This KHN special series examines the reach and the role of Medicaid, the federal-state program that began as a medical program for the poor but now provides a wide variety of services for a large swath of America.
Donna Wall cares for her three adult autistic children at her home in Lewiston, Maine. It's a full-time job. Sons Christopher and Brandon have frequent outbursts, and the stress of tending to them can be overwhelming.
When her twin sons turned 18 a year and a half ago, Maine's Medicaid program dropped her health insurance. Wall is considered a "childless adult" in Maine and other states that didn't expand Medicaid, and so she isn't eligible for coverage. She can no longer get her antidepressants and anti-anxiety medications. She can't see her psychologist or a doctor to check up on a troubling spot on her eye.
She needs to stay whole, she said, for her kids.
"I'm 60 years old. Things start going wrong when you get older," she said. "I haven't had a Pap smear or breast exam in two years. I'm just worried something will happen to me, because who is going to take care of them? It's a big job. If I put the boys in a home, it would cost the state a lot more to take care of them than it would be to pay my medical."
Even on frigid, wintry nights, Wall delivers newspapers, earning $150 a week when her kids are asleep.
"I go out about 2 in the morning. And it usually takes me four to five hours," she said. "I try really hard not to fall, but I have had a few accidents. One of them was on black ice last winter."
At one point, Wall thought she might have broken a rib. But she stayed away from the emergency room for fear of a costly medical bill.
At least 70,000 low-income Maine residents like Donna Wall should gain Medicaid health insurance because of the ballot measure that passed last fall. Advocates collected signatures to put the question to voters, and, in November, Maine became the first state to get approval at the ballot box to expand Medicaid, passing with 59 percent approval.
But even though voters here in Maine decided to expand Medicaid, the law's fate is unclear. Republican Gov. Paul LePage has said that opening up the program to more poor adults threatens the state's financial stability and that lawmakers shouldn't raise taxes to pay for it.
"You have to pay for the law," LePage said. "It's going to cost money. And I intend to implement it, and the Legislature is required to fund it. If they do not fund it, it will not be implemented."
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LePage has been in power for seven years, and, because of term limits, is heading into his final year in office. He vetoed five Medicaid expansion bills passed by the Legislature before voters approved it.
Lawmakers must now pay for the new law without raising taxes or dipping into the state's rainy day fund, he said. And he warned that the expansion could threaten services for people with disabilities and the elderly.
"When able-bodied people, who are able and should be working, choose not to work, then I don't think it's society's responsibility to cover their insurance at the expense of our mentally ill, our disabled and our elderly," he said. "We're asking hardworking Maine families to pick up the extra tab for people who should be working, but elect not to be."
Sara Gideon, the speaker of Maine's House of Representatives and a Democrat, said the governor's remarks are not true.
"Let's start with the population of people who will actually be eligible for health insurance now," she said. "We're talking about people, almost 70 percent of whom are people who are actually in the workforce, who are earning a living, but not actually able to afford health care with the low income that they earn."
Gideon said LePage must follow the law. Moreover, she is confident the Legislature will find a way to fund the state's share of $54 million and keep its promises to the elderly and disabled.
"It's not a choice between people, one group of people over another. It's a false choice that this governor is trying to present. And we say, we're not going to make that choice. It is the law. And we're simply going to make sure that that law is implemented," said Gideon.
For rural hospitals in Maine, the Medicaid expansion can't come fast enough.
"Our rural hospital is struggling," said Marie Vienneau, CEO of Mayo Regional Hospital in Dover-Foxcroft. "We don't make money. We lost a million and a half dollars the last two years."
Maine's rural towns and their hospitals have been hit hard. Factories have closed and many residents have moved away. As workers lost their jobs, more uninsured patients turned to rural hospitals desperate for medical care but unable to pay. Mayo is facing financial uncertainty, and at least three rural hospitals in Maine have closed in recent years.
Deanna Chevery was laid off after 25 years when the Dexter Shoe Co. factory closed in Dexter, Maine. Now 60 years old and uninsured, she's recovering from an addiction to pain pills prescribed by her doctor for back pain.
She overdosed five times, costing Mayo Regional Hospital more than $200,000 in unreimbursed care. Before Chevery found the charity recovery program at Mayo Regional, she said she was turned away when she sought help because she couldn't pay.
"You can only go so many places. Nobody will take you," said Chevery. "They don't care if you're crawling on the ground. I'm just fortunate Dover helps me."
But Vienneau said the hospital cannot keep up with Maine's growing opioid epidemic and ever-rising costs without expanded Medicaid.
"You can only go so many years in a row where your business doesn't lose money, before you depreciate to the point that you have to start closing services, decreasing services," said Vienneau. "And then access goes away."
Medicaid advocates, like Maine Equal Justice Partners, are pressuring lawmakers to put the new law into effect quickly. The group has been receiving postcards from around the country congratulating them on becoming the 32nd state to expand Medicaid, and advocates in many other red states that refused to expand Medicaid are eyeing their own ballot measures, including Nebraska, Utah, Idaho, Florida and Missouri.
Patrick Willard, a senior director at Families USA, a progressive advocacy group based in Washington, D.C., said that after years of Republicans attacking the Affordable Care Act, voters are beginning to shift their views.
"What we have heard is that other states suddenly see an opportunity now to figure out a way that they can get around legislatures that have been holding this up," said Willard.
As state lawmakers in Maine work out the details of the new law, many disagree with LePage about how much it will cost. His administration estimates the price tag will be twice what the Legislature's nonpartisan fiscal office has projected.
If they can't resolve the impasse, LePage said, he will take legal action, if necessary.
"We will go to court, because I know — listen, one thing that I know better than the Legislature is financial responsibility. And I have proven it over the last seven years," said LePage.
Advocates say those who are eligible for Medicaid could enroll as early as this summer. But if there are delays, they too will sue.
Just days after our interview, Donna Wall fell during her middle-of-the-night paper route and broke her ankle. She still doesn't have health insurance and is unsure how she will care for her autistic children and uncertain what the future will bring.