Gov. Paul LePage attacked Maine’s hospitals on Friday for supporting the Medicaid expansion referendum on the Nov. 7 ballot, which if approved would provide free health care to about 70,000 low-income Mainers. 
 
 LePage aimed criticism in particular at Maine Med president and CEO Richard Petersen, who expressed support for the ballot question in a hospital newsletter. 
 
 “It’s obvious the CEO of Maine Med and other hospitals do not care about taking resources away from our most vulnerable Mainers – including our elderly and intellectually and physically disabled people – just so they can give free, taxpayer-funded healthcare to adults who should be working and contributing to the cost of their own health insurance,” LePage said. 
 
 Maine Medical Center responded in a statement provided to the Portland Press Herald by hospital spokeswoman Caroline Cornish. 
 
 “While we do not share his point of view, we understand that the governor has had a consistent position regarding Medicaid expansion, as has our organization. We hope Maine people will take the time to learn about this important issue and vote on Nov. 7,” the statement said. 
 
 Medicaid expansion would result in a number of benefits to Maine, supporters say, such as making the population healthier and more likely to access preventive care, creating 4,000 jobs in the health care industry, and driving down the uninsured rate. Maine’s uninsured rate was 9.1 percent in 2016, according to Gallup polling. 
 
 LePage has vetoed five attempts by the Legislature to approve Medicaid expansion, but would not be able to do so if voters approve the referendum on Nov. 7, a consideration that spurred the effort by an advocacy group to put the measure on the ballot. 
 
 LePage remains a steadfast expansion opponent, and he argued that hospitals would benefit financially “on the backs” of Maine taxpayers. About 265,000 Mainers currently have Medicaid. 
 
 “Since hospitals are nonprofit organizations, they don’t have to pay taxes on much of their vast real estate holdings. Mainers do not have that luxury – in addition to paying their own high premiums and deductibles, they will have to pay to give ‘free’ healthcare to adults who should be working,” LePage said in a statement. “As I always say, ‘free’ is very expensive to somebody. If hospital CEOs have their way, that somebody would be Maine taxpayers.” 
 
 LePage’s relationship with Maine hospitals has soured considerably since 2013, when he fought a successful battle with the Legislature to pay off $105 million in unpaid MaineCare reimbursements to hospitals. The money came from a bond financed with state revenues from a new wholesale liquor contract. LePage characterized the payoff as an investment in jobs because of the capital it would provide to hospitals, and he was so adamant about making the reimbursement that he threatened to veto every bill that landed on his desk until lawmakers agreed. 
 
 In his statement blasting hospitals on Friday, LePage repeated his frequent contention that Medicaid expansion would cost Maine taxpayers $500 million over five years, or $100 million per year. 
 
 But that’s incorrect, according to the Legislature’s nonpartisan Office of Fiscal and Program Review. 
 
 State taxpayers would be on the hook for $54 million per year, but Maine would receive $525 million per year from the federal government for Medicaid expansion, the office said. 
 
 The federal government is paying 90 percent or more of the cost of covering the expansion population. Maine is one of 19 states – and the only one in New England – that hasn’t approved Medicaid expansion. Instead, the state has reduced Medicaid eligibility since LePage took office in 2011, cutting off Medicaid for childless adults and tightening eligibility for parents. 
 
 Ann Woloson, public policy director for Maine Equal Justice Partners, the group behind Medicaid expansion, said many rural hospitals are struggling financially in part because of the free health care they must provide to the uninsured. Medicaid expansion would put these hospitals on more solid financial footing, Woloson said. 
 
 “These hospitals are in danger of closing their doors, and Medicaid expansion would not only help with that, but also help these hospitals with workforce shortages to attract doctors and nurses to work there,” she said. 
 
 Jeff Austin, vice president of government affairs and communication for the Maine Hospital Association, said that hospitals have “supported expansion for four years and continue to do so.” 
 
 “Hospitals see tens of thousands of patients every year who don’t have insurance and need care,” Austin said. “The question is about what is the smartest way to take care of that population and we believe the answer is Medicaid expansion.” 
 
 Austin declined to get into a point-by-point refutation of LePage’s statements against the hospitals. 
 
 LePage framed expansion as a move that would take money away from others, saying “hospitals are only concerned with their pocketbooks, and they don’t care about the hardships it will cause for taxpayers, the elderly and the disabled.” 
 
 Medicaid expansion would not take away care for the elderly and disabled, expansion advocates say. States have some leeway on how to spend Medicaid money, they said, and expanding Medicaid would not hamper programs for the elderly or intellectually disabled. 
 
 Joe Lawlor can be contacted at 791-6376 or at: 
 
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 Twitter: @joelawlorph 
 
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 This iframe contains the logic required to handle Ajax powered Gravity Forms. ||||| Maine residents voted decisively last fall to expand the state’s Medicaid program. But almost six months later, Gov. Paul LePage still refuses to take action as the state’s legislative session winds down, putting the Obamacare coverage program in doubt. 
 
 LePage, a tea party Republican who’s derided Medicaid expansion as a “boondoggle,” for years vetoed bills to join the program. Frustrated state lawmakers thought they finally found a way around the recalcitrant governor last November, when nearly 60 percent of Maine voters approved the first-ever ballot initiative on Medicaid expansion. 
 
 Story Continued Below 
 
 “That we have had to fight this battle time and again is discouraging,” said Andi Parkinson, an organizer with the nonprofit Kennebec Valley Organization. 
 
 The ballot initiative made Maine the 32nd state to embrace Medicaid expansion and one of the rare states to do it as the Trump administration has pushed unprecedented new restraints on the program, including work requirements for some. 
 
 Undeterred by Maine’s fight, however, health care advocates are backing similar ballot initiatives in other Republican-led states this year, hoping voters can override conservative governors and legislatures. Ballot measure campaigns are underway in Idaho, Nebraska and Utah. Meanwhile, Virginia‘s Legislature is the only statehouse where lawmakers are seriously debating Medicaid expansion this year. 
 
 POLITICO Pulse newsletter Get the latest on the health care fight, every weekday morning — in your inbox. Email Sign Up By signing up you agree to receive email newsletters or alerts from POLITICO. You can unsubscribe at any time. 
 
 LePage, now in his last year in office, has insisted he won’t green-light expansion, which is expected to cover 80,000 low-income Maine adults, unless state lawmakers meet his conditions for funding the program that he contends could otherwise bankrupt the state. As chances of a deal with LePage dwindle, the organizers of the Maine ballot initiative are now preparing for a legal showdown to enforce voters’ wishes. 
 
 “The law is clear,” said Robyn Merrill of Maine Equal Justice Partners, an advocacy group that spearheaded the Medicaid expansion referendum. “People will have a right [to coverage] and we will represent them in court.“ 
 
 Individuals are supposed to become eligible for Medicaid coverage on July 2, according to the Maine ballot measure. The legislative stalemate leaves few options other than litigation to force LePage’s hand. Ultimately, the issue may not be resolved until after Maine elects its next governor in the fall. 
 
 Supporters say there’s no doubt the state will eventually adopt the program — it’s just a question of whether it comes after a quick legislative resolution or a protracted legal fight. 
 
 Obamacare supporters in Maine say the LePage administration has already ignored timelines mandated by the ballot initiative. Maine earlier this month skipped a deadline to file routine paperwork notifying the Centers for Medicare & Medicaid Services it would join the Obamacare expansion. 
 
 LePage’s office and the Maine Department of Health and Human Services did not respond to requests for comment. 
 
 Medicaid expansion under the Affordable Care Act covers low-income adults earning up to 138 percent of the federal poverty line — roughly $16,800 for an individual and $34,600 for a family of four. While the federal government provides the vast majority of Medicaid expansion funding, states this year must contribute 6 percent of the costs, and their share eventually rises to 10 percent. 
 
 Maine lawmakers left late last week without formally closing the session after a Medicaid expansion funding deal fell apart. Split control of the Maine Legislature has complicated the Medicaid expansion talks this year. Republicans narrowly control the Senate, but they have been more receptive to Medicaid expansion. Democrats run the state House, where Republicans remain steadfastly opposed to the program and the debate has been tied up in a battle related to taxes and a minimum wage increase. 
 
 “The Democrats are obsessed with Medicaid expansion, to the point where they’re risking our most vulnerable in the state by demanding that they be put in the spending package,” said House Minority Leader Ken Fredette, one of four Republican candidates running to replace the term-limited LePage. 
 
 LePage has argued Democrats are inviting a fiscal crisis by expanding the program, and he’s insisted that state lawmakers can’t tap into rainy day funds or raise taxes to fund the expansion. Democrats say the state already has enough money in the budget to cover Maine’s costs through May 2019. 
 
 The deal that collapsed last week would have provided the Maine health department with $3.8 million to cover administrative costs associated with expansion, including hiring new staff. 
 
 LePage and lawmakers, however, have disputed how much the state should expect to spend on health benefits for new Medicaid enrollees. LePage's health department says it will cost the state roughly $60 million for the 2019 fiscal year to provide coverage, about double the estimate from the state's independent Office of Fiscal and Program Review. 
 
 Lawmakers will eventually return for a veto session this year, but it’s unclear when or whether they’ll revisit Medicaid. 
 
 Advocates pushing for ballot measures say they’re not discouraged by the Maine dispute because they expect other states would defer to the voters if they approved the program. 
 
 “We’re confident that we can overcome any legislative or executive opposition to it,” said Jonathan Schleifer of the Fairness Project, a national group that is bankrolling the state ballot campaigns. “If there are fights after the fact, we’re ready to fight those fights.” 
 
 Last week, Obamacare supporters in Utah submitted more than 165,000 signatures to state officials to get Medicaid expansion on the ballot, well above the requirement for 113,000 valid signatures. Utah’s lieutenant governor will announce by next month whether the measure qualifies for the November ballot. ||||| MaineCare Expansion Debate 
 
 Despite being rejected five times previously, once again, a push to expand MaineCare—the state’s Medicaid program—will be debated. For the sixth time, the LePage Administration and this Department will stand against it 
 
 The truth is Maine has already experienced the devastating consequences of expanding Medicaid under previous Administrations. When Maine expanded in 2001 and again in 2003, it led to annual shortfalls in MaineCare of $50 million to more than $100 million . As a result, the state stopped paying its bills, racking up hundreds of millions in debt owed to Maine’s hospitals. 
 
 We cannot afford to abandon the sound financial management that exists within the program today that has directed resources to our elderly, disabled, and has allowed the state to responsibly manage without a perpetual financial crisis. The Maine Department of Health and Human Services has refocused the program on its neediest and most vulnerable beneficiaries by funding our nursing homes, strengthening home care options and providing services to those with intellectual and developmental disabilities that had been languishing on waitlists. 
 
 Currently, the Legislature cannot afford to care for our neediest and most vulnerable, it will only get worse if expansion is passed. Governor LePage’s biennial budget sought increases of $46 million in funding to reduce waiting lists for services for the intellectually and developmentally disabled; $28 million to expand access to primary care; and $22 million to adequately fund Maine’s nursing homes. Ultimately, the Legislature only funded a portion of these requests (e.g., $16 million for the waitlists), leaving considerable funding requirements in the program for our neediest and most vulnerable. These would only worsen if Maine chose to add thousands of able-bodied childless adults to its Medicaid rolls. 
 
 Medicaid expansion backers ignore key facts when it comes to discussing Medicaid Expansion. 
 
 Expanding MaineCare would cost Maine taxpayers approximately $315 million over the next five years . Despite claims that expansion is free—it is not. MaineCare accounts for 24 percent of Maine’s General Fund. Over the next two fiscal years, expansion would cost nearly $100 million, or enough to fund the Department of Marine Resources, Department of Labor, Department of Environmental Protection, and Department of Defense, Veterans and Emergency Management over that period of time. 
 
 Costs would continue to rise from there: 
 
 By 2021, the additional funds needed for Medicaid expansion could fund nearly half of the University of Maine’s annual budget. 
 
 Expansion would not affect children or pregnant women . MaineCare enrollment peaked at 354,000 in 2011. Today, enrollment is approximately 282,000. Medicaid expansion would allow childless, able-bodied adults into the program and increase eligibility for parents of dependent children. 
 
 An overlooked fact is that any individual who earns at least 100 percent of the federal poverty level is eligible to purchase heavily subsidized health insurance on the federal exchange. Simply put, most childless, able-bodied adults and all parents have access to subsidized health insurance under the current system. 
 
 There are options for the uninsured . Currently, the only Mainers who are not eligible for Medicaid or subsidized health insurance are able-bodied, childless adults earning less than 100 percent of the federal poverty level-- $11,770 in 2016. 
 
 For those uninsured, federally qualified health centers provide no-cost healthcare to low income individuals without insurance. They receive enhanced rates in other areas like Medicaid reimbursements. Hospital-owned physician practices also provide care to anyone regardless of ability to pay. 
 
 Expansion would not solve the drug epidemic . Medicaid Expansion supporters argue that expanding Medicaid is the key to resolving Maine’s substance abuse problem. There is no evidence this is true. Maine already funds more than $20 million annually on treatment and prevention for the uninsured, and expansion states like New Hampshire and Vermont have some of the highest fatal overdose numbers in the country. The latest data from New Hampshire’s medical examiner shows that 414 people suffered fatal overdoses in 2015, up from 326 in 2014 and 192 the year before. 
 
 Due to underestimated enrollment and overly optimistic savings projections, numerous expansion states are facing significant budget shortfalls . 
 
 Vermont : The state now projects a $30 million shortfall for the current fiscal year and a $60 million gap in the next fiscal year due to Medicaid expansion. 
 
 : The state now projects a $30 million shortfall for the current fiscal year and a $60 million gap in the next fiscal year due to Medicaid expansion. Massachusetts : The state Medicaid caseload spiked in fiscal year 2014, leading to an increase in spending of more than $1.1 billion. While the federal government covers a significant portion of Medicaid costs, the expense paid by state taxpayers was $5.1 billion, up from $4.7 billion in 2013. “The administration is taking several other steps to rein in costs, including holding flat most of the rates paid to providers and moving more MassHealth members into managed care plans, in which the state pays insurance companies set budgets to coordinate the care of patients.” (Boston Globe, January 28) 
 
 : The state Medicaid caseload spiked in fiscal year 2014, leading to an increase in spending of more than $1.1 billion. While the federal government covers a significant portion of Medicaid costs, the expense paid by state taxpayers was $5.1 billion, up from $4.7 billion in 2013. New Mexico : The state projected large savings as a result of Medicaid expansion. Those savings have not materialized, leaving a Medicaid shortfall of $85 million in FY 2017. As a result, the state likely will cut reimbursement rates to hospitals, doctors and social workers, as well as increase copays for those patients in the government insurance program. “What we've done, unfortunately, is double down on borrowed money to pay for the state operating expenses," said Rep. Brian Egolf, a Santa Fe Democrat who serves as the House minority leader.” (The Santa Fe New Mexican, February 18) 
 
 : The state projected large savings as a result of Medicaid expansion. Those savings have not materialized, leaving a Medicaid shortfall of $85 million in FY 2017. As a result, the state likely will cut reimbursement rates to hospitals, doctors and social workers, as well as increase copays for those patients in the government insurance program. 
 
 As this issue is debated once again, it is important to remember the financial crisis our state was in less than 10 years ago and how our neediest and most vulnerable paid the price. As well as the hundreds of millions of dollars it would cost Maine taxpayers over the next decade.
– On Nov. 7, Maine will take an unprecedented step for a state when it allows residents to vote on expanding Medicaid under the Affordable Care Act, the New York Times reports. Maine is one of 19 states where Republicans have blocked Medicaid expansion available under the ACA. The Maine legislature has voted repeatedly to expand Medicaid only to have Gov. Paul LePage veto expansion five times. However, if expansion is approved by voters through a referendum next month, LePage would be unable to veto it. If the referendum passes, approximately 80,000 more Maine residents making up to 138% of the poverty level will be eligible for Medicaid. In addition to decreasing the number of uninsured Maine residents, supporters of the referendum say it will add jobs and help rural hospitals stay open. LePage, while attacking Maine hospitals for their support of the referendum on Friday, said it would take "resources away from our most vulnerable Mainers" to "give free taxpayer-funded healthcare to adults who should be working and contributing," the Press Herald reports. Under the ACA, at least 90% of Medicaid expansion costs would be covered by the federal government. The other 18 states where Medicaid expansion has been blocked are carefully watching what happens in Maine. It's estimated more than 2.5 million Americans would gain access to health care if all 19 holdout states allowed Medicaid expansion.