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Maine and the ACA’s Medicaid expansion

Maine voters approve Medicaid expansion ballot initiative; state has until July 2 to expand coverage

maine Medicaid guide

Medicaid set to expand by July 2, after voters approve expansion ballot initiative

After years of battling with their Governor, advocates for Medicaid expansion in Maine took the issue to the voters in the 2017 election. Question 2, the Medicaid Expansion Initiative, was approved, with 59 percent of voters supporting Medicaid expansion. Once the measure is enacted as called for by voters, Maine will become the 33nd state (including DC) to accept federal funding to expand Medicaid under the ACA.

Under the terms of the ballot initiative, Maine has until April 3 to submit a proposal to the federal government outlining their plan to expand Medicaid. And they have until July 2 to have expanded Medicaid coverage available to eligible Maine residents. This is required under state law now that the ballot initiative passed, and no legislation is necessary in order to move forward with expansion.

Unlike some other states that have used 1115 waivers to expand Medicaid with state-specific guidelines, Question 2 called for straightforward expansion as called for under the ACA, so Maine’s Department of Health and Human Services will essentially just be informing HHS that their Medicaid program will expand as called for in the ACA, rather than requesting HHS approval to create a unique approach to expansion. They have until April 3 to get their expansion plan submitted to HHS.

It’s estimated that 70,000 to 80,000 additional people in Maine will qualify for Medicaid once eligibility is expanded to those with household income up to 138 percent of the poverty level, as called for in the ACA.

Will other states follow Maine’s lead?

In all of the other states that have expanded Medicaid, the decision was made either by lawmakers or the governor or both — Maine is the first state where the issue has been decided via ballot initiative. The success of the ballot measure in Maine is likely to inspire similar initiatives in other states that have not yet expanded Medicaid, but where there is strong grassroots support for expansion. Idaho, Missouri, Nebraska, Oklahoma, South Dakota, Utah, and Wyoming are all states that have thus-far rejected Medicaid expansion, but that allow citizens to place measures on the ballot.

Most of the states that have expanded Medicaid did so as soon as possible, with coverage effective January 2014. But there have been several late expansions, the most recent of which was Louisiana, in July 2016. None of the holdout states expanded Medicaid during 2017, a year that was fraught with uncertainty over the fate of Medicaid expansion and the ACA itself.

But all of the bills that would have eventually repealed the ACA—and prevented any additional states from expanding Medicaid—ultimately failed, and Medicaid expansion remains available for any states that want to accept the federal funding to do so (the federal government currently pays 94 percent of the cost; that will decline to 90 percent by 2020, and remain at that level going forward, as long as the ACA’s Medicaid expansion provision is left intact).

Governor remains opposed, but cannot block Medicaid expansion from taking effect

Although Question 2 had strong support from voters in the 2017 election, Governor Paul LePage — who has long been outspoken in his opposition to Medicaid expansion — vowed immediately that implementation would not move forward until state lawmakers could find a way to fund the state’s portion of the cost of Medicaid expansion (the up-to-10 percent of costs that the state will have to pay). And LePage laid out several conditions in terms of that funding, saying that he wouldn’t support any measures that involve raising taxes, cutting benefits for existing disabled and/or elderly Medicaid enrollees, or tapping into Maine’s rainy day fund.

The legislative session in Maine began on January 3, 2018. As of mid-February, no bills to specifically allocate funding for Medicaid expansion had been introduced. But Maine People’s Alliance explained that because the ballot initiative became law, Medicaid expansion will move forward, regardless of whether the legislature specifically allocates money to cover the state’s portion of the cost.

The state’s cost for the first year of expansion is projected to be about $55 million, while the federal government will contribute about $525 million. These numbers make it clear why Medicaid expansion is a win for states; half a billion dollars in federal funding being pumped into the state’s economy will have a positive impact that goes well beyond the effect for people who gain coverage; thousands of jobs will be created, hospitals—particularly rural hospitals—will be more likely to remain financially viable, and of course, fewer people in Maine will be uninsured.

By mid-February, activists were planning a rally during LePage’s State of the State address, and frustrations were mounting that the state had not yet made visible progress towards outlining an expansion proposal to submit to the federal government by the beginning of April. But according to Maine People’s Alliance, all Gov. LePage can do at this point is potentially throw up roadblocks that might delay the process, but he can no longer prevent Medicaid expansion from taking effect.

Lawmakers in Maine had been trying for years to accept federal funding to expand Medicaid and provide coverage for at least 70,000 of the state’s lowest-income residents (some of these people are eligible for premium subsidies in the exchange, but people with income under the poverty level are in the coverage gap created by the Governor’s refusal to expand Medicaid). Over the years, they’ve passed five bills that called for expanding Medicaid, but Governor LePage’s ongoing opposition on the issue has been an insurmountable stumbling block. LePage has vetoed all five Medicaid expansion bills, and lawmakers have not had the votes to override his vetoes. The 2016 bill, LD633, passed but only by one vote — far from a veto-proof majority. It was tabled and died at the end of the 2016 legislative session.

Medicaid has been a political battle in Maine. Not only has LePage rejected Medicaid expansion, he also cut existing coverage through eligibility changes that went into effect March 1, 2013, and Jan. 1, 2014. And many Republicans in the legislature have also opposed Medicaid expansion, preventing the legislature from getting enough votes to overcome LePage’s vetoes.

Wording of the ballot initiative was contentious

The Maine Secretary of State announced in February 2017 that the initiative to expand Medicaid had garnered enough signatures to appear on the November 2017 referendum ballot. But the wording of the ballot initiative became a point of contention, with proponents of Medicaid expansion calling it “insurance” and opponents — including LePage — insisting that it be called “welfare” or something similar.

Ultimately, the wording of the ballot initiative was changed to “coverage” and the official language of Maine Question 2 is 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?”

According to Ballotpedia, Medicaid expansion supporters had raised $196,163 by September 22, 2017 in support of a “yes” vote on Maine Question 2. Opponents had raised $229. Ultimately, by the conclusion of the campaign, supporters of Question 2 had raised nearly $2.7 million, while opponents had raised about $428,000.

Eligibility guidelines for Maine Medicaid

As of 2016, Maine residents who meet the following income limits qualify for Medicaid:

  • Children up to 1 year old: 191 percent of the federal poverty level (FPL)
  • Children ages 1 to 18: 157 percent of FPL; children with family income up to 208 percent of FPL qualify for the Children’s Health Insurance Program
  • 19 and 20 year olds: 156 percent of FPL
  • Pregnant women: 209 percent of FPL
  • Parents and other caretakers: 100 percent of FPL

Details for each state’s Medicaid and CHIP eligibility rules are here.

Apply for MaineCare

Maine’s Medicaid program is called MaineCare. If you think you may qualify, here is how you can submit an application.

LePage reversed Maine’s pre-ACA Medicaid expansion

Gov. LePage has reversed the course on Medicaid set by former Gover John Baldacci, who authorized Dirigo Health in 2003. The program expanded Medicaid and subsidized private health insurance for middle-income residents. However, the program faced several financial difficulties as about 25 percent of the state’s residents enrolled in Medicaid by 2010 and Medicaid spending consumed nearly 30 percent of the state budget. The state fell behind in Medicaid reimbursements to hospitals, which were due nearly $500 million in state and federal payments.

LePage took office in 2011 and has since led efforts to cut the state’s Medicaid program. First, he reduced the eligibility limits for adults with dependents and reduced benefits for elderly Medicaid beneficiaries. Second, Maine ended coverage for adults without dependents, effective Jan. 1, 2014. The stricter eligibility limits resulted in about 25,000 people losing Medicaid eligibility. Third, the LePage administration petitioned the federal government for approval to end coverage for 19- and 20-year olds.

When the federal government rejected the request, the administration appealed the decision in circuit court with the help of outside counsel. The state’s attorney general declined to represent the state, saying the appeal had lacked merit. The 1st Circuit Court of Appeals in November 2014 upheld the federal government’s decision. The state petitioned to have the case heard by the Supreme Court, but the petition was denied in June 2015. Since the Supreme Court wouldn’t hear Maine’s case, the lower court’s decision stands, and Maine has continued to provide Medicaid coverage for roughly 6,500 eligible 19 and 20-year-olds.

As of October 2014, about 291,000 people were enrolled in MaineCare. By July 2016, enrollment had decreased to 270,827. And by November 2017, it had decreased even further, to 261,478. Nationwide, Medicaid/CHIP enrollment has grown by 29 percent since the end of 2013, including states that have expanded Medicaid as well as those that have not. Medicaid enrollment in Maine is expected to increase by at least 70,000 people once coverage is expanded, which will take it well above the 291,000 who were enrolled as of 2013.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

Maine Medicaid

How to apply

Go to MyMaineConnection to apply online. Print an application and mail it 114 Corn Shop Lane, Farmington, ME 04938. Call 1-855-797-4357 to enroll by phone. Visit your local Office for Family Independence to enroll in person.

Who is eligible

Children up to 1 year old with household income up to 191% of FPL. Children ages 1-18 with household income up to 157% of FPL; children with family income up to 208% of FPL qualify for the Children’s Health Insurance Program. 19 and 20-year-olds with household income up to 156% of FPL; pregnant women with household income up to 209% of FPL; parents and other caretakers with household income up to 100 percent of FPL.

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