AUGUSTA — Maine is the only state with voters who have approved expanding Medicaid to low-income residents, but the start of expansion originally set for Monday is in limbo as a legal battle between the fiscally conservative governor and advocates continues.

Last fall, nearly three out of five voters approved the expansion of Medicaid to cover an estimated 70,000 Mainers. It was the first time since former President Barack Obama’s Affordable Care Act took effect four years ago that the expansion question has been put to voters.

Roughly 11 million people in 31 states have gained coverage through the expansion of Medicaid, the state-federal health insurance program for lower-income Americans. Since Maine’s vote last fall, Virginia lawmakers voted to expand Medicaid, and expansion initiatives are set to appear on ballots in Utah and, potentially, in Nebraska and Idaho.

Late last year, Republican Gov. Paul LePage swore to block expansion unless lawmakers provided funding under his terms to pay for Maine’s share of expansion. Last month, lawmakers sent him the funding bill he demanded, but LePage vowed to veto it, possibly Monday, partly because he says it would harm the state’s economy.

Meanwhile, the state faces lingering questions about the fate of expansion, the cost of the governor’s efforts to block Medicaid and the impact of potential work requirements.

LePage had vetoed five attempts by the politically divided Legislature to expand the program and take advantage of the federal government picking up most of the cost. That led to the citizen initiative where voters approved expansion, but the governor ignored an April 2018 deadline to submit the necessary paperwork to eventually receive more than $500 million in annual federal funding to pay for most of it.

Advocacy groups and potential Medicaid recipients then filed suit, and a Superior Court judge sided with them, ordering the LePage administration to file a state plan amendment with the federal government that would set the health coverage in motion.

But the administration appealed the order, and the Maine Supreme Judicial Court said LePage doesn’t have to file the paperwork during the appeal. Legal arguments are set for July 18, and advocates are encouraging low-income Mainers to apply for Medicaid on Monday even though the LePage administration is not ready for a surge in applicants.

The governor disputes the estimated, first-year cost of about $30 million after savings and says lawmakers should recall their “hasty, ill-conceived” funding plan that relies on surplus and tobacco settlement funds. “We cannot afford to return to the days of out-of-control spending on Medicaid and a $750 million debt to our hospitals,” he said Friday.

Peter Miller, an Ellsworth man who lost Medicaid eligibility in 2013 under LePage-era cuts, said he hasn’t followed the political and legal twists and turns.

“I gave up on the hope of this going my way,” said Miller, who cannot afford weekly treatments for a blood clot and resorts to keeping old asthma inhalers in a bowl in his living room. He said his pay as a prep cook isn’t enough for him to qualify for financial assistance to help him afford health insurance under Obama’s law.

“I’m just hoping that I survive,” he said.

WORK REQUIREMENTS

LePage has said he considers Medicaid another form of welfare that will bankrupt his state. His plan to require certain recipients to work and pay premiums exempts those who prove they’re physically or mentally unable to work.

Four states – Kentucky, Indiana, Arkansas and New Hampshire – have had their 20-hour-a-week work requirements approved by Republican President Trump’s administration, a development that has won over some Republican lawmakers long opposed to Medicaid expansion. Virginia is set to seek federal permission for such restrictions, while Utah wants a limited Medicaid expansion with work requirements.

But the future of such work requirements is unclear as seven states, including Maine, await federal permission for their own plans. On Friday, a federal judge blocked Kentucky’s work requirements and has ordered the Trump administration to reconsider the program.

LePage’s plan to limit Medicaid coverage to three months in a 36-month period for those who don’t meet work requirements has been little-discussed as advocates lawyer up, but observers like Maine Primary Care Association Board President Martin Sabol said they’re worried. LePage’s administration predicts an unknown number of “able-bodied” adults will lose coverage under a plan that could save Maine roughly $130,000 annually.

“There often aren’t a whole lot of jobs available to people who don’t have a lot of job skills,” said Sabol, who directs health services at a community health care center serving 5,500 patients. “Folks are going to be losing their coverage, and that’s going to mean we’re going to have a whole lot more uncompensated care.”

LEGAL COSTS

Meanwhile, LePage’s legal costs are mounting. Democratic attorney general and gubernatorial candidate Janet Mills has refused to represent LePage in the ongoing Medicaid lawsuit, and has allowed him to retain Boston lawyer Patrick Strawbridge.

LePage’s office hasn’t responded to requests for Strawbridge’s billing for Medicaid litigation. But Maine’s online database of governmental spending shows Maine’s risk management claims fund paid $16,478 on May 25 to Strawbridge’s firm Consovoy McCarthy Park. The fund has paid out $92,000 this year to the firm, which has represented the governor in four legal matters in the past year.