During a mid-April campaign swing through Lincoln County, U.S. Rep. Mike Michaud, the Democratic candidate for governor, sat down in the Boothbay Town Office with senior citizens who were fired up about last year’s closing of St. Andrews Hospital and Healthcare Center.

The town manager was trying to squeeze an additional $400,000 out of the local budget to fund the increased cost of ambulance services, and the seniors were concerned about being hit with a double-whammy – a reduction in service and an increase in property taxes.

Michaud used the opening to slam Republican Gov. Paul LePage for not expanding MaineCare – the state’s Medicaid program – under the Affordable Care Act.

He told the group of nearly two dozen seniors that expanding MaineCare would cover an additional 70,000 people, including 3,000 veterans. If more residents were insured, Michaud said, the town would not need to shoulder as much of the ambulance costs.

“On Day One, I will submit legislation to cover those 70,000 people,” Michaud said, referring to his plans if he beats LePage and independent Eliot Cutler. Michaud said he was also working on a plan to create a statewide health insurance exchange by looking at best practices nationwide.

Michaud’s support for Medicaid expansion stands in sharp contrast to LePage’s fierce opposition, offering a clear example of how the Affordable Care Act is emerging as a central issue in Maine’s gubernatorial race, which is attracting national attention.

The Republican Governors Association has already targeted Michaud in news releases for his support of the act, reflecting a party strategy that aims to capitalize on the relative national unpopularity of the law, also known as Obamacare.

LePage refers to the Medicaid program as “welfare.” He argues that Maine already exceeds the national average in Medicaid coverage, which consumes 17 percent of total state spending.

Cutler is using the act to hit Michaud, who started his career as anti-abortion but is now pro-choice, for casting an anti-abortion vote as recently as 2010, during House debate on health care reform. Cutler said he supports universal health care, including abortions.

He says the law doesn’t go far enough to meet the need for affordable health care in Maine.

“This is not full access to health care,” Cutler said.

Michaud was slow to support Obamacare, but he is now one of the few Democrats running on, not away from, the Affordable Care Act, which is riding a wave of good news this month.

“I think overall it will benefit people in Maine and across the country,” Michaud said in an interview at his Portland campaign office.

THE POLLING

Under the act, insurance companies cannot deny coverage to people with pre-existing conditions. Children can stay on their parents’ insurance plans until the age of 26. And the law reduces prescription drug costs through Medicare by closing the so-called doughnut hole.

It also requires people to have health insurance, which they can get at group rates on the private market through health exchanges, or through Medicaid.

Initially, the law required states to expand Medicaid eligibility to more low-income people, but the U.S. Supreme Court struck down that provision and left Medicaid expansion decisions in the hands of individual states.

Twenty-six states, as well as Washington, D.C., are moving forward with Medicaid expansion, while 19 are not, according to the Kaiser Family Foundation. Debate continues in five other states.

Although technological problems hampered the October launch of the federal health insurance website, enrollment hit 8 million by the sign-up deadline at the end of March, prompting President Obama to rally Democratic support for the law at an April 17 news conference.

Obamacare also got a boost when the nonpartisan Congressional Budget Office said this month that the law will cost the federal government $104 billion less over the next 10 years than it previously projected – including $5 billion less in 2014.

But national polls show that most Americans oppose the act. Real Clear Politics, an independent website that draws from all parts of the political spectrum, reviewed the results of seven credible surveys on Obamacare from March 26 to April 20 and found that an average of 52.7 percent of Americans opposed the law.

The review included a poll by USA Today/Pew Research Center in early April that found 50 percent of Americans opposed the act, as well as a Fox News poll taken around tax day, April 15, which put opposition at 56 percent.

Polling in Maine has focused on the issue of MaineCare expansion.

An April 8 poll of 583 likely voters by Public Policy Polling found that statewide support for MaineCare expansion stood at 57 percent. Forty-five percent of people said Gov. LePage’s vetoes of expansion would make them less likely to vote for him, while 30 percent said they would be more likely to vote for him.

The Pan Atlantic SMS Group Omnibus poll of 400 Mainers released April 16 found that 48.5 percent supported MaineCare expansion. More than 42 percent of those surveyed said the issue would be very important to their decisions in November, while another 30.5 percent said it would be somewhat important.

THE POLITICS

Maine’s gubernatorial election is attracting national attention. And with that comes national politics, including attack ads from outside groups.

The Republican Governors Association hammered Michaud on the issue in a news release last month.

“Nearly four years ago, Mike Michaud voted in favor of Obamacare and said the law would ‘move us in the right direction.’ Nothing could be further from the truth for many Mainers,” the association’s communications director, Gail Gitcho, said in a written statement.

The association said the act will cost jobs. They note that thousands of Mainers lost health plans they were told they could keep and are losing Medicare benefits, even though Medicare reductions are largely through reducing fraud.

“And now Michaud stands on the sidelines, offering no fix to this disaster. Maine deserves better,” Gitcho said.

But Michaud shrugs off attacks like those from the association with his typical aw-shucks demeanor. “It’s an election year. Unfortunately, this has become a political issue,” he said.

Michaud was slow to embrace the act, because he said he feared that Maine, which had previously expanded its Medicaid program, would be punished. He said he supported the bill, after the administration agreed to provide higher basic reimbursement rates to the handful of states that expanded their programs before Obamacare was enacted.

But Cutler wants to portray Michaud’s support for the act as contingent upon banning federally funded abortions.

Michaud was one of 64 Democrats to vote in support of the Stupak-Pitts amendment, which under the House version banned federally funded abortions. The amendment was described by Planned Parenthood as a way for anti-reformers and anti-abortion leaders to “hijack” and “kill” health care reform.

The amendment was dropped after Obama agreed to issue an executive order prohibiting federally funded abortions, except in cases of rape, incest or danger to the life of a mother.

Cutler said Maine has the fifth highest health care spending per capita in the nation. He believes costs could be lowered by increasing scrutiny on hospitals, which are expanding their buildings and buying new equipment. Better access to primary and secondary preventive care will reduce health costs, he said. And Maine should test pilot programs involving telemedicine links to major hospitals, medical transportation and strategically located critical care hospitals.

Cutler also faults LePage for not taking roughly $150 million in federal funding to help establish a health exchange specific to Maine’s aging, low-income population.

While supportive of expanding Maine- Care and establishing state-based exchanges, Cutler said the act falls short of his goal of providing universal health care. “I think (universal access) includes abortion coverage for every woman in the state of Maine,” Cutler said in an interview.

He called Michaud’s vote in support of the Stupak-Pitts amendment a “big deal,” but Michaud described it as a “non-issue.”

“I would have voted for the bill without the amendment,” Michaud said. “Eliot is desperate. His campaign is deteriorating. He is trying to divide my base, which he hasn’t been successful in doing.”

Michaud would rather focus on Le- Page’s opposition to MaineCare expansion, which he says is blocking efforts to increase Maine’s reimbursement rate to the Boston rate. That would generate an additional $168 million a year for hospitals, Michaud said.

LePage, who joined a national lawsuit challenging the constitutionality of the Affordable Care Act, has vetoed three bills to expand MaineCare, including one with Republican support.

He describes expansion as “welfare” for “able-bodied adults,” saying it would have a “disastrous impact” on the budget and services for the elderly and disabled. He’s skeptical the federal government will fully fund expansion for the first three years and then 90 percent thereafter.

LePage called cost-saving projections often cited by Michaud – $600 million in savings to the state and an additional $348 million in revenue for hospitals – as “merely mirages.”

LePage attributes $750 million in debts his administration repaid to hospitals to Maine’s previous Medicaid expansion. He touts paying off those debts without raising taxes as one of his key accomplishments.

“Previous expansions of the program have taught us that when we grow a welfare program like Medicaid, people will drop their private insurance and flock to government assistance,” LePage said in his veto message.

THE BACKLASH

When health care reform was working its way through Congress in 2009, Michaud, along with other members of the fiscally conservative Blue Dog Coalition, did not fall in line early.

The Blue Dogs slowed down the process, extending the debate on health care reform through the 2009 summer recess, much to the chagrin of their Democratic base. Congressmen holding town hall meetings throughout the country were met with raucous, tea party-coordinated opposition to the bill.

Unlike many of his Blue Dog colleagues, Michaud did not pay a political price for his foot-dragging during the 2012 elections, where only 23 of 54 members were re-elected.

Michaud still thinks elements of the bill should be changed: More small businesses should be exempt from employer mandates and excise taxes on high-cost health plans, known as Cadillac plans, should not occur in 2018.

The Republican Governors Association has hit Michaud for “sitting on the sidelines” and not offering legislation to address his concerns, but Michaud is also quick to point the finger at House Republicans, who have voted “about 52 times” to repeal Obamacare, for the lack of progress.

“Right now we’ve been on the defensive because of the make-up of the House,” he said. “They just want to repeal it.”

THE TRACTION

Mainers will likely see more national messaging around the Affordable Care Act, but will it matter to voters?

“If anything, (the law) helps fire up the base for both LePage and Michaud,” said James Melcher, a political science professor at the University of Maine at Farmington. “The person that is left out in the cold is Eliot Cutler.”

Melcher said there is little room for Cutler to be helped or hurt by the health care debate, whereas Michaud can – and has – pointed to other Republican governors in the U.S. who once opposed the act but are now helping to implement it in their states.

“It’s easier for Michaud to use. It shows the governor is outside the mainstream,” Melcher said.

Jamie McKown, who holds the James Russell Wiggins chair in government and polity at the College of the Atlantic in Bar Harbor, believes the Republican attacks on Michaud over the act could backfire, by making Michaud more attractive to progressive voters – people who may be more inclined to support Cutler.

McKown noted that the Pan Atlantic poll showed that half of Cutler’s supporters think that Michaud is the best candidate to defeat LePage.

“The real issue that will decide this election is whether or not Michaud can persuade Cutler voters to come over and vote for him,” McKown said. “If the Republicans want to paint Michaud as someone who is more progressive and characterize him that way, are they going to be increasing his viability among Cutler voters?”

Melcher thinks the Republican Governors Association will launch a series of ads against Michaud’s support of the act, and other votes in Congress.

“It’s a very competitive race,” Melcher said. “Every poll is within the margin of error and Maine is a really cheap media buy.”

Randy Billings can be contacted at 791-6346 or at:

rbillings@pressherald.com

Twitter: @randybillings