AP Photo/Robert F. Bukaty

Activist Susan Johnston helps coordinate the Election Day canvassing effort at the Mainers for Health Care headquarters in Portland

Imagine that expanding Medicaid coverage to tens of thousands of people somehow meant that hunting and fishing licenses would be more expensive. Fearing a price hike, hunters and fishermen would surely surge to the polls in off-year election to vote no on a Medicaid expansion ballot question. Which is why one of the ads unleashed by opponents of Maine’s Medicaid expansion voter initiative made that very—and very ridiculous—claim.

Maine’s Republican Governor, Paul LePage, pugnacious as usual, was the face of the anti-expansion campaign. He took to Maine’s influential talk radio programs to dial up his base, backed by a PAC called Welfare to Work launched by one of his former advisors in August to fight the Medicaid measure. The message? “Able-bodied people” looking “medical welfare” should get off their collective butts and get to work.

Those scare tactics backfired.

Mainers voted 59 percent to 41 percent to expand Medicaid, making Maine the first state to approve Medicaid expansion at the ballot box. Both the turnout and the margin of victory were higher than expected in a year with no candidate elections and just four voter initiatives on ballots statewide.

How do you successfully counter misinformation on an issue as critical as health care? Mainers for Health Care, the statewide coalition that helped lead the successful yes campaign, countered the hunting and fishing license price hikes and other tall tales by relentlessly repeating a few salient data points. Medicaid expansion would create 6,000 new jobs and give the state a $500 million infusion of federal funding each year. Most importantly, the measure would provide health care to 70,000 Mainers.

To get out the vote, canvassers hit the road and knocked on more than 200,000 doors. But according to Mainers for Health Care’s David Farmer, the decisive factor was the coalition’s decision to deploy a “leadership team” of people who would be newly eligible for Medicaid if the measure passed. The team included people like Donna Wall, a Lewiston woman who is the full-time caregiver for her three disabled adult children. She earns just $7,000 a year from a newspaper route and sells her plasma to have enough money to take her kids to McDonald’s. After her two sons aged out of the program, leaving her as an “able-bodied adult,” she lost Medicaid coverage.  

Wall was one of a number of such Maine residents who told powerful stories at town halls and were featured in ad campaigns and newspaper articles. “That cuts through the bullshit of hunting and fishing licenses,” says Farmer, the coalition’s spokesman. “For all the benefits you’ll have for the economy and for hospitals, there are faces and families behind those numbers.”

The ballot initiative expands Medicaid to people who earn 138 percent of the federal poverty level in Maine, $16,643 for a single individual and $22,412 for a family of two. Before the measure passed, 20 percent of Mainers were already on Medicaid; the rate jumps to nearly 30 percent in four rural Maine counties. Hospitals, especially in rural areas, continue to bear the brunt of providing uncompensated medical care to tens of thousands of uninsured people. In 2016, many of the state’s hospitals were in financial distress.

The results generally played out along Maine’s urban-rural divide. The initiative did well in cities like Portland, Lewiston, and Bangor and less so in rural areas. But there were notable exceptions. Voters in five rural Republican districts voted to expand Medicaid even though their state representatives remained vocal opponents of expansion. In some towns, the no vote prevailed narrowly.

Health care has long been a divisive topic in Maine. LePage came into office vowing to pay off state debts to hospitals incurred under a Medicaid expansion in the 2000s. But the governor also declined to expand Medicaid even when confronted with the Affordable Care Act’s generous federal dollars, which account for 90 percent of the additional spending. Instead, he tightened eligibility requirements for MaineCare, the state’s Medicaid program. In the past five years, 40,000 Mainers have lost health insurance.

After LePage reshaped the state’s system, a person whose yearly income is $7,000 was still not poor enough for health insurance. “The whole fight over repealing and replacing Obamacare was positive in that it reminded Mainers of why they care about health care,” says Amy Fried, a University of Maine political science professor. “People want more and better health care, not less and worse health care.”

The multiple assaults on the ACA in Washington also spotlighted one of Maine’s own, Republican Senator Susan Collins, and her refusal to countenance an ACA repeal. Collins’s stance dialed up her popularity (passengers greeted Collins with applause last summer when she arrived at Bangor’s airport after one of her no votes, a first for her) and contributed to her decision to stay in the Senate and not run for governor in 2018. The Maine vote “gives her even more strength and legitimacy to draw the line on cuts to Medicaid and to health care,” says Farmer.

But Medicaid expansion supporters remain on guard in a state where successful voter initiatives have a history of running aground. The Legislature failed to override LePage’s veto of a bill that would have created a framework for implementation for a recreational marijuana law that a slim majority of voters approved last year. The path forward for another 2016 initiative, ranked-choice voting, remains uncertain after Maine’s Supreme Judicial Court issued an advisory opinion finding that sections of the law violated the state constitution.

Surprising exactly no one, LePage has now pledged to not to implement the Medicaid expansion until the Legislature funds the state’s Medicaid match using the administration’s estimates of those costs (which are almost twice as high as the figures put forward by the nonpartisan budget office that provides analyses for state lawmakers).

Several factors may mute LePage’s bluster. Failing to implement expansion would violate the state constitution which requires voter initiatives to be implemented 45 days after the Legislature convenes in January; 90 days later the state Department of Health and Human Services must come up with an implementation plan. Eligible residents could enroll in Maine Care by mid-summer 2018. “If [the governor] does not meet the very specific timelines and deadlines in the law when it takes effect, then he is going to find himself in court,” says Farmer. “And his press releases and bluster are not going to play as well as they do on talk radio.”

State lawmakers aren’t likely to play ball with the governor either. They have passed a Medicaid expansion bill five times only to run up against five LePage vetoes. The initiative’s win, coming shortly before legislators hit the campaign trail next year, means that they must weigh LePage’s latest ultimatum against the expressed opinion of Maine voters.

Health care was also the single most-cited issue driving voters to the polls in Virginia, according to exit polls, where voters turned against a Republican legislature that had blocked Medicaid expansion. Maine’s experience also serves as a template for Medicaid expansion supporters in Idaho, Kansas, Missouri, Nebraska, North Carolina, and Utah who want to put the issue to a vote. The Pine Tree State’s success may alleviate the some of the trepidation among national health-care advocates that emerged when the ballot initiative idea came up about three years ago.

Meanwhile, the Medicaid expansion victory sows a minefield for two prominent GOP gubernatorial candidates on the eve of Maine’s governor’s race. Former state health and human services commissioner Mary Mayhew toes LePage’s hard line, while state Senate President Mike Thibodeau opposed the ballot question and has voted against expansion twice. (His mid-coast district came out strongly for expansion.) Former House Speaker Mark Eves and Attorney General Janet Mills, who both support Medicaid expansion, are the leading contenders in a crowded Democratic field. In Maine, health-care reform remains a wedge issue for Democrats that could blunt the Republicans’ health-care-as-welfare mantra next year.

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How Maine’s Medicaid Expansion Campaign Got to Yes