The LePage administration’s proposal to further tighten Medicaid eligibility requirements would make Maine one of the stingiest states in the nation when it comes to allowing able-bodied, low-income adults to qualify for the federal health care program.

“The implications are dire,” said Robyn Merrill, executive director of Maine Equal Justice Partners. The advocacy group for low-income Mainers estimates that Gov. Paul LePage’s budget would trim Medicaid rolls by up to 20,000 people.

Under the budget proposal, released Friday night, adults with children could earn no more than $9,720 – 40 percent of the federal poverty level of $24,300 for a family of four – to qualify for MaineCare, the state’s name for Medicaid. The children would still receive MaineCare.

Meanwhile, adults removed from MaineCare under LePage’s proposal would not qualify for federal subsidies to purchase Affordable Care Act insurance because the subsidies do not kick in until a person earns at least 100 percent of the poverty level.

While 31 states have expanded Medicaid coverage under the ACA, Maine has made it more difficult to qualify for Medicaid since LePage took office in 2011, joining states such as Alabama, Mississippi, Idaho, Texas and Kansas that have traditionally restricted access. LePage also has vetoed efforts by the Legislature to expand Medicaid, and has cut back the program by reducing eligibility and making other changes.

The governor’s budget proposal noted that tightening Medicaid eligibility would save $33 million, which he wants to divert to other health and human services programs for the “neediest and most vulnerable” populations, such as the elderly and disabled.

DHHS spokeswoman Samantha Edwards said in an email response to questions that reducing the tax burden for Mainers as the LePage budget aims to do would do a better job of reducing poverty than traditional welfare programs such as Medicaid.

“We cannot continue to focus our budgets and public policy based on the dependency that has been created by years of promoting welfare programs, but rather must focus on reducing the size and cost of state government,” Edwards wrote. “Through these efforts to increase jobs in Maine, we will do far more to support longer-term success for those who have been trapped in poverty by short-sighted welfare policies that have perpetuated dependency.”

But Dr. Patricia Hymanson, a Democratic state representative from York and co-chair of the Legislature’s Health and Human Services committee, said cutting off Medicaid for low-income parents is “cruel” and helps keep families trapped in poverty.

“If the parents are struggling with their health, the children struggle, too,” Hymanson said.

Overall, the DHHS budget would be trimmed by $140 million, according to the 30-page budget analysis released Friday.

“Given the significant pressures on U.S. health care costs – and the rapidly increasing Medicaid expenditures seen in other states – the ability of DHHS to rein in MaineCare spending is a significant accomplishment,” LePage’s budget overview states.

Andrew Coburn, a research professor and director of the Maine Rural Health Research Center at the University of Southern Maine, said given that Maine lawmakers nearly approved Medicaid expansion, it seems unlikely that the Legislature, where Democrats hold the majority in the House and Republicans hold the Senate by one seat, would approve such a deep cut to MaineCare.

Support for Medicaid expansion included some State House Republicans, including Sens. Roger Katz of Augusta, Tom Saviello of Wilton and David Woodsome of North Waterboro.

“It seems almost like this budget is a political statement,” Coburn said. “I’m hard-pressed to think of a rationale for this.”

Coburn said MaineCare cuts would harm families, as well as shift costs and create ripple effects in other parts of the health care system, such as requiring hospitals to provide more free care to the uninsured and create upward pressure on the price to provide private employer-based insurance.

People without insurance tend to wait until they have an emergency to go to the hospital, which is more costly to the system than getting preventive care available under Medicaid.

“It’s a proposal that would have serious consequences,” Coburn said.

Maine Equal Justice Partners is organizing a petition drive to place Medicaid expansion on the ballot as a statewide referendum, either in 2017 or 2018. At the same time, Congress is mulling whether to repeal the ACA, but no comprehensive replacement plan has been identified.

Medicaid is a federal program administered by the states and paid for with a blend of state and federal dollars. While states must cover the disabled and children with Medicaid, they have wide latitude when it comes to adults.

Maine currently ranks as the 18th stingiest state when measuring Medicaid eligibility for able-bodied single adults and parents, according to the Kaiser Family Foundation, a nonprofit that conducts health care research. If LePage’s proposal is approved, Maine would become the 10th stingiest state in terms of Medicaid eligibility.

Adults without children were removed from Maine’s Medicaid rolls about three years ago, but adults who had children in the home currently still qualify for Medicaid in Maine if they earn up to 100 percent of the federal poverty level, or $24,300 for a family of four.

Some states make it nearly impossible to qualify for Medicaid for adults who are not disabled.

For instance, in Texas and Alabama, adults without children do not qualify, and adults with children become ineligible for Medicaid if they earn more than 18 percent of the federal poverty level.

By contrast, the District of Columbia, Connecticut, Alaska and Indiana make it easier for their residents to qualify for Medicaid benefits than it would be under Medicaid expansion through the Affordable Care Act, which allows people who earn up to 138 percent of the federal poverty limit.

About 287,000 Mainers are on MaineCare, and the cutbacks would make up to 20,000 adults ineligible for Medicaid, according to Maine Equal Justice Partners. Maine also used to allow low-income parents with children in the home to qualify for MaineCare for those who earned up to 200 percent of the poverty limit, but that was cut to 100 percent of the poverty limit in recent years.

Merrill said other LePage cutbacks to the social safety net proposed in the just-released two-year budget – such as the elimination of General Assistance and cutbacks to Temporary Assistance for Needy Families – threaten to increase poverty levels in Maine.

“This can destroy people’s lives, put them into bankruptcy or make them lose their home,” Merrill said.

LePage has made welfare reform one of the cornerstones of his two terms as governor, but some of the changes have been heavily criticized by Democrats and advocacy groups.

State Sen. Eric Brakey, R-Auburn, and co-chair of the Health and Human Services Committee, said he’s still examining the LePage budget in detail, so he doesn’t have a stance yet on the Medicaid proposal.

“That said, I’m very open-minded about any proposals that seek to prioritize our limited welfare resources for Maine’s most vulnerable,” Brakey said in a written statement to the Press Herald.

Merrill said the LePage administration proposal is real and coincides with the governor’s political ideology, so it shouldn’t be assumed that it will be defeated.

“Let’s hope reason and compassion prevail,” she said.