AUGUSTA, Maine — A handful of Republican state lawmakers, if they haven’t already, are about to become the most popular — or depending on how you look at it —- among the most wanted people at the Legislature in the weeks ahead.
“There is a fair amount of pressure coming from both sides,” said Rep. Corey Wilson, R-Augusta.
Wilson, a first-term legislator, is among five Republicans in the Maine House who have previously voted for an expansion of the state’s Medicaid program, MaineCare — a prospect Republican legislative leaders and Gov. Paul LePage are dead-set against.
Republican leaders and LePage say the state’s low-income health care program is a constant source of budgetary woe. Expanding it, they say, is a massive expansion of welfare.
Expanding the program under the federal Affordable Care Act has been a top priority for Democrats over the last two years. Democrats also maintain the expansion, because it will be largely paid for with federal funds, would pump $700,000 a day into the state’s economy.
But Republicans, pointing to a recent report produced by a private consultant hired by LePage’s administration, say an expansion will cost the state more than $800 million over the next 10 years.
Republicans also say that until the state does something to provide health care to some 3,100 children, elderly and disabled that are currently on waiting lists for MaineCare programs they won’t support expanding the program to cover more Mainers.
Democrats estimate the expansion would give health care to about 70,000 more low-income Mainers but Republicans argue the figure is more like 100,000.
“Adding 100,000 able-bodied people to Medicaid is just a bad idea when it comes to our state’s budget and the ability of taxpayers to sustain it,” said David Sorensen, a spokesman for House Republicans. “We don’t intend on meeting halfway on a bad idea. This isn’t a biennial budget bill; it doesn’t need to be passed.”
Sorensen and others also say that about half of those who would be covered under a Medicaid expansion could buy health insurance on the open market that would be covered by federal subsidies under the ACA. Democrats counter that most of the expansion would be for people too poor to be eligible for a subsidy under the ACA.
While most Republicans are digging their heels in, a handful including Wilson and Rep. Jarrod Crockett, R-Bethel, say there’s more room for compromise on the issue than the party stalwarts are letting on.
Wilson is careful to say he’s not a flat-out “yes” vote on expansion, but he would support it as part of legislation that also aims to control costs and improve the quality of the medical care that’s delivered to MaineCare recipients.
“To me, we can use [expansion] as an opportunity to put in measures to control costs,” Wilson said.
The high cost of care, not necessarily the number of people using MaineCare, is the biggest problem with the system now, Wilson said.
Adding sliding scale co-payments for emergency room visits or other requirements for MaineCare recipients that encourage preventive care and create incentives for healthier lifestyles could be elements in a compromise on expansion, Wilson said.
Other ideas include the establishment of so-called “medical homes” — a primary care practice where a Medicaid recipient would receive most of their health care — instead of accessing it at relatively high-cost emergency departments.
Expansion, according to Wilson, shouldn’t be just an extension of the status quo with MaineCare.
Wilson said details of what a compromise on expansion might look like are still emerging.
“I’m not really willing to give specifics but there’s nothing that isn’t on the table,” Wilson said. “We have a lot of different options to improve the bill that’s out there now.”
The offer on the table so far expands eligibility for an estimated 70,000 more Maine people but it also cuts funding for that expansion in 2016 — if a future Legislature chooses not to continue it.
While Democrats have pointed to the sunset provisions as a compromise, noting the state doesn’t have to commit long-term to funding the expansion, Republicans have said the bill including the sunset provision is a regurgitation of a failed effort in 2013. A bill expanding Medicaid in Maine passed both the House and Senate in 2013 but was unable to survive a LePage veto as the House fell just short of the votes needed to override LePage’s official objection.
Maine political observers, however agree, with Wilson that there will be a great deal of pressure on lawmakers, especially those from more rural districts that host hospitals, to expand.
James Melcher, a political science professor at the University of Maine at Farmington, said Maine’s Legislature has plenty of independent-minded Republicans. They will also want to do what their constituents want in an election year, Melcher noted.
“Many Rs in the Legislature have shown a willingness to go against the governor’s policies generally at times, even when LePage is vocal about them,” Melcher wrote in an email to the Sun Journal.
“We’re seeing several cases nationally where Republican governors who were skeptical of Medicaid expansion have come to the conclusion that, with the federal money, it’s worth it to expand the program,” Melcher wrote. “John Kasich in Ohio is a prominent recent example, but Rick Snyder in Michigan and others have as well. I suspect some of these legislators see this as a potential for economic stimulus in their districts.”
Both the Maine Hospital Association and the Maine Medical Association have come out in favor of the expansion. Hospitals say their existing Medicaid reimbursement rates are being curtailed under the ACA. For Maine, that means a loss in hospital revenue of about $900 million over the 10-year period.
Expanding Medicaid allows them to recoup that federal loss but also allows them to improve health outcomes while providing more people with health care.
Dan Demeritt, a Republican consultant and former LePage staffer who is working for the Maine Medical Association, said he also believes there are more Republicans who will want to support an expansion than the party’s talking heads let on.
“It’s a lot easier to draw a line in the sand than it is to build consensus,” Demeritt said. “But you have some Republicans who definitely see an opportunity to achieve fiscal reform in the Medicaid program.”
He said those Republicans will want to come to negotiations to “deliberate, that’s what governing looks like.”
“When you say ‘no,’ that ends the discussion. ‘Maybe’ keeps it going,” Demeritt said.
Demeritt also agrees that Republican lawmakers in rural districts need to be careful about how deep they want to dig in on an expansion.
“In many rural parts of the state, the health care industry remains the biggest employer, or one of the biggest employers,” Demeritt said. “There are people with critical needs, so if there is an opportunity to inject additional spending into those industries, Republicans from rural parts of Maine have to consider the potential upside for their districts.”
Crockett, who also announced he won’t seek re-election in 2014, said if Democrats are willing to go along with some other welfare reforms being proposed by Republicans including to require welfare beneficiaries to show they are looking for work and some reforms on Electronic Benefit Transfer cards, then he believes Democrats will get the votes they need to override a near-certain LePage veto of any expansion bill.
“Everybody acknowledges that we’ve got to reduce the costs of health care,” Crockett said. “I would be willing to go along with it but I want to see some kind of compromise on the bill.”
The questions for Democrats will now be how many more Republicans will be willing to go along and what kind of compromises will they offer to secure those votes?