Supporters of Medicaid expansion rally outside the State House prior to former Gov. Paul LePage's final State of the State address on Tuesday, Feb. 13, 2018, in Augusta. The program has seen a massive enrollment spike during the coronavirus pandemic. Credit: Robert F. Bukaty / AP

AUGUSTA, Maine — Nearly 18,000 people have joined Maine’s expanded Medicaid program since the coronavirus hit in March, bringing the program close to early enrollment estimates as lawmakers look to shield coverage from a massive budget shortfall.

Maine is not alone as millions across the country have joined the federal-state health care program for low-income people during a pandemic that prompted record-smashing unemployment filings. The national economic recovery has been slow, with 50,000 fewer jobs in Maine alone this September relative to the pre-pandemic month of February.

It has put a spotlight on Medicaid expansion, a key option to states under the Affordable Care Act authorized by Maine in 2017. Estimates had long shown 70,000 Mainers could be eligible for coverage that is matched by the federal government at a rate of roughly 90 percent.

After the law was implemented by Gov. Janet Mills in early 2019, enrollment bucked expectations as a high share of young adults signed up quickly. It hovered in the 40,000s prior to the pandemic while reaching more due to people coming on and off the program.

But expansion enrollment grew 40 percent from 45,000 on March 1 to 63,000 by Oct. 1 in Maine. Costs have not been as great as they could be amid increased federal funding and people seeking less medical care than in pre-pandemic times, but Medicaid could join a litany of state budget challenges amid an estimated $1.4 billion shortfall over three years.

Job losses are the main problem. An estimated 5.4 million Americans — 14,000 of them Mainers — lost health insurance due to job losses between February and May, according to a report from Families USA, an advocacy group. Medicaid enrollment grew by 3.4 million across the country between February and June, the Kaiser Family Foundation said.

Maine lawmakers say maintaining services will be critical as the pandemic continues and that rebounding revenue in August and September could lessen the financial pressure when the Legislature crafts the next two-year budget over the first half of next year.

The slow start to expansion helped the state save money. It spent about 87 percent of its Medicaid budget in the fiscal year ending in June. Use of services such as hospital visits have not kept pace with enrollment and remain below pre-pandemic levels as routine visits dropped, according to Maine Department of Health and Human Services data. Telehealth use spiked early in the pandemic, but has since decreased.

People who might have lost coverage by failing to renew, for example, are also not being kicked off of Medicaid in many cases because of a provision for increased federal matching rates provided under a federal virus response law in March that does not allow states to cut eligibility during a public health emergency.

“Medicaid is doing what it’s supposed to do,” Kathy Kilrain Del Rio, the director of health care advocacy at Maine Equal Justice, said. “People shouldn’t have to worry about losing health care during a pandemic.”

Jackie Farwell, a Maine DHHS spokesperson, said increased federal matching rates will be critical to paying costs associated with increased enrollment. She reiterated Mills’ call for Congress to provide more relief funds and increase flexibility for already allocated money.

It is difficult to know if there are still many who were eligible for Medicaid expansion prior to the pandemic who have not been enrolled yet. Del Rio said she has heard anecdotally that people may be wary to sign up for a new state program if they struggled to get benefits through the state’s embattled unemployment insurance system.

Expansion has been a political sticking point before. Former Republican Gov. Paul LePage vetoed several legislative expansion bids and fought the voter-approved law in court, handing implementation to Mills, a Democrat. But lawmakers in both political parties say the program provides too much necessary care to consider reducing it during a pandemic.

Sen. Cathy Breen, D-Falmouth, who co-chairs the Legislature’s budget committee, said revenue projections may change for the better, but it all depends on how effective the state is at keeping virus levels low, which will directly affect how reopening proceeds.

“One of the last places we should be looking at when it comes to a revenue shortfall is a state expenditure that gets extensive matching money,” she said.

Rep. Kathy Javner, R-Chester, who sits on the Legislature’s health committee, said she did not see the number of people on Medicaid as positive, saying she would rather people be able to afford private insurance. But she disliked the idea of reducing services and said unfilled positions should stay frozen before considering cuts.

One of the people who got coverage in the pandemic was Maia Steinberg. The 22-year-old Belgrade resident was working as a mental health support specialist before the pandemic hit, which involved going to people’s homes. She stopped working because she was afraid of getting sick and passing the virus to her parents or clients.

Being on Medicaid not only ensures coverage, but helps her deal with a persistent health problem — an unknown condition that has caused her to menstruate daily for two years. Medicaid has allowed her to continue trying medications and will pay for an exploratory surgery soon.

“It opened up my options to try to find things that would work,” Steinberg said. “I’m really grateful for that.”