Maine and Wisconsin would be the first states in the nation to charge monthly Medicaid premiums to people living in extreme poverty and bar them from re-enrolling in the program before they catch up on late premiums, if requests by the two states are approved by the Trump administration.

In addition, Maine and Wisconsin would be the first states to impose work or volunteer requirements on some Medicaid enrollees.

“Never in the 50-plus years of Medicaid’s existence has health coverage been conditional to whether you’re working,” said MaryBeth Musumeci of the Kaiser Family Foundation. “This would be breaking new ground, and the question is how far would the Trump administration go in allowing these proposals to move forward.”

Under the proposal, premium payments would be required even for those earning less than 100 percent of the federal poverty level, which is $11,800 per year for a single Mainer, or a family of three earning less than $20,100. The annual premiums would be $168, or $14 per month.

About 265,000 Mainers are enrolled in Medicaid, and an estimated 50,000 would be affected by the premiums imposed for those earning less than the federal poverty level, according to Maine Equal Justice Partners, a liberal advocacy group.

Four other states – Indiana, Montana, Iowa and Michigan – charge modest premiums for low-income Medicaid recipients, but patients can stay enrolled if they don’t pay their premiums, and they don’t have to pay up before re-enrolling, making the payments unenforceable.


If the federal government approves the waiver request, which is expected to be submitted by the Maine Department of Health and Human Services in the coming months, Maine Equal Justice Partners said it would file a lawsuit to block the action.

“If the Trump administration approves this waiver or something close to it, yes, we would sue,” said Jack Comart, an attorney for the group. “You can’t just say that I don’t like a law and therefore it should be waived.”

Comart said the Medicaid waiver, if approved, would violate the law, which requires that waivers must expand access to coverage, not result in fewer people having health insurance.

“The LePage administration will try anything to reduce eligibility for Medicaid. That’s been their MO (modus operandi) since LePage came into office” in 2011, Comart said. Maine’s Medicaid population has declined from 350,000 in 2011 to 265,000 this year, largely because the LePage administration has reduced eligibility for childless adults and parents.


“Historically, these waivers have been granted to add eligibility or expand services, not take them away,” said Tim Gronniger, former chief of staff at the U.S. Centers for Medicare & Medicaid Services in the Obama administration. “Many would struggle to pay their premiums.”


Gronniger said the waivers being proposed in Maine and Wisconsin are making a political point and are ideologically driven.

“These waivers are not being proposed by any doctors’ groups, nurses or health system administrators. These are not health care proposals,” he said.

Hundreds objected to the Maine waiver request during public hearings in May in Portland and Augusta.

But Jonathan Ingram, vice president of research for the Foundation for Government Accountability, a conservative public policy think tank based in Florida, said he believes it’s likely the Trump administration will approve the Maine waiver and similar waivers proposed by other states.

“The president has made it clear that encouraging work should be a priority for welfare programs. They are likely to approve these waivers with minimal changes,” Ingram said. “Maine is in the forefront of working to reduce dependency, and the waiver is taking a big step toward that goal.”

Ingram said limiting coverage to able-bodied adults allows states to focus on populations like the disabled and children.


He said any legal challenges would fail because the executive branch has wide discretion to grant Medicaid waivers.


At the same time the waivers are being considered, the Trump administration is proposing dramatic cuts to Medicaid, through its budget proposal and the American Health Care Act, which would repeal and replace former President Obama’s Affordable Care Act.

The Maine waiver, a sweeping request that would make dramatic changes to MaineCare, as Medicaid is known in Maine, would charge $14 monthly premiums for those earning less than 100 percent of the federal poverty limit, or $20,100 in household income for a family of three.

Brianna Nielsen, 36, of Portland, said MaineCare coverage is crucial for her family of three, because she is in recovery from addiction to OxyContin and is receiving treatment for substance abuse.

Their household income is $11,000, and even a $14 monthly premium would be a financial hardship, she said.


“We are so stretched financially right now,” Nielsen said. She said she needed time off from work to recover from substance use disorder, but she will be seeking part-time work over the summer, and her long-term goal is to go back to school and become a substance abuse treatment counselor.

“I would be devastated right now if I lost MaineCare insurance,” she said. “Our family would be in a crisis.”


The $14 premiums would affect about 50,000 people, according to Maine Equal Justice Partners. About 265,000 Mainers have Medicaid, with 75 percent of the beneficiaries either disabled, children or low-income seniors who are eligible for both Medicaid and Medicare. Maine’s Medicaid budget is about $2.3 billion, with the federal government paying for about 65 percent of the program, and state tax dollars paying for the rest.

Maine would also charge $43 premiums for able-bodied adults earning between 100 and 200 percent of the poverty limit, and $66 for those earning above 200 percent of the poverty limit. But health advocates say those premiums would affect very few people because with rare exceptions, able-bodied adults earning more than 100 percent of the poverty level do not qualify for Medicaid in Maine. States have flexibility on what groups of people are eligible for Medicaid.

Maine Equal Justice Partners does not have an estimate for how many of the 50,000 would end up without insurance, because the changes would be unprecedented.


But Musumeci, associate director for the program on Medicaid and the uninsured at the Kaiser Family Foundation, said the research shows that other “personal responsibility” requirements in other programs, such as food stamps and Temporary Assistance for Needy Families, have little effect.

“Over the long term, the research shows these measures don’t result in increased employment. By and large, people who are able to work are already working,” Musumeci said.

The Kaiser Family Foundation published a review Thursday of 65 studies from 2000 to 2017 that examined the impact of charging premiums or setting other cost-sharing responsibilities for low-income families. The review found that under such programs, families lose health care coverage and use emergency rooms more frequently.


In addition, states don’t save money by charging premiums or setting other cost-sharing responsibilities because increased administrative costs generally offset any revenue generated.

Under Maine’s waiver proposal for Medicaid, enrollees would also be required to work 20 hours a week or volunteer 24 hours a month to maintain their eligibility for benefits.


Ingram, at the conservative think tank, said Medicaid is a welfare program similar to TANF and food stamps, and so it makes sense to impose a “nominal” premium and ask people to chip in for receiving public assistance.

He said many of the work provisions can be easily met, either by volunteering one hour per day or obtaining a note from a health professional saying you’re unable to work.

Ingram said that in other welfare programs, when states require work or other “personal responsibility” measures, people go out and get jobs.

“The best result for someone collecting welfare is to get a job,” he said.

But Chris Hastedt, public policy director at Maine Equal Justice Partners, said Medicaid already provides an incentive to work by giving people the ability to control chronic health conditions so they can hold a job, if they are able to. Taking away their Medicaid makes it more difficult to work.

“They have it exactly backwards,” Hastedt said. “Medicaid supports work by giving people access to health care. People don’t forgo full-time jobs with benefits in order to keep their Medicaid.”


While the LePage administration is seeking a Medicaid waiver, Maine voters will decide a ballot question in November that would expand access to benefits. LePage has vetoed several attempts by the Legislature to expand Medicaid.

Joe Lawlor can be contacted at 791-6376 or at:

Twitter: joelawlorph

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