Maine is headed for a “Dirigo” moment this Nov. 7. That’s when an expansion of the MaineCare program, funded better than 90 percent with federal Medicaid dollars, will be on the ballot.

Maine will thus become the first state ever to vote directly, rather than through the Legislature, on whether to embrace the principles and policies of the Affordable Care Act, also known as “Obamacare.” The timing couldn’t be better.

When backers of the referendum gathered signatures at the same moment voters nationally were pairing Donald Trump with a Republican Congress, there was uncertainty over the Medicaid expansion that’s taken place in 31 states — but not including Maine, which because of Gov. Paul LePage’s vetoes is the only Northeastern state to reject ACA funding.

That uncertainty was removed when U.S. House Speaker Paul Ryan proposed a “repeal and replace” bill to continue Medicaid expansion through 2020, providing Maine at least three years of coverage if the referendum passes. Ryan’s plan is surely as far as congressional Republicans will go toward “repeal,” though a vocal GOP sub-caucus — and LePage — want to terminate expansion immediately.

Ryan undoubtedly envisioned a compromise between different GOP factions — but he also faces opposition from Senate Republicans nervous about cutbacks. These elaborate political calculations were exploded when the Congressional Budget Office, led by a conservative Republican economist, projected the effects of Ryan’s bill.

The ACA provides 20 million Americans with health insurance; it would be closer to 30 million had many Republican governors not blocked Medicaid expansion. The CBO estimates 14 million of those 20 million would lose coverage immediately, rising to 24 million over time.


The biggest drop reflects Ryan’s decision to eliminate the “individual mandate” that requires all adults to obtain health insurance or pay an income-based penalty. The mandate is “unpopular” in the sense people don’t like it, but also necessary if you want a private health insurance system that gets anywhere near universal coverage.

The Republican “replacement” tells us all we need to know about the mindset driving all GOP plans for the federal government. Instead of a “mandate” whose proceeds go to the public funding pool, the Republicans envision a 30 percent penalty — payable to private insurers — for anyone seeking coverage after letting insurance lapse.

We already know people often put off buying insurance until they face a major illness — that’s what the old, notorious “pre-existing condition” exclusion was all about — and the Republican plan would make everything worse. Not only would there would be no incentive to buy insurance while healthy, but consumers would face a double whammy — the 30 percent surcharge — when they finally buy insurance.

Republicans are apparently unwilling to give up their fixed idea that, in any sphere of life, private is always better than public. In health care, no national system anywhere in the world conforms to this notion, for the obvious reason that it doesn’t work. In fact, the private elements of our own system are exactly where prices have soared.

The outline of the ACA’s approach to public and private sectors is now, at long last, reasonably well understood. What we’ve forgotten in how the privatization of Medicare, undertaken in 2003 by a Republican president and Congress, has distorted our one successful and popular public health care program.

The Bush-era Medicare changes dramatically increased “Advantage” plans offered by private insurers and, even more egregiously, turned the new Part D prescription drug plan over to private insurers — then prohibited insurers from negotiating prices.


The system almost encourages outrageous gouging for “orphan” drugs, plus routine markups that make many prescriptions twice as expensive as anywhere else. Those new to the game, such as President Trump, naturally favor negotiating prices, but he’s unlikely to win over Republicans who designed the system.

Most Republican plans for health care, past and present, rest on the erroneous assumption that privatization is always best. In this case, “repeal” would lead not only to a huge loss in coverage, but sharply higher premiums for older Americans, still shy of Medicare, who’ve lost their jobs, and benefits.

Paul Ryan and Senate Leader Mitch McConnell have a choice. They can push through this bill with only Republican votes, and face a major electoral backlash in 2018 — or give up the project.

Either way, Mainers will get to decide on Nov. 7. Will we provide health insurance to those who have no hope of getting it otherwise? Or will we turn our backs on them — and, by 2026, an estimated 24 million additional Americans who would become uninsured if the replacement plan is put into effect, and whose principal hope of staying healthy will be not getting sick?

Douglas Rooks has covered the State House for 32 years. His first book, “Statesman: George Mitchell and the Art of the Possible,” is now available. Comment is welcomed at: [email protected]

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