ELIOT, Maine — Five times Medicaid expansion has passed the Maine Legislature and all five times the expansion bills met the same fate: a veto from Republican Gov. Paul LePage.

On Nov. 7, the people of Maine will vote on whether or not to expand Medicaid through a citizen’s initiative question, giving voters a final say by possibly circumventing the governor’s prior refusals after legislators failed to override his previous vetoes. If passed, Maine would join 32 other states, including the District of Columbia, that have expanded Medicaid through the Affordable Care Act.

Question 2 asks citizens, “Do you want to want Maine to expand Medicaid to provide healthcare coverage for qualified adults under age 65 with incomes at or below 138 percent of the federal poverty level, which in 2017 means $16,643 for a single person and $22,412, for a family of two?”

Proponents of the ballot question say a Medicaid expansion will lead to lower premiums for people who buy private health insurance and end up providing “charity” care when people with no health care coverage need emergency medical procedures and also tens of thousands of Maine citizens would gain access to some form of health care, while creating thousands of new jobs, according to David Farmer, director of communications for Mainers for Healthcare, the ballot committee supporting Question 2.

“Voters can send a message throughout Maine and down to D.C. that we want more health care, not less; more people with health care coverage, not less, lower premiums, not higher premiums,” Farmer said. “Question 2 does all that. Expanding Medicaid is something that has had wide support from Democrats, Republicans and Independents. When one person stands in the way of this passing, it was imperative this issue was taken directly to voters.”

According to a study by Dr. Elizabeth Kilbreth, associate research professor emerita in the Muskie School of Public Service at the University of Southern Maine, expansion of Medicaid would be paid for with mostly federal dollars through the first year, injecting $490 million into Maine during the first full year of the expansion in 2019, which covers 94 percent of the expansion cost and declines to 90 percent in federal funding by 2021. Farmer said 2018 would be a “partial implementation” of the expansion with the state receiving $230 million in federal funding with Maine matching $13.5 million in 2018. According to the Maine Office of Fiscal and Program Review, Maine would have to match $31 million in 2019, topping out at nearly $54.5 million in matching funds to receive nearly $525 million in federal funds in 2021.

Some 80,000 additional people would be eligible for Medicaid coverage, according to Kilbreth’s study. She estimates the expansion would generate 4,000 new jobs in health care and 2,000 jobs in other sectors, and combined with the federal dollars, it would result in more than $700 million in additional economic activity for Maine in 2019.

York Hospital CEO Jud Knox said his hospital supports Question 2 passing because even though roughly 7 percent of York Hospital patients are Medicaid recipients, he believes Medicaid expansion will benefit more people in rural areas because they will have more access to services at their local hospitals.

“Generally, if people have coverage of some kind, it means they can receive services,” he said. “In the northern part of the state for the population with little or no coverage, clearly that is a huge barrier to whether or not they can get care. At York Hospital, we take care of everything for everyone; if that’s an emergency procedure or a routine checkup. But to cover people with no coverage, the cost is either borne by people with private insurance; leaving them to pay higher premiums or it’s left to the hospital to pay and that can be a struggle to make ends meet, especially in parts of the state where there’s fewer people on private health-care plans.”

Democratic State Rep. Mark Lawrence, who represents Eliot and parts of Kittery and South Berwick, will speak at an informational forum hosted by the Eliot and South Berwick Democratic Committees alongside Knox on Tuesday, Oct. 24 at 7:30 p.m. at the John F. Grange Hall in Eliot. Lawrence said even though Maine voters may approve the expansion, there is no guarantee it will become law.

“There’s nothing to say this will not get caught up in the Legislature and get delayed in going into effect,” he said. “For instance, the public passed term limits through referendum and I’m not in favor of term limits but I always respected the role of the public and the referendum process is an important way to have the peoples’ voices heard. The law was put into place because the Legislature was not listening to the will of the public, so if the expansion passes, it’s a direct representation of the public’s wishes.”

However, Farmer contends that since the Medicaid expansion received “tri-partisan” support each time it passed the Legislature, he believes the expansion would encounter less friction in being rolled out compared to other citizens’ petitions that are still being debated in the Legislature, such as establishing the retail infrastructure for recreational marijuana and a minimum wage increase long after they were passed through public referendum.

“It’s important to remember that five different times Democrats, Republicans and Independents have come together to pass Medicaid expansion, if voters vote yes that will make the expansion the law of the land,” Farmer said. “So the support is already in place, and we believe the Legislature will fully execute the expansion. That level of support was not the case with the other proposals.”

LePage opposes Question 2. He said Medicaid expansion would cost Maine taxpayers $500 million over the next five years while, “racking up massive budget shortfalls every year,” he said in a recent letter to the Maine State Chamber of Commerce made available to the Portsmouth Herald. “Maine should not expand Medicaid to give free health care to able-bodied people who should be working and can contribute to the costs of their own health care,” LePage stated in the letter. “Medicaid was designed as a safety net for the truly needy — not for adults who are more than capable of working.”

On Oct. 11 during his weekly radio address, LePage criticized supporters of Question 2, calling them “socialists (pushing) their agenda through the ballot box.”

“Expanding Medicaid to give them ‘free’ health care removes this incentive to work,” LePage said. “As I always say, ‘free’ is very expensive to somebody. Maine learned this the hard way when it expanded Medicaid in 2002 under then-Gov. (Angus) King. Medicaid expansion did not decrease the number of uninsured Mainers. It did not reduce emergency-room utilization. Instead, it nearly destroyed the state budget and created a $750 million debt to our hospitals. To pay for this ‘free’ health care, Maine took money away from our nursing homes and it put vulnerable people on waitlists for services they need.”

Farmer said if passed, LePage or one of his allies in the Legislature would have to introduce a new bill to repeal the new Medicaid expansion. LePage’s office did not respond to multiple requests asking if he would plan on introducing a repeal bill if the expansion were to pass.

Lawrence said overall, the ways in which health care is financed in the United States leaves a lot to be desired.

“It’s a pieced-together system of financing and if you were starting from scratch, you would not choose the way we do it now,” he said. “You have all the subsidies, private insurance, Medicare and Medicaid and it’s a really complicated puzzle for people. Therefore, passing Medicaid expansion will be important for taking pressure off the health care system otherwise we’ll see more insurance providers leaving Maine’s marketplace like Anthem deciding to leave at the start of 2018.”