saddled with, and potentially, even more welfare costs. The easiest way to explain this stunt is that Democrats are basically selling tickets on the Titanic as it sinks."
• Mary Mayhew, commissioner of the Maine Department of Health and Human Services, stated, "A bloated Medicaid system means fewer resources for Maine's most vulnerable citizens—our elderly and disabled. When MaineCare is running $50 million to $100 million annual shortfalls—it hinders the state from making investments in other key priorities, such as our infrastructure, law enforcement, economic development or lowering Maine's uncompetitive tax rates for businesses and individuals."
• Rep. Heather Sirocki (R-28) said, "Question 2 will dramatically expand Medicaid, and the proposal before the voter involves health benefits for people who are able to work with no premiums, no sliding scale, no deductible. Where is the “skin-in-the-game”?"

Campaign finance

See also: Campaign finance requirements for Maine ballot measures

Five ballot question committees, Mainers for Health Care, Insure Maine's Future, The Fairness Project Maine PAC, Maine People's Alliance - BQC, and Planned Parenthood Maine Action Fund PAC were registered in support of the initiative. The committees raised $2.67 million. The Fairness Project was the top donor to support committees, providing $1.05 million or 39 percent of the campaign's total contributions. The committees expended $2.56 million. Insure Maine's Future was active during the signature drive, but was terminated thereafter.

One political action committee, the Welfare to Work PAC, was registered to oppose the initiative. The committee had received $427,785 in contributions and spent $414,170. The largest contributors to the opposition were two individuals who each donated $50,000—George Schott and Paul Coulombe.

	Cash Contributions	In-Kind Contributions	Total Contributions	Cash Expenditures	Total Expenditures
Support	$2,314,264.53	$408,707.36	$2,722,971.89	$2,184,297.13	$2,593,004.49
Oppose	$420,200.00	$7,585.24	$427,785.24	$406,585.20	$414,170.44
Total	$2,734,464.53	$416,292.60	$3,150,757.13	$2,590,882.33	$3,007,174.93

Support

The following table includes contribution and expenditure totals for the committees in support of the measure.

Committees in support of Question 2
Committee	Cash Contributions	In-Kind Contributions	Total Contributions	Cash Expenditures	Total Expenditures
Mainer's for Health Care	$1,924,388.48	$354,072.37	$2,278,460.85	$1,924,424.29	$2,278,496.66
Maine People's Alliance - BQC	$332,704.26	$0.00	$332,704.26	$222,250.87	$222,250.87
Insure Maine's Future	$5,000.00	$54,634.99	$59,634.99	$5,000.00	$59,634.99
Planned Parenthood Maine Action Fund PAC	$52,171.79	$0.00	$52,171.79	$32,621.97	$32,621.97
The Fairness Project Maine PAC	$0.00	$0.00	$0.00	$0.00	$0.00
Total	$2,314,264.53	$408,707.36	$2,722,971.89	$2,184,297.13	$2,593,004.49

Donors

The following were the top donors to the committee.

Donor	Cash Contributions	In-Kind Contributions	Total Contributions
Sixteen Thirty Fund	$800,000.00	$65,606.43	$865,606.43
The Fairness Project	$696,000.00	$0.00	$696,000.00
The Fairness Project	$325,000.00	$32,385.00	$357,385.00
Maine People's Alliance	$100,000.00	$105,861.79	$205,861.79
Open Society Policy Center	$200,000.00	$0.00	$200,000.00

Opposition

The following table includes contribution and expenditure totals for the committees in opposition to the initiative.

Committees in opposition to Question 2
Committee	Cash Contributions	In-Kind Contributions	Total Contributions	Cash Expenditures	Total Expenditures
Welfare to Work PAC	$420,200.00	$7,585.24	$427,785.24	$406,585.20	$414,170.44
Total	$420,200.00	$7,585.24	$427,785.24	$406,585.20	$414,170.44

Donors

The following were the top donors to the committee.

Donor	Cash Contributions	In-Kind Contributions	Total Contributions
George Schott	$50,000.00	$0.00	$50,000.00
Paul Coulombe	$50,000.00	$0.00	$50,000.00
Gary Bahre	$25,000.00	$0.00	$25,000.00
Robert Bahre	$25,000.00	$0.00	$25,000.00
Robert Fuller	$25,000.00	$0.00	$25,000.00

Methodology

To read Ballotpedia's methodology for covering ballot measure campaign finance information, click here.

Media editorials

See also: 2017 ballot measure media endorsements

Support

• Kennebec Journal and Morning Sentinel (CentralMaine.com) said: "Thirty-one states have participated in Medicaid expansion, and there is plenty of evidence that it has not broken the bank. Instead, expansion states report not only that their state budgets are stable, but their hospital balance sheets are positive and insurance rates are lower than in non-expansion states. This is a good deal. It’s time Maine took part in this program."
• Seacoast Media Group said: "Medicaid expansion has passed the Maine Legislature five times. Each of those times, it has been met with a veto from Republican Gov. Paul LePage. Gov. LePage is wrong, blinded to the needs of the people he was elected to serve by his nasty political ideology. We urge Maine voters to support Question 2 to expand Medicaid in the state."
• Bangor Daily News said: "Now, Maine voters have a chance to overcome LePage’s intransigence to join the states that have expanded the reach of health insurance to people who, although they are working hard, can’t afford it. [...] Simple math shows the benefits to Maine far outweigh the costs by nearly 10-to-1."

Opposition

Ballotpedia did not find media editorials opposing the measure. If you are aware of an editorial, please email it to editor@ballotpedia.org.

Background

Medicaid expansion under the ACA

See also: Medicaid and Obamacare

The Affordable Care Act (ACA), also known as Obamacare, was signed into law on March 23, 2010. The ACA provided for the expansion of Medicaid to cover all individuals earning incomes up to 138 percent of the federal poverty level, which amounted to $16,394 for individuals and $33,534 for a family of four in 2016. The law was designed to provide 100 percent of funding to cover the new recipients for the first three years and to cut off federal Medicaid funding to states that chose not to expand coverage. However, the United States Supreme Court ruled in National Federation of Independent Business v. Sebelius (2012) that the federal government could not withhold Medicaid funds from states that chose not to expand eligibility. According to the Kaiser Family Foundation, this ruling had the practical effect of making Medicaid expansion optional for states. By January 1, 2017, 19 states, including Maine, had chosen not to expand eligibility.

From 2014 to 2016, the federal government covered 100 percent of the costs of state expansion of Medicaid. In 2017, the total cost that the federal government financed decreased to 95 percent. The ACA was designed to decrease the amount the federal government covers to 94 percent in 2018, 93 percent in 2019, and 90 percent in 2020 and subsequent years.

The Affordable Care Act had not provided tax credits to adults with household incomes less than the federal poverty line because the law had aimed to cover these people under Medicaid. In states that did not expand Medicaid, many of these adults fell into a coverage gap in which they neither qualified for Medicaid nor for federal tax credits to purchase health insurance. As of 2016, around 2.6 million people fell into this coverage gap across the 19 states that did not expand Medicaid.

Status of Medicaid expansion in Maine

See also: Medicaid spending in Maine and Healthcare policy in Maine

Maine's Medicaid program is known as MaineCare. As of January 1, 2017, Maine had not expanded Medicaid under the Affordable Care Act (ACA). In his 2014 State of the State address, Governor Paul LePage (R) stated his opposition to Medicaid expansion, saying that "[w]e must protect our hard-working families from the higher insurance premiums and higher taxes that will result from further expansion." The state legislature passed bills expanding Medicaid under the ACA five times, but Gov. LePage vetoed each bill.

In 2016, Senators Thomas Saviello (R-17) and Roger Katz (R-15) co-sponsored a plan to expand Medicaid but to require enrollees to make premium payments equivalent to around two percent of their income for their insurance. The legislation, titled LD 633, was modeled on expansion plans proposed in Tennessee and Wyoming. In the Maine Senate, the bill was approved 18 to 17, with all Democrats and three Republicans voting in favor. The one-vote margin of approval indicated that the bill was not veto-proof, as overriding a governor's veto requires a two-thirds vote in Maine. LD 633 passed 85 to 64 in the Maine House of Representatives, with all Democrats and independents and three Republicans voting for approval. The bill was tabled and never received a concurrence vote in the Senate before the legislature adjourned.

Adoption of Medicaid expansion under the ACA

As of October 1, 2017, 31 states and D.C. had expanded Medicaid under the Affordable Care Act (ACA), and 19 states had chosen not to expand Medicaid. Maine was the only state in the northeastern United States not to expand Medicaid under the ACA.

Proposed changes to Medicaid in Maine

On January 25, 2017, Mary Mayhew, commissioner of the Maine Department of Health and Human Services, asked President Trump's nominee to lead the U.S. Department of Health and Human Services, U.S. Rep. Tom Price, to approve a number of changes to the state’s Medicaid program. Price became the U.S. Secretary of Health and Human Services on February 10, 2017. The following were changes outlined in Mayhew's letter to Price:

• Establish a work or education requirement for able-bodied adults to receive Medicaid.
• Establish a lifetime limit of five years, with limited exceptions, for able-bodied adults to receive Medicaid.
• Make able-bodied adults ineligible to receive transportation to and from non-emergency medical services; provide for more stringent requirements for when Medicaid recipients can receive transportation to and from non-emergency medical services.
• Charge monthly premium payments for adult Medicaid recipients with charges scaled to the ability to earn an income; remove Medicaid recipients who fail to pay monthly premiums for a set period.
• Charge monthly coinsurance payments of $20 for Medicaid recipients.
• Allow providers to seek a fee for missed services by Medicaid recipients.
• Establish an asset test to receive Medicaid.
• Waive the retroactive coverage of services during the 90 days prior to Medicaid eligibility.

Path to the ballot

See also: Laws governing the initiative process in Maine and Signature requirements for ballot measures in Maine

Petition drive

The ballot initiative was approved for circulation on October 28, 2016. Supporters of the measure needed to collect 61,123 valid signatures by January 26, 2017, to get the measure certified to appear on the 2017 ballot. The petition for the initiative had an expiration date of April 28, 2018, meaning petitioners could have collected signatures until that date and aimed for the 2018 ballot instead of the 2017 ballot.

On December 15, 2016, Maine Equal Justice Partners, an organization supporting the measure, reported that more than 65,000 signatures were collected from the state's 16 counties. Sponsors of the measure gave the state legislature until the signature filing deadline to pass a bill expanding Medicaid. No legislation expanding Medicaid was approved by January 25, 2017, one day before the deadline. A total of 70,302 signatures were submitted to the secretary of state's office on January 25, 2017.

The secretary of state had 30 days to certify the signatures. As 66,434 signatures were certified, the measure was sent to the state legislature for consideration during its 2017 legislative session.

Cost of signature collection:
Sponsors of the measure hired Maine Center for Economic Policy to collect signatures for the petition to qualify this measure for the ballot. A total of $965.74 was spent to collect the 61,123 valid signatures required to put this measure before voters, resulting in a total cost per required signature (CPRS) of $0.02.

Legislative action

The initiative was introduced into the Maine State Legislature as Legislative Document 1039 (LD 1039). On April 27, 2017, the state Senate voted to indefinitely postpone a vote on the initiative. As the state Legislature did not act on the initiative, the measure was certified for the ballot. The legislative session ran from December 7, 2016, through July 4, 2017. Approval by the legislature and governor would have enacted the law.

Drafting the ballot question

On August 2, 2017, Secretary of State Matt Dunlap (D) drafted a ballot question for Question 2. The public was allowed to file comments regarding the draft's form and content through September 1, 2017. The original draft of the ballot question described Medicaid as health insurance.

On August 22, 2017, Rick Bennett (R), former Maine Republican Party chairperson and former state Senate president, sent a letter asking the secretary of state to describe Medicaid as taxpayer-funded health benefits or government-funded health benefits, rather than health insurance. Rep. Heather Sirocki (R-28), Rep. Paula Sutton (R-95), Rep. Phyllis Ginzler (R-69), Rep. Ellie Espling (R-65), and Rep. Stephanie Hawke (R-89) co-signed the letter.

On August 24, 2017, Gov. Paul LePage (R) said Medicaid is "free health care paid for by the taxpayers, and it’s got to be said that way. ... It’s pure welfare. If you don’t want to call it welfare, call it an entitlement." He also stated, "They're calling it insurance. ... we probably have a basis to challenge that language. ... I'm going to challenge that [language]."

On September 7, 2017, Secretary of State Matt Dunlap (D) released the official ballot question for Question 2. The question described Medicaid as health coverage, whereas the original draft described Medicaid as health insurance.

Jason Savage, Executive Director of the Maine Republican Party, responded, "We thank Secretary of State Matt Dunlap for recognizing that Medicaid is not insurance. It is encouraging to see a correct and non-partisan decision made in the interest of informing voters about this very expensive proposal to expand Maine’s welfare benefits."

David Farmer, a spokesperson for the support campaign Mainers for Health Care, stated, "I think the Secretary of State’s Office did a good job of accurately describing what the initiative will do and who it will help. It is clear that Medicaid is insurance, but we believe describing the initiative as an effort to expand health care coverage follows the principles as required by law."

Reports and analyses

Editorial note: Ballotpedia includes coverage of studies and analyses conducted surrounding ballot questions because they can play a role in the campaigns both in support and opposition. By displaying the study below, Ballotpedia is not endorsing it or commenting on whether or not the report is accurate, unbiased, or comprehensive. If you know of an analysis or study conducted concerning Question 2 that is not listed below, please email editor@ballotpedia.org.

Elizabeth Kilbreth, PhD—Associate Research Professor Emerita in the Muskie School of Public Service

A study titled The Real Impact of Medicaid Expansion in Maine was published by Elizabeth H. Kilbreth, PhD. The study compared states in which Medicaid was expanded under the ACA and states in which it wasn't. It concluded that Question 2 could have the following effects:

• $490 million in federal funding added to the state's economy in 2018-2019 and similar amounts in later years;
• about 6,000 new jobs;
• about $714 million in new economic activity; and
• other effects included potentially lower increases in the cost of insurance premiums and fewer residents without coverage.

State profile

Demographic data for Maine
	Maine	U.S.
Total population:	1,329,453	316,515,021
Land area (sq mi):	30,843	3,531,905
Race and ethnicity**
White:	95%	73.6%
Black/African American:	1.1%	12.6%
Asian:	1.1%	5.1%
Native American:	0.6%	0.8%
Pacific Islander:	0%	0.2%
Two or more:	2%	3%
Hispanic/Latino:	1.5%	17.1%
Education
High school graduation rate:	91.6%	86.7%
College graduation rate:	29%	29.8%
Income
Median household income:	$49,331	$53,889
Persons below poverty level:	16.6%	11.3%
Source: U.S. Census Bureau, "American Community Survey" (5-year estimates 2010-2015) Click here for more information on the 2020 census and here for more on its impact on the redistricting process in Maine. **Note: Percentages for race and ethnicity may add up to more than 100 percent because respondents may report more than one race and the Hispanic/Latino ethnicity may be selected in conjunction with any race. Read more about race and ethnicity in the census here.

Presidential voting pattern

See also: Presidential voting trends in Maine

Maine voted for the Democratic candidate in all seven presidential elections between 2000 and 2024.

Pivot Counties (2016)

Ballotpedia identified 206 counties that voted for Donald Trump (R) in 2016 after voting for Barack Obama (D) in 2008 and 2012. Collectively, Trump won these Pivot Counties by more than 580,000 votes. Of these 206 counties, eight are located in Maine, accounting for 3.88 percent of the total pivot counties.

Pivot Counties (2020)

In 2020, Ballotpedia re-examined the 206 Pivot Counties to view their voting patterns following that year's presidential election. Ballotpedia defined those won by Trump won as Retained Pivot Counties and those won by Joe Biden (D) as Boomerang Pivot Counties. Nationwide, there were 181 Retained Pivot Counties and 25 Boomerang Pivot Counties. Maine had seven Retained Pivot Counties and one Boomerang Pivot County, accounting for 4.42 and 4.00 percent of all Retained and Boomerang Pivot Counties, respectively.

More Maine coverage on Ballotpedia

• Elections in Maine
• United States congressional delegations from Maine
• Public policy in Maine
• Endorsers in Maine
• Maine fact checks
• More...

Related measures

Other Medicaid expansion initiatives

Before Maine Question 2, the citizen initiative process had not been used to put Medicaid expansion before voters. As of November 16, 2017, however, initiatives to expand Medicaid were filed targeting a place on the 2018 ballot in the following states:

• Idaho
• Missouri
• Utah

Moreover, two Medicaid-related initiatives were filed for circulation in Alaska: the Alaska Medicaid and Denali KidCare Expansion Law Initiative and the Alaska Specific Affordable Care Act Requirements as State Law Initiative.

2017 healthcare-related measures

Healthcare measures on the ballot in 2017
State	Measures
Ohio	Ohio Issue 2: Drug Price Standards Initiative d

See also

Suggest a link

• Maine 2017 ballot measures
• 2017 ballot measures
• Laws governing the initiative process in Maine
• Healthcare on the ballot
• Healthcare policy in Maine
• Affordable Care Act

External links

Information

• Maine Secretary of State's List of Citizens Initiatives & People's Veto
• Maine Citizen’s Guide to the 2017 Referendum Election

Support

• Mainers for Health Care
• Mainers for Health Care on Facebook

Opposition

• Welfare to Work
• Welfare to Work on Facebook

Recent news

The link below is to the most recent stories in a Google news search for the terms Maine 2017 Medicaid expansion initiative. These results are automatically generated from Google. Ballotpedia does not curate or endorse these articles.

Maine Question 2, Medicaid Expansion Initiative (2017) - Google News