Addiction specialists caution against reading too much into a new study released this week that compares two popular medications for opioid addiction. This much-anticipated research is the largest study so far to directly compare the widely used treatment Suboxone with relative newcomer Vivitrol.

Researchers who compared the two drugs found them equally effective once treatment started. But there are fundamental differences in the way treatment begins, which makes these findings difficult to interpret.

Vivitrol, an injection of naltrexone that lasts 28 days, has gained a foothold among treatment providers, especially those working with the criminal justice system.

Until recently, no major study had compared it to Suboxone, a combination of buprenorphine and naloxone that is taken by mouth daily.

Now researchers have found the two medications to be equally effective at preventing relapse once patients start treatment, according to a study published Tuesday in The Lancet. A smaller, shorter study out of Norway that was published in October came to a similar conclusion.

But the Lancet study highlights a limitation for patients starting on extended-release naltrexone: Patients have to detox before receiving their first dose of Vivitrol. That requirement creates a significant barrier to beginning treatment, says Dr. Joshua Lee, associate professor at the NYU School of Medicine and lead author of the report.

“It’s going to take a few days or a week or more to get them on naltrexone in the first place,” he says. “And that detox hurdle does not exist for buprenorphine.”

Still, the research indicates that it would be advisable for treatment providers to offer both medications, he said. “Relapse rates are extremely high if you don’t get onto and continue a medication,” said Lee.

The two medications work in very different ways. Buprenorphine (like another addiction medication, methadone) is a long-acting opioid that’s taken daily. There are decades of research showing that it helps reduce cravings and prevent withdrawal symptoms.

The Lancet study looked at a combination of buprenorphine and naloxone, which reverses the effects of opioids and is designed to prevent users from injecting or snorting the medication. Naltrexone is an antagonist — it blocks receptors in the brain and prevents opioids from having any effect. Vivitrol, which is delivered as a monthly injection, was approved to treat opioid use disorder in 2010 and until recently, no studies comparing buprenorphine and Vivitrol had been published.

“We’ve had trials of each one, but not together,” said Lee. The latest study followed 570 patients from inpatient detoxification centers. They were randomly assigned to one of the drugs for six months. “Once people were on either one, they did reasonably well over time,” said Lee.

But because extended-release naltrexone can throw people into withdrawal if administered too soon after opioid use, patients must first go through detox — abstaining from drug use — which often causes debilitating flu-like symptoms for several days. More than a quarter of patients assigned to naltrexone didn’t complete detox, and most of them relapsed.

Buprenorphine treatment doesn’t require patients to go through detox. “So up front there’s a clear clinical advantage,” said Lee. “Buprenorphine products are clearly easier to use.”

Alkermes, the company that manufactures Vivitrol, has heavily marketed its flagship product to nonmedical professionals. As NPR and Side Effects reported earlier this year, the company has targeted lawmakers, judges and other criminal justice officials — people who may be ideologically opposed to using opioids to treat opioid addiction — in order to boost sales of its drug.

Given the tendency for criminal justice officials to favor non-opioid treatment options, Dr. Camila Arnaudo, an addiction psychiatrist who teaches at the Indiana University School of Medicine in Indianapolis, said she worries people will oversimplify the results of the study. “I’m a little bit concerned about headlines that I’ve already seen,” she said, many of which have indicated that the products are equally effective, leaving out the caveat that many people initially failed out of treatment with extended-release naltrexone. “I’m concerned that it’s going to lead to policies where patients are shunted into treatment with extended-release naltrexone, which is more acceptable to the criminal justice system.”

She cautions people against reading too much into any one study, and pointed again to the detox hurdle. “You’re weeding out the less committed people,” she said, potentially skewing the results in favor of extended-release naltrexone. She said some patients will do better on one drug or the other depending on the case.

“I think we can say that both are viable options for patients and they prevent opioid use,” she said. “I think what we cannot say, though, is that they’re equivalent based on this study.”

She added that some of the study authors reported receiving financial support and consulting fees from Alkermes.

Vivitrol treatment is more expensive. Each Vivitrol shot costs more than $1,200, according to Medicaid data, while a monthly supply of Suboxone can cost a few hundred dollars, depending on the dose.

Some inpatient treatment centers may also be ideologically opposed to starting someone on buprenorphine, particularly after detox, said Lee, but his study shows that it can be an effective option even starting in an inpatient setting. And in any event, relapse rates are higher among people who don’t use medications for their opioid addiction.

“Detox episodes are brief,” he said. “They don’t generally last in terms of how you look a week later.”

He added that if patients enter treatment with hopes of getting on Vivitrol but can’t make it through detox, they should be offered buprenorphine. The bottom line, he said, is that both medications should be widely available and offered to patients suffering from opioid addiction.

“We’re not doing a good enough job in this country of getting people into treatment and offering them these types of medications,” said Lee. “So were just going around undertreating the opiate epidemic.”

This story was produced in partnership with WFYI and Side Effects Public Media, a news collaborative focused on public health.

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When U.S. officials feared an outbreak of the Zika virus last year, the Department of Health and Human Services and state officials kicked into high gear.

They tested mosquitoes neighborhood by neighborhood in Miami and other hot Gulf Coast communities where the virus was likely to flourish. They launched outreach campaigns to encourage people to use bug spray. And they pushed the development of a vaccine.

“The response was swift,” says former Surgeon General Vivek Murthy, and was even faster during the Ebola outbreak a year earlier.

But last month when 50 people died and more than 400 were injured in Las Vegas, and weeks later another 26 died in Texas of the same cause, public health officials have had almost no role.

That’s because the victims in Las Vegas and Texas were killed with guns. And over the last three decades, Congress has made it clear that they don’t want the public health community looking too hard into the causes of the violence.

“If you look at the number of people who have died or been injured from gun violence, that dwarfs the number of people who have been affected by Zika or Ebola. There’s absolutely no comparison,” Murthy says.

More than 30,000 people are killed with guns in the U.S. every year. That’s more than die of AIDS, and about the same number as die in car crashes or from liver disease. But unlike AIDS or car crashes, the government doesn’t treat gun injuries or deaths as a public health threat.

Murthy and other public health experts say it should.

“It should be no different than the approach we take to cancer, heart disease or diabetes,” he says.

But such an approach would have to start essentially from scratch. The government spends only about $22 million a year on research into gun violence — a tiny fraction of what it spends on other major health threats.

That’s because of Congress. Back in 1997, lawmakers added a provision in the bill that funds the Centers for Disease Control and Prevention barring the agency from doing anything that would “advocate or promote gun control.” At the same time, they cut CDC’s budget by the exact amount it had been spending in gun violence research up until then.

So government research into the causes of gun deaths virtually stopped.

The issue comes up routinely after mass shootings. Two years ago, after a young man killed nine people in a church in South Carolina, a reporter asked former Republican House Speaker John Boehner about the CDC restrictions.

“The CDC is there to look at diseases that need to be dealt with to protect the public health. I’m sorry but a gun is not a disease,” he said at the time.

After the most recent shootings, Democrats in Congress have called for more restrictions on guns while Republicans, including President Trump, say the problem is mental health.

But neither conclusion is backed by research, says Dr. Georges Benjamin, the executive director of the American Public Health Association.

“When a new disease, particularly an infectious disease, enters the community … we have a mechanism to anticipate it, track it, get our arms around it,” he says. “We do that when he have measles, mumps, chicken pox, zika. But firearm-related death and disability, we don’t.”

That kind of prior knowledge could lead to policies that reduce the toll of gun injuries without cutting off access to them.

“Firearms are a tool, and … a consumer product. And unlike other consumer products, we’re not working hard to make that consumer product safer,” he says.

Take cars for example. Benjamin points to the combination of safety features — airbags and seat belts — and safety policies like requiring licensing and banning drunk driving — that have made cars less lethal, while ensuring they’re still available.

A similar strategy with guns could lead to some laws or regulations that make them safer.

That could involve barring large ammunition clips to limit the number of shots a person could take, or requiring trigger locks that open by fingerprint, allowing only the gun owner to fire a weapon.

“We could think about where firearms ought not to be,” he says. “Alcohol and firearms and people who might get a little rowdy probably are not a good combination. There are solutions to that.”

Creating more shooting ranges may be a good idea so gun owners have a safe place to use their weapons, he says.

Today, Benjamin says, there is no data to show whether people are safer in communities with more or fewer guns.

Something has to change, because up until now, “We have done everything we can to ensure that this epidemic of death and disability from firearms is only going to get worse,” he says.

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Updated 5:56 p.m. ET

Senate Republicans now plan to try to repeal the Affordable Care Act’s individual mandate as part of a tax overhaul bill.

Several Senate Republicans said Tuesday that including the repeal in tax legislation, currently making its way through a key Senate committee, would allow them to further reduce tax rates for individuals without adding more to the deficit.

The decision was a rapid change of direction for Republicans, who previously believed it would be politically dangerous to add any health care measure to the tax legislation.

Senate Majority Leader Mitch McConnell told reporters Tuesday that members of the Senate Finance Committee believe tacking on the repeal will ensure the bill has sufficient votes to pass when it comes up for a vote in the Senate.

“We’re optimistic that inserting the individual mandate repeal would be helpful,” McConnell said, “and that’s obviously the view of the Senate Finance Committee Republicans as well.”

The Congressional Budget Office said last week that such a repeal would reduce federal deficits by $338 billion over the next 10 years, which would help the GOP avoid exceeding a $1.5 trillion cap on how much the tax bill can add to the deficit over the same time period. The repeal would also increase the number of uninsured by 13 million by 2027, according to the CBO.

Sen. John Thune, R-S.D., a top McConnell deputy, said the savings from the repeal would give Republicans more room to cut taxes for the middle class.

“It will be distributed in the form of middle-income tax relief,” Thune said. “It will probably mean adjusting the rate structure as we have today. We’ll probably still have seven brackets, but they would be at different rates.”

Asked if he was confident such a bill could pass, Thune said yes, adding that leaders had already “whipped” the bill, meaning they already know how their colleagues will vote.

Not all Republicans agree with the decision. Moderate Sen. Susan Collins, R-Maine, said she had not decided how she will vote on the tax bill, but she worries that ending the individual mandate could increase health care premiums.

“I personally think it complicates tax reform to put the repeal of the individual mandate in there,” Collins said. “I’m going to wait and see what the bill says.”

But adding it in could appeal to other skeptics of the legislation, including Sen. Rand Paul, R-Ky., who supports the individual mandate repeal.

The Senate Finance Committee is expected to release an updated version of the legislation Tuesday evening. The committee plans to approve the bill later this week in hopes of holding a vote in the full Senate before Thanksgiving.

Republicans on the Finance Committee worked around the clock in recent days to try to bring down the long-term cost of their tax bill. Republicans want to take advantage of complicated Senate budget rules, known as reconciliation, that would allow them to pass the tax bill with 51 votes rather than the 60 needed for most other legislation. That would allow the 52 Senate Republicans to pass the bill without the help of any Democrats.

But those same budget rules require that the tax overhaul not add to the deficit after 10 years. The Senate bill appeared to violate those regulations as recently as Tuesday morning. Repealing the individual mandate could help ease the fiscal pressure.

Democrats, enraged over McConnell’s announcement, said adding the individual mandate to the legislation effectively ended any chance for bipartisan agreement on taxes. Sen. Ron Wyden, D-Ore., the top Democrat on the Finance Committee, said repealing the mandate would hurt the middle class.

“In their desperation to secure an ideological trophy, no matter the consequences,” Wyden said, “Republicans are choosing to pay for corporate tax cuts by raising premiums for middle class families and ripping away health care altogether from millions more.

“This is a con job on the American people.”

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A California judge could decide Tuesday if Gloria Single will be reunited with her husband, Bill. She’s 83 years old. He’s 93. The two have been married for 30 years. They lived in the same nursing home until last March, when Gloria Single was evicted without warning.

Her situation isn’t unique. Nationwide, eviction is the leading complaint about nursing homes. In California last year, more than 1,500 nursing home residents complained that they were discharged involuntarily. That’s an increase of 73 percent since 2011.

Gloria Single has a number of ailments. One of them is Alzheimer’s disease. So when her son Aubrey Jones comes to visit her in her new nursing home, he brings old photos to show her. She can still recognize faces from long ago — one picture shows her three sons when they were just little kids.

Jones says the photograph makes him and his brothers look like real troublemakers. “You are troublemakers,” his mom teases.

Jones also shows his mother a more recent photo. It was taken at Pioneer House, the nursing home where Gloria Single and her husband Bill lived together before her eviction. They’re gazing into each other’s eyes and smiling.

When Jones tells her he loves that photo, Gloria Single slyly replies that’s “because [Bill’s] got his hand on my knee.”

In court documents, Pioneer House paints a more troubling picture of Gloria Single. They say that she became aggressive with staff and threw some plastic tableware. So Pioneer House called an ambulance and sent her to a hospital for a psychological evaluation. The hospital found nothing wrong with her, but the nursing home wouldn’t take her back. They said they couldn’t care for someone with her needs.

Jones protested his mother’s eviction to the California Department of Health Care Services. The department held a hearing. Jones won.

“I expected action — definitely expected action,” says Jones.

Instead, he got an email explaining that the department that holds the hearings has no authority to enforce its own rulings. Enforcement is handled by a different state agency. He could start over with them.

This Catch-22 situation attracted the interest of the legal wing of the AARP Foundation. Last year, attorneys there asked the federal government to open a civil rights investigation into the way California deals with nursing home evictions. Now, they’re suing Pioneer House and its parent company on Gloria Single’s behalf. It’s the first time the AARP has taken a legal case dealing with nursing home eviction.

“We certainly hope we can get Mrs. Single some relief,” says William Alvarado Rivera, the foundation’s senior vice president for litigation. “But we also hope that there is a lesson to be learned by facilities — that there will be accountability for their failure to respect the due process rights of their residents.”

Nursing home residents have a lot of rights guaranteed in state and federal law. For example, they have to be given 30 days’ notice before they’re moved involuntarily. And the nursing home has to hold their bed for a week if they’re in the hospital.

Rivera says Gloria Single didn’t get any of that. As a result, she was stuck in the hospital for four and a half months before being accepted by another facility. During that time Single received none of the services and activities she would have had in a nursing home. She lost her ability to walk and now relies on a wheelchair.

Rivera says that “in the absence of state enforcement, it will depend on individuals like Mrs. Single having to advocate for themselves to get their rights respected and enforced.”

Fourteen years of public records obtained by NPR show that nursing homes rarely pay a price for illegally evicting residents. Just 7 percent of nursing homes that were found to have violated the law in California were fined by the state. With just a couple of exceptions, the highest fines assessed were $2,000. The majority were $1,000 or less — and most fines were never paid in full.

Diana Dooley, California’s secretary of health and human services, declined NPR’s request for an interview, citing pending litigation against the state on a similar issue.

Frustration with the lack of state enforcement led the California Long-Term Care Ombudsman Association to join the Single lawsuit as a co-plaintiff. The organization represents long-term-care ombudsmen. Those are the public officials who track complaints about nursing homes and advocate for residents. But Leza Coleman, the group’s executive director, says the spike in complaints about evictions is so overwhelming, that it’s “impacting our ability to handle other complaints.”

Coleman believes another reason that eviction complaints are going up, is that the number of nursing homes is going down. State records show there are about 2,300 fewer beds in California than there were six years ago.

“Those residents that are more challenging — those that have to be repositioned often, those that don’t want to sit quietly and watch television — … they’re more expensive,” she says. “They can be very taxing on the staff of a facility, and if a facility has one bed and two people looking at it, they’re going to take the person that’s easier to care for.”

But eviction complaints need to be seen in a different context, says Jim Gomez, CEO of the California Association of Health Facilities. “We have a very low rate of complaints regarding discharge,” he says, adding that roughly 1,500 complaints is “less than a half of 1 percent of some 300,000 discharges” a year.

And when residents are involuntarily discharged, Gomez says, “it’s for the safety of staff and other residents.

“We’ve had many attacks on residents and staff,” he says. “Are you going to allow that person back to the facility?”

Pioneer House and its parent corporation, the Retirement Housing Foundation, declined to be interviewed for this story. They sent a written statement which says, in part, “We intend to vigorously defend the allegation set forth in the lawsuit.”

Meanwhile, Aubrey Jones says the lawsuit is not just about his mother any more.

“If anything,” he says, “I want the dial to be turned a little bit so this thing doesn’t happen again —[so] it’s less likely to happen to someone else.”

Most of all, Jones says, he wants to see his mother and stepfather reunited, so they can be together for the little bit of time they have left.

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As the administration and Republicans in Congress look to scale back Medicaid, many voters and state lawmakers across the country are moving to make it bigger.

On Tuesday, Maine voters approved a ballot measure to expand Medicaid under the Affordable Care Act. Advocates are looking to follow suit with ballot measures in Utah, Missouri and Idaho in 2018.

Virginia may also have another go at expansion after the Legislature thwarted Gov. Terry McAuliffe’s attempt to expand Medicaid. Virginia voters elected Democrat Ralph Northam to succeed McAuliffe as governor in January, and Democrats made inroads in the state legislature, too.

An exit poll of Virginia voters on Election Day found that 39 percent of them ranked health care as their No. 1 issue. More than three-quarters of the Virginians in this group voted for Democrats.

A study from the Urban Institute may shed some light on why Medicaid eligibility remains a pressing problem: medical debt. While personal debts related to health care are on the decline overall, they remain far higher in states that didn’t expand Medicaid.

In some cases, struggles with medical debt can be all-consuming.

Geneva Wilson is in her mid-40s and lives outside of Lowry City, Mo. She has a long history of health problems, including a blood disorder, depression and a painful misalignment of the hip joint called hip dysplasia.

She’s managed to find some peace living in a small cabin in the woods. She keeps chickens, raises rabbits and has a garden. Her long-term goal is to live off her land by selling what she raises at farmers markets.

Her health has made it hard to keep a job and obtain the insurance that typically comes with it. And Missouri’s stringent Medicaid requirements — which exclude nondisabled adults without children — have kept her from getting public assistance.

Since graduating from college more than 20 years ago, Wilson has mostly had to pay out of pocket for medical care, and that’s left her with a seemingly endless pile of medical debt.

“As soon as I get it down a little bit, something happens, and I have to start all over again,” Wilson says.

Right now her medical debt stands at about $3,000, which she pays down by $50 a month. She desperately needs a hip replacement, but she canceled the surgery because, even with deeply discounted rate from a nearby hospital, she can’t afford it.

“Approximately $11,000 is what would come out of my pocket to pay for the hip. That’s my entire pretax wage from last year,” Wilson says. “So it’s kind of on hold, but I don’t know if I can survive the year without going ahead and trying to get it done.”

For many people like Wilson, medical debt can be nearly as problematic as their illness. In 2015, 30.6 percent of Missouri adults ages 18 to 64 had past due medical debt, the seventh-highest rate in the country. Kansas, at 27 percent, had the 15th highest rate. In Maine, which voted to expand Medicaid this week, it was 27.7 percent.

Researchers Aaron Sojourner and Ezra Golbertstein of the University of Minnesota studied financial data from 2012 to 2015 for people who would be eligible for Medicaid where it was expanded.

They found that in states that didn’t expand, the percentage of low-income, nonelderly adults with unpaid medical bills dropped from 47 to 40 percent within three years.

“The economy improved and maybe other components of the ACA contributed to a 7 percentage point reduction,” Sojourner says. “Where they did expand Medicaid, it fell by almost twice as much.”

Those states saw an average drop of 13 percentage points, from 43 to 30 percent.

In Kansas, the rate of medical debt for nonelderly adults fell by 4 percentage points to 27 percent. In Missouri, the rate dropped 4 points to 31 percent, according to the Urban Institute. In Maine, it dropped only 1.4 percentage points between 2012 and 2015.

Medicaid, as opposed to private insurance, is the key, says The Urban Institute’s Kyle Caswell, because it requires little out-of-pocket costs.

Even if Medicaid patients need lots of care, there aren’t on the hook for big out-of-pocket costs in the same way someone with private insurance might be.

“We would certainly expect that their risk to out-of-pocket expenses to be much lower, and ultimately the risk of unpaid bills to ultimately be also lower,” Caswell says.

But Medicaid’s debt-reducing advantages over private insurance could disappear under the leadership of the Trump administration.

Shortly after Seema Verma was confirmed as the Administrator for the Centers for Medicare & Medicaid Services, she and Tom Price, then head Department of Health and Human Services, sent a letter to the governors outlining their plans for Medicaid.

The letter encouraged states to consider measures that would make their Medicaid programs operate more like commercial health insurance, including introducing premiums and copayments for emergency room visits.

Verma says that by giving recipients more “skin in the game,” they will take more responsibility for the cost of care and save the program money.

Republican proposals in Congress to repeal and replace the Affordable Care Act would have eliminated or limited Medicaid expansion. And that would have affected the last few years’ downward trend in medical debt.

“Anything that reduces access to Medicaid most likely would have the reverse effect of what of we’re seeing in our paper,” Caswell says. “Reduced access to Medicaid would likely increase exposure to medical out-of-pocket spending and ultimately unpaid medical bills.”

As Geneva Wilson tends to her chickens, she says she tries not to think too much about her medical debt or how she’ll pay for that hip replacement.

“It’s going to the point where, if I were to go shopping at Walmart, I would have to get one of the carts you drive because I can’t manage,” she says.

Wilson has already sold her jewelry, some furniture and a wood stove to pay down her debts. Now there’s not much left to sell except her cabin and her land.

“Probably the homestead and garden that I want, that I’ve been wanting and trying to work for, I don’t think they are a viable dream either,” Wilson says. “It’s hard losing your dreams.”

This story is part of a reporting partnership with NPR, KCUR and Kaiser Health News. Alex Smith can be reached on Twitter at @AlexSmithKCUR.

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Getting rid of the requirement that everyone in the country have health insurance coverage would save the government $338 billion over the next decade, according to a Congressional Budget Office analysis released Wednesday.

But that savings would come with 13 million fewer people having insurance coverage by 2027, CBO analysts say. Some of those people would not want to buy insurance, but others couldn’t afford it. The CBO also predicts that average premiums would be 10 percent higher in most years than they would be under current law.

House Republicans are toying with the idea of repealing the so-called individual mandate — a key part of the Affordable Care Act — as part of their plan to overhaul the tax code.

Including the provision could be a win-win for Republicans. The move would allow them to offset more of the tax cuts they want in their tax plan and give them the chance to claim they repealed one of the most hated parts of the Affordable Care Act, also known as Obamacare.

“That depends upon through what prism you look at the issue,” says Chris Jacobs, a health policy analyst at Juniper Research Group. “As a matter of tax policy, including $338 billion in additional revenue to pay for tax reform is a positive outcome. But as a matter of health policy, repealing the mandate without repealing any of Obamacare’s insurance regulations will raise premiums.”

House Speaker Paul Ryan has said repeatedly that one of his goals in repealing the Affordable Care is to make insurance cheaper and give people more choices.

President Trump has pressed lawmakers to include the repeal of the individual mandate in the tax overhaul plan. He took to Twitter on Nov. 1 and mused that it would be “great to Repeal the very unfair and unpopular Individual Mandate in ObamaCare.”

But on Monday, House Ways and Means Committee Chairman Kevin Brady said he is not inclined to add health care policies to the tax bill.

The new CBO report is an update of an estimate from last December that concluded that repealing the individual mandate would cut the deficit by about $416 billion over 10 years.

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Maine is one of 19 states that rejected Medicaid expansion through the Affordable Care Act. But on Tuesday, it could be the first to approve it at the ballot box.

Question 2 asks Maine voters if they want to provide roughly 70,000 Mainers with health care coverage by expanding eligibility of Medicaid, known as MaineCare. It provides health coverage for people living at or near the poverty line.

The national battle over Medicaid expansion began with a 2012 U.S. Supreme Court decision that conservatives originally hoped would hobble the Affordable Care Act, President Obama’s signature legislative achievement.

But instead of repealing the law’s individual mandate requiring that most Americans obtain health insurance, the court upheld it. The court then struck down a provision requiring all states to expand eligibility of Medicaid.

That surprise 2012 court ruling shifted the political battle. While the GOP-led House of Representatives would go on to take over 50 symbolic ACA repeal votes, progressive and conservative activists descended on state legislatures to fight over Medicaid expansion.

The intensity of those battles illustrated the importance of Medicaid expansion as a component of the ACA. The program not only lowered the number of people without health insurance, it also has arguably made repealing the health care law harder.

Medicaid funding cuts included in Senate bills to repeal ACA were the primary reason that Sen. Susan Collins, R-Maine, broke ranks with most of the GOP to oppose the bills.

“First, both proposals make sweeping changes and cuts in the Medicaid program. Expert projections show that more than $1 trillion would be taken out of the Medicaid program between the years 2020 and 2036,” she said in September. “This would have a devastating impact to a program that has been on the books for 50 years and provides health care to our most vulnerable citizens, including disabled children and low-income seniors.”

Collins has also cited the impact on Maine’s rural hospitals, which are heavily dependent on Medicaid reimbursement payments.

Effects On The Uninsured

Architects of the federal health care law sought to lower the number of people without health insurance by requiring most Americans to have coverage. The law also lets states expand access to Medicaid, a federal program run by the states and funded with a mix of state and federal money.

In 2013, Maine’s legislature voted to expand the state’s program, and Republican Gov. Paul LePage vetoed the bill. It was the first of a half dozen vetoes.

About 9 percent of Maine residents lacked insurance in 2016, comparable to 8.6 percent in the 31 states and the District of Columbia that expanded Medicaid. That could be because the state had expanded its program in 2002 and 2003.

The number of people enrolled in Medicaid has been dropping, as the LePage administration moved aggressively to restrict eligibility

In 2012, there were 345,000 Mainers receiving Medicaid. There were 268,000 through June of this year, according the Department of Health and Human Services. The state spends $2.6 billion on the program, with two-thirds of that coming from the feds.

Meanwhile, roughly 70,000 Mainers have fallen into what’s known as the ACA coverage gap. The gap occurs in the 19 states that did not expand Medicaid.

The ACA originally conceived Medicaid expansion as a bridge between low-income adults already eligible for Medicaid coverage and those who could qualify for subsidies to purchase their own individual plans.

But without expansion, thousands of Mainers neither qualify for subsidies nor Medicaid.

Most of the 70,000 people who would gain coverage if Question 2 passes earn up to 138 percent of the federal poverty level — about $16,000 a year for an individual and $34,000 for a family of four.

For And Against

Conservative and progressive activists have engaged in a long, pitched fight over Medicaid expansion. The arguments for and against expansion haven’t changed much, and neither have the methods of persuasion.

Conservatives repeatedly note that Maine was an early expander of Medicaid in 2002-2003. They claim that the state’s uninsured rate was unaffected by increasing eligibility and that the program became a budget buster, creating deficits when state revenues declined during the economic downturn.

Progressives counter that early expansion helped keep Maine’s uninsured rate steady while other states saw a surge. Additionally, they argue that the higher federal reimbursement rate offered through the ACA protects the state.

If expansion passes, the federal government will initially cover 94 percent of the cost. That ratchets down to 90 percent by 2020 and stays at that level, as long as Congress doesn’t cut reimbursements.

But Brent Littlefield with the anti-expansion Welfare to Work PAC says there’s still a cost to Maine taxpayers.

“The current plan would have state taxpayers paying between $50 million to $100 million per year,” he says.

The expansion debate has been marked by its heated rhetoric. Opponents have repeatedly called would-be recipients “able bodied,” while calling the proposal “welfare expansion” — descriptions designed to tap sharply divided public perceptions of people receiving public assistance.

Proponents, meanwhile, have been stressing the human impact,focusing on personal stories of those who would benefit from the program.

High Stakes

Question 2 has been billed by some as a final resolution, but it could also be a litmus test for public sentiment about the Affordable Care Act. GOP repeal efforts have not polled well. While the ACA has not been a centerpiece of the proponents’ arguments for expansion, an affirmative expansion vote on Nov. 7 could be spun as a tacit public endorsement for the health care law, because Medicaid is such a key component.

Locally, the political stakes are high. LePage has been a leading critic of expansion, and he’s taking an active role in opposing Question 2. Defeating Question 2 could validate the governor’s stance. Conversely, an affirmative vote could deal a blow to the governor’s full-court press against the law.

But a victory for supporters of Question 2 could be fleeting. The state legislature changed, delayed or attempted to repeal all four of the ballot initiatives that voters approved last year.

Steve Mistler is chief political correspondent for Maine Public Radio.

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