First in a five-part series

The next governor will have a lot to say about access to health care, housing and social services for Maine residents, how those services are managed – and who is going to foot the bill.

One of the biggest questions will be whether Maine should join the 28 other states that have expanded Medicaid, as allowed under the Affordable Care Act. Those states – even some led by Republican governors – have taken advantage of the millions in federal dollars available to support expansion.

Republican Gov. Paul LePage has consistently rejected expansion, saying the state is already spending more than it can afford and can’t count on federal support. His opponents, Democratic U.S. Rep. Mike Michaud and independent Eliot Cutler, both favor Medicaid expansion and have criticized LePage for his stance.

That’s only one of numerous differences among the three candidates for Maine governor on issues related to health care.

Michaud and Cutler both say that the Department of Health and Human Services, the largest state agency, has been plagued by scandal and mismanagement under LePage’s watch, although they differ on how to improve the department. LePage counters that DHHS became bloated and inefficient under decades of Democratic rule, and that he would continue with reforms he launched in his first term, if re-elected.

The candidates also have ideas on solving a pair of health care-related problems that are less politically polarizing but no less critical: How to effectively and efficiently house Maine’s growing elderly population and how to deal with a shortage of primary care physicians, especially in rural areas.

Here’s a look at where the three candidates stand on health care issues:

• MEDICAID EXPANSION

Expanded coverage would be mostly paid for with federal money

Medicaid expansion has been wholly political and not just in Maine. Of the 22 states that have not expanded Medicaid, all but three (Missouri, Montana and Virginia) are led by Republican governors. The federal government has promised to cover 100 percent of the expansion population between 2014 and 2016. Supporters of the law say Maine is losing $1 million a day in federal money by rejecting the measure. The reimbursement level is scheduled to be gradually reduced to 90 percent by 2022.

LEPAGE has consistently vetoed Medicaid expansion bills passed by the Legislature. He said Maine’s Medicaid system is among the most expensive in the country already, and expanding it would cost the state $75 million a year. He’s also not convinced the federal government will keep its promises to give Maine an estimated $3 billion in reimbursement for expansion costs. LePage pointed out that Maine just recently paid off $500 million in hospital debt that he said was created by the last Medicaid expansion. “Maine must re-prioritize its welfare system and rejecting Obamacare’s welfare expansion is a major step in doing so,” he said.

MICHAUD said if elected governor he would introduce a Medicaid expansion bill to provide coverage to 60,000-70,000 Mainers on his first day in office because, “Not only is it the morally right thing to do, it’s the fiscally responsible thing to do.” “Medicaid expansion can help Maine close the gap in health care coverage and help strengthen our economy. It will save our state hundreds of millions of dollars over 10 years and help our people to live healthier, more productive lives,” he said.

CUTLER also said Maine should expand Medicaid out of fairness and moral obligation. “Because of our failure to expand coverage,” he said, “nearly 70,000 Mainers have no access to preventive health care services, reimbursements to Maine hospitals are reduced, uninsured people are forced to go to the emergency room for care, and the hospitals are forced to write off millions in unpaid medical bills and charge higher costs to the rest of us.” Cutler said he would take it one step further and work toward creating a universal health care system.

• DHHS ACCOUNTABILITY

The state must decide how to deal with its largest department

The Department of Health and Human Services is the largest state agency and accounts for about one-third of all state spending. It also has seen its share of problems over the last decade, including many during Gov. LePage’s first term, among them a document-shredding controversy within the Maine Center for Disease Control and Prevention, a plagiarism-tainted consultant report, poor oversight of child care facilities and ongoing problems with Riverview Psychiatric Center in Augusta.

MICHAUD has proposed creating an independent Office of Inspector General to serve as a watchdog over DHHS. He also said he would order a complete audit of the department, something he acknowledged would be difficult. “We must restore faith in state government and that starts with taking control of DHHS,” he said.

CUTLER agreed that DHHS has experienced repeated failures over the last four years and said they all “flow directly from Paul LePage’s shortcomings as a chief executive.” He does not, however, support Michaud’s plan to create an Office of Inspector General. “I’ve overseen big government agencies, and I certainly don’t think that the answer to the problems at DHHS is to set up another layer of bureaucracy over it,” he said. “The issue is good management.”

LEPAGE said many of the problems at DHHS predated his first term as governor. “Governor LePage has focused on creating a more lean, smarter agency that no longer tries to be all things to all people, but ensures that our truly needy citizens get the help that they need,” said campaign spokesman Alex Willette. If re-elected, LePage said he would work to eliminate waiting lists for all programs and also increase support to nursing homes.

• ELDERLY HOUSING

Maine struggles with problems stemming from its aging populace

Maine is among the oldest states in the country, a demographic reality that already has put a major strain on elderly housing programs. Part of the problem is housing, part of it is affordable housing and part of it is lack of options and support for growing old at home.

CUTLER said he would take advantage of new supports for family caregiving under the ACA and promote successful models of aging in place. “Rising property taxes and energy costs are forcing too many of our seniors to move to assisted living facilities or nursing homes, often leaving homes they lived in their entire lives,” he said. Cutler supports the KeepME Home initiative proposed by Democratic House Speaker Mark Eves, which would develop 1,000 apartments for seniors in 40 locations across the state.

LEPAGE said he already has been working to provide more public dollars for nursing homes by shifting Medicaid dollars that had been going to healthy, working-age adults. He also said MaineHousing, the state’s public housing authority “should re-prioritize its efforts to help the elderly population,” and pledged to see that happen if elected to a second term.

MICHAUD, under his Maine Made economic plan, has proposed an “Aging-in-Place” grant program to help communities meet the challenges of an aging population. It would be paid for through bonding. “We need to create incubators of innovation within local communities that support affordable housing, multi-generational support systems, and private and public payment service options,” he said.

• THE SHORTAGE OF PRIMARY CARE DOCTORS

Rural areas are underserved relative to the rest of the state

An analysis by the Maine Sunday Telegram this year found that the state faces a shortage of primary care physicians, particularly in rural areas. In Cumberland County, there were 163 primary care doctors per 100,000 people in 2010, the latest numbers available. In more rural counties, the per capita rate is less than half that: 45.7 in Washington, 53.6 in Oxford, 65.2 in Sagahadoc, and 65.1 in Somerset.

LEPAGE said he has been meeting with medical professionals across the state over the last several months, listening to ideas on how to address the doctor shortage. He said the state has one tool, the Rural Medical Access Program, which promotes prenatal care in underserved areas, but said if elected to a second term he would continue to work with the health care community to explore additional opportunities that can increase the number of physicians in Maine.

MICHAUD said addressing the primary care doctor shortage starts with controlling the cost of education. He has a plan to make the sophomore year of college free for Maine residents who attend college in Maine, a proposal estimated to cost $15 million. Michaud also said he would maximize telehealth initiatives and evaluate the Doctors for Maine’s Future loan forgiveness program to see if it’s working or not. Finally, he said Maine needs to better support successful programs, such as the partnership between Tufts Medical School in Massachusetts and Maine Medical Center, which places residents in rural areas and brings more medical students to Maine for their training.

CUTLER also said telemedicine will help address the rural doctor shortage but won’t solve it. “Maine needs to expand our pool of primary care physicians by attracting, training and keeping more young physicians who are willing to provide these vital primary care services,” he said. He also referenced the Tufts-Maine Med partnership and other similar multistate partnerships as models of success.