Bolder Advocacy

Summary

Mainers for Health Care was formed to support a ballot initiative to expand Medicaid coverage in Maine. The initiative was proposed after the state’s governor vetoed Medicaid expansion legislation five times. As the governor’s vetoes continuously thwarted legislative efforts, a coalition formed to take the question directly to voters.

Mainers for Health Care was composed of a broad range of nonprofits, including a mix of (c)(3)s, (c)(4)s, labor unions, and religious organizations, as well as for-profits and other entities. Steering committee members included Maine Center for Economic Policy, Maine Equal Justice Partners, Maine Voices Network (all 501(c)(3)s), as well as Maine People’s Alliance and Planned Parenthood of Northern New England Action Fund, both 501(c)(4) organizations.

On Election Day, voters supported the initiative, but the coalition’s work continues to ensure the state implements and fully funds the program.

Strategies

501(c)(3) organizations were indispensable to the overall effort. As the initiative was certain to place a fiscal cost on taxpayers, an important component of the educational work was to focus on the value of Medicaid in not only bettering people’s lives but also the state’s economy. In addition to their research and messaging roles highlighting the importance of Medicaid in general, (c)(3)s focused on passing the measure itself. Some made direct contributions to the ballot measure campaign (staying within their lobbying limits) while others endorsed the measure—lending their names and reputations—without spending much money or time. With this solid base of support, non-501(c)(3) partners were able to dedicate their resources to the lobbying-intensive component of the campaign.

501(c)(4)s were critical from start to finish. They funded the initial “boots on the ground” efforts to collect enough signatures to place the measure on the ballot as well as get out the vote (GOTV) activities to ensure supporters cast their votes. In between, they funded TV ads that helped voters understand why they should vote yes. The first ad featured a Maine hairdresser who could not afford health coverage. The woman had a chronic illness and in the ad, she explained how she was often faced with “a choice between oxygen and paying my bills.” The second ad featured a nurse who talked about how the expanded coverage would benefit patients who could not afford care. These ads can be viewed on the Mainers for Healthcare campaign website.

The coalition, through its various partners, also encouraged voters to submit public comments on the ballot initiative language and worked to ensure a long list of endorsers, including business owners, health care providers, and government officials. The coalition then published the list of endorsers on its website and disseminated the list to media outlets.

A group of health care providers joined in support of the ballot initiative. At a gathering of providers on October 12, 2017, several spoke about the necessity to expand health care coverage. Bryan Wyatt, representing Maine Primary Care Association said: “Maine’s failure to expand Medicaid has created a crisis for many of the clinics in the state . . .” The group also heard from Sam Zager of the Maine Academy of Family Physicians and Maine Providers Standing Up for Healthcare, who said: “(i)ncreasing the number of Mainers with health insurance by expanding Medicaid would improve quality of life, increase workplace productivity and save lives.”

Small business owners not only signed on to support the ballot measure but also sent letters to the editors of local newspapers explaining the importance of expanding Medicaid. In one such letter to the editor, the leader of the Maine Small Business Coalition wrote “I work with small-business owners every day who say that their business depends on both the physical and financial health of their employees and communities. Expanding Medicaid would create 3,000 jobs, spurring local demand for products and services, and ensuring more employees have secure health care.”

Foundation Role

Coalitions can also engage the help of private foundations in various ways. In the case of Mainers for Health Care, the coalition was able to use research published by the Maine Health Access Foundation whose mission is to promote access to quality health care in Maine, especially to the uninsured and underserved. In April 2015, the foundation issued a report on the estimated positive impact Medicaid expansion would have on the state budget. Building on that report, the foundation also commissioned a series of fact sheets covering basic details about the Medicaid program, such as funding and coverage, as well as analyzing the importance of Medicaid to the state’s health system.

According to Jesse Graham, director of the (c)(4) Maine People’s Alliance, the foundation’s materials were valuable to the coalition’s research and communication teams. He recommended that coalitions talk to private foundations in the earliest stages of forming a coalition, so private foundations’ restricted funds can be used for preliminary issue education.

Outcome

The coalition’s efforts were a success, as almost 60 percent of voters supported the initiative, making Maine the first state in the nation to use a ballot measure to expand Medicaid coverage.

Despite the clear support of voters, Maine’s governor, Paul LePage, continues to obstruct Medicaid expansion. In April 2018, a lawsuit (Maine Equal Justice Partners et al. v. Hamilton) was filed seeking to force the governor’s administration to submit a state plan to the U.S Department of Health and Human Services to expand the Maine Medicaid program. A (c)(3) coalition partner, Maine Equal Justice Partners, led the litigation effort. Since litigation does not generally constitute lobbying, (c)(3)s have great flexibility to participate in legal challenges. The trial court judge ordered the governor to implement the law by July 2nd, and the coalition turned its attention to the legislature for the money needed for the program.

Mainers for Health Care, with its (c)(4) partners, persuaded the legislature to appropriate $60 million from the state surplus and tobacco settlement money to fund their first year of coverage. Yet Governor LePage vetoed the spending bill and has appealed the trial court decision. The governor has said he will not implement the law until the legislature provides a long-term funding plan that does not rely on using state surplus money. In mid-July 2018, the Maine Supreme Judicial Court heard arguments about whether the governor needs to act while his appeal is pending. Just days before the state’s highest court held hearings in the matter, Governor LePage said, “I will go to jail before I put the state in red ink. And if the court tells me I have to do it, then we’re going to be going to jail.”

Despite the struggles in Maine to implement the ballot measure, groups in Idaho, Nebraska, and Utah are mounting similar ballot measure campaigns this year to expand their states’ Medicaid eligibility coverage.