Maine Medicaid Vote Sets Stage for Other States’ Expansion Efforts

Stay ahead of developments in federal and state health care law, regulation and transactions with timely, expert news and analysis.

By Victoria Pelham

Maine’s innovative use of the ballot box to expand Medicaid coverage will likely lay the groundwork for future initiatives in other parts of the country.

“I certainly think it is a real wake-up call for states where there has been strong popular support for the expansion but elected officials who for philosophical reasons have opposed it,” Sara Rosenbaum, health policy professor with George Washington University, told Bloomberg Law Nov. 8, the day after Maine voters approved a Medicaid expansion measure.

That could mean a jolt of support in places that have already mulled the idea such as Idaho and Kansas, she said. Rosenbaum until recently chaired a congressional advisory group on Medicaid.

Medicaid expansion under the Affordable Care Act is optional for states. The Kaiser Family Foundation estimates about 2.5 million people could be added to the Medicaid rolls if the remaining 19 states (including Maine) followed suit and expanded coverage. But getting those states to expand and finding the funding for such efforts are ongoing challenges.

Meanwhile, Republican lawmakers this year—with the Trump administration’s blessing—tried unsuccessfully to taper off the higher federal match rate for the expansion population.

Which Way Is Medicaid Headed?

Maine’s expansion vote fell the same day a federal official indicated the Trump administration may be clamping down on enrollments. Seema Verma, the administration’s top Medicaid official, told state officials Nov. 7 the Centers for Medicare & Medicaid Services would approve waivers requiring more of able-bodied, working-age expansion beneficiaries, saying they’re straining a program intended for vulnerable groups and placing a premium on them with a higher federal match.

They should be helping them “move up, move on, and move out,” Verma said. Verma is a former consultant who worked with the Indiana Medicaid program.

Gauging Support

Support will probably grow for Medicaid expansion across state lines in the wake of the Maine vote, health law experts said.

“I imagine [others] will take heart from what happened in a state that’s quite conservative in many ways,” Rosenbaum said.

Kansas, Tennessee, North Carolina, Georgia, and Idaho have all seen strong pushes to try to approve Medicaid expansion. The ACA expansion by a majority of the states added about 11 million people with income up to 138 percent of poverty level.

Utah also has an initiative in the works to get a Medicaid expansion vote onto its ballot.

This could spur those conversations forward as their legislative sessions pick up in 2018, Cindy Mann, a partner with Manatt Health, said. And new states could start to consider growing their safety-net programs. What form that could take is more up in the air, since some states don’t allow a vote like Maine’s. More likely will be reinvigorated debates and potential legislative efforts into 2019.

“Now people have spoken at the ballot, so it’s a pretty powerful endorsement of the idea that people should have coverage,” she told Bloomberg Law.

Mann was a CMS official in the Obama administration.

Overstating Impact?

But not everyone saw that as the takeaway.

Michael Cannon, the libertarian Cato Institute’s director of health policy studies, told Bloomberg Law Nov. 8 that Maine’s vote to expand Medicaid was “phony” and a “meaningless poll” because it didn’t include tax increases or detail how the state would cover its cost.

“Whether the people really want this is not the question this referendum answers,” he said. “This referendum answered the question, ‘Would you want it if it were free?’”

States would have to pick up a 10 percent tab for the new enrollees, with a federal match rate of 90 percent—money Cannon said is being borrowed from the future generation. If ballots really want to measure support, there should be a referendum on a mechanism to cover that full 100 percent cost.

This, instead, sends a message to other state officials that “if you want to make Obamacare’s Medicaid expansion look popular, have a phony referendum like this one,” Cannon said.

Challenges Ahead

Policy analysts across the ideological spectrum said the Maine referendum will also set the stage for challenges. Already, Maine’s Republican governor, Paul LePage, has warned he won’t take action to expand the state’s Medicaid program until the dollars have been appropriated in the Legislature, and won’t agree to raise taxes, use money from Maine’s rainy day fund, or reduce services for seniors and the disabled.

It’s up against the same obstacles other states have faced on how to finance it, Cannon said.

“Voters reject the sweeping tax increases that would be necessary to expand these federal health-care programs,” he added.

Rosenbaum and Mann took issue with that claim, pointing out that states often see savings when they expand such as by bringing in federal resources to help cover the cost of existing state and local programs and reducing uncompensated care.

Additionally, Verma’s Nov. 7 speech signaled an intent to approve state requests to make Medicaid requirements more restrictive for expansion beneficiaries. Verma was involved in crafting Indiana’s expansion plan laden with cost-sharing and other conservative elements.

The Obama administration continually rejected work requirements, believing them to be contrary to the Medicaid statute’s goal of boosting coverage and care. “The thought that a program designed for our most vulnerable citizens should be used as a vehicle to serve working age, able-bodied adults does not make sense,” Verma said Nov. 7.

The Trump administration’s stance might raise obstacles to states pursuing expansions going forward, some said.

Rosenbaum said she’s concerned about the future of expansion waivers and if the Trump administration will block expansion efforts or make it harder to gain approval if they don’t include a work requirement or “play ball” with what federal officials want. And she called the language about able-bodied beneficiaries a “smear” of “poor, working-age adults, most of whom work in jobs where there are are no health benefits.”

The efforts in Washington to change the Medicaid program—which covered 74.8 million people in 2017, according to a recent PricewaterhouseCoopers report—point to why expansion advocates should consider referendums covering the full cost of expanding the program, Cannon said.

Verma’s speech “tells states that this is not your father’s Medicaid expansion or Medicaid program,” he said. “If you think you’re going to expand Medicaid and get the Medicaid program you want, you may be mistaken about that.”

Mann said administration officials might not like an expansion, but they can’t stop a state from doing something allowed by law.

To contact the reporter on this story: Victoria Pelham in Washington at

To contact the editor responsible for this story: Brian Broderick at

Copyright © 2017 The Bureau of National Affairs, Inc. All Rights Reserved.

Request Health Care on Bloomberg Law