May 22, 2019
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Medicaid expansion overdue, but hasty rollout raises concerns

Robert F. Bukaty | AP
Robert F. Bukaty | AP
Gov. Janet Mills delivers her inaugural address after taking the oath of office, Wednesday, Jan. 2, 2019, at the Augusta Civic Center in Augusta, Maine.

This week, Gov. Janet Mills announced that roughly 500 people have been approved for health care coverage through Medicaid expansion.

We have long advocated for expanding Medicaid here in Maine and criticized former Gov. LePage for his unwillingness to implement it, despite a clear message from Maine voters in 2017 and subsequent court order. But even expansion proponents should be cautious about cheering Mills for this move, at least right now.

Mills and her administration have acted quickly in her first week, not only to begin implementation, but to also start offering benefits before the federal government has signed off on Maine’s implementation plan. With the latter action, there should be some concern that her administration is moving ahead a bit too rapidly and without federal approval or at least a chance for meaningful deliberation with the new Legislature.

It’s not that these 529 Maine people now eligible for health care do not need or deserve that coverage. They do, and expanding Medicaid for this population of low-income and working Mainers is a proven idea backed up by the experience of other states that have already increased access to health coverage under the expansion process available through the Affordable Care Act.

These benefits are most helpful to Maine people, however, if they’re dependable and available long-term. Despite a reference to funding expansion in a sustainable way during her inaugural address and general references to working with the Legislature on a new two-year budget, Mills has yet to offer a detailed blueprint on how to accomplish that goal. Her office says funding currently in the state Medicaid account will cover new enrollees through June 30.

Expansion does not provide this population with long-term certainty and support if there is an open question about the availability of benefits beyond this summer.

Mills officials say an existing Medicaid surplus can cover the costs of expansion for now and that the administration will work with the Legislature on a long-term plan. They are confident that the Centers for Medicare and Medicaid Services will approve Maine’s State Plan Amendment outlining how implementation will work. That approval is not in hand, however.

Cindy Mann, a former head of Medicaid during the Obama administration, said the state plan approval process is routine and expected Maine’s application to be approved, as has been the case for more than 30 other states that have expanded Medicaid. Mann, now a partner at a law firm in Washington, said her firm is working with the state in an advisory capacity during implementation.

Mann was unaware of other states that have moved forward with expansion before their plan was approved, but noted it is not uncommon for states to do so with nonexpansion plan amendments.

Medicaid expansion, as passed by Maine voters, is the law. And Superior Court Judge Michaela Murphy previously ordered the LePage administration to adopt rules as required by that expansion law by Feb. 1. But based on that ruling and the law passed by voters, there does not appear to be a legal imperative for Mills to start providing benefits before that rules deadline.

By moving forward first instead of taking the time to work with the Legislature to identify a long-term funding source, the Mills administration has potentially rushed this important launch and opened the door to benefits it currently cannot guarantee past the end of June.

With fellow Democrats now in control of both houses in the Legislature, Mills should not have difficulty finding support to fund the expansion — and willingness to do so quickly. Speaker of the House Sara Gideon has introduced legislation aimed at funding the expansion law, though we have not seen the details yet.

In January 2016, the Republican Senate and Democratic House were able to come together and pass an anti-drug bill in the first few weeks of session. So it’s not impossible for the Legislature to tackle big issues right out of the gate. Why not have that debate first, and secure the likely federal approval for the sake of certainty and predictability?

Mills’ initial executive order to begin the process of implementation seemed to thread the needle nicely between her campaign promise to implement expansion on day one and the realities of governing. This immediate expansion of benefits, with no engagement — at least publically — with both houses and parties in the Legislature and no federal approval, feels hasty.



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