PORTLAND, Maine - The roiling national debate over the government's proper role in health care is coming to a head in a state more commonly known for moose, lobster and L.L. Bean.
On Nov. 7, voters in Maine will decide whether to join 31 other states and expand Medicaid under former President Barack Obama's Affordable Care Act. It's the first time since the law took effect nearly four years ago that the expansion question has been put to voters.
The ballot measure comes after Maine Republican Governor Paul LePage 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.
It also acts as a bookend to a year in which President Donald Trump and congressional Republicans tried and failed repeatedly to repeal Obama's law.
Activists on both sides of the issue are looking at the initiative, Maine Question 2, as a sort of national referendum on one of the key pillars of the law, commonly known as Obamacare. Roughly 11 million people nationwide have gained coverage through the expansion of Medicaid, the state-federal health insurance program for lower-income Americans.
Republican consultant Lance Dutson called Maine's initiative a national bellwether in which the needs of the people could trump political ideology.
"People believe there are good parts to Obamacare and bad parts to Obamacare. And without taking Medicaid expansion, we are leaving one of the good parts on the table while still suffering from the bad parts of it," said Dutson, who supports Question 2.
Maine may not be the last state to put the Medicaid question before voters. Expansion proponents in Idaho and Utah have launched similar efforts in those states aimed at the 2018 ballot.
If the initiative passes, an estimated 70,000 people in Maine would gain health coverage. The issue is personal to many in an aging, economically struggling state with a population that is smaller than the city of San Diego.
Nature painter Laura Tasheiko got dropped from Medicaid three years ago after successfully battling breast cancer. Since then, she has relied on the charitable services of a hospital near her home in Northport, a seaside village of less than 2,000 people about 100 miles northeast of Portland.
She worries about having another serious health problem before she's eligible for Medicare when she turns 65 next year.
"Some of the after-effects of the chemo can be severe, like heart failure," she said. "Having no insurance is really scary."
Maine's hospitals support the Medicaid expansion and say charity care costs them over $100 million annually. The initiative's supporters have reported spending about $2 million on their campaign, with hundreds of thousands of dollars coming from out-of-state groups. By comparison, the lead political action committee established to oppose the measure has spent a bit less than $300,000.
Among those who say Maine will benefit from the expansion is Bethany Miller. She said her adult son, Kyle, needed Medicaid because he couldn't afford subsidized monthly insurance premiums even though he was working.
She remembers watching as her son's eyes went hollow and his body turned skeletal in the weeks before he died, at age 25, from a diabetic coma a year ago.
"He had a job, but he didn't make enough money to pay for his basic needs and his insulin, and he couldn't live without his insulin," said Miller, who lives in Jay, a small paper mill town about 70 miles north of Portland.
LePage, a Trump supporter, is lobbying furiously against the initiative. He and other critics warn that the expansion will be too costly for Maine, even with the federal government picking up most of the tab. After 2020, the state's share of paying for the expansion population would be 10 percent and the federal government would pay 90 percent.
LePage warns that he would have to divert $54 million from other programs -- for the elderly, disabled and children -- to pay for Medicaid expansion.
"It's going to kill this state," he said.
LePage said he considers Medicaid another form of welfare and wants to require recipients to work and pay premiums.
Maine currently serves about 268,000 Medicaid recipients, down from 354,000 in 2011. LePage credits the drop to his administration's tightened eligibility restrictions.
If Question 2 passes, the Medicaid expansion would cover adults under age 65 with incomes at or below 138 percent of the federal poverty level. That's $16,643 for a single person or $22,412 for a family of two.
State Rep. Deborah Sanderson, a Republican, said Maine is already struggling to serve its rapidly aging population as nursing homes shutter and rural hospitals struggle.
"I get accused on occasion of trying to pit one population of folks against another," she said. "It's a case of only having a certain amount of resources to take care of a large number of needs."
Finances are a concern in a state marked by factory closures and sluggish wage growth.
But with more people living on the margins, advocates of the expansion say that's all the more reason to extend the benefits of Medicaid. About 8 percent of Maine residents do not have insurance, a little less than the national percentage.
Democratic Sen. Geoffrey Gratwick, a retired rheumatologist, said he has seen many patients throughout his career who didn't have health insurance and came to him with a disease already in its late stages. He voted for all five Medicaid expansion attempts.
"They are just as good people as you or I, but their lives will be shorter and they will be sicker," he said. "Compassion, common sense and our economic interest demand that we get them the health care they need."
Nathalie Arruda and her husband, Michael, are in that group that's sometimes without insurance. They live in the farming community of Orland, halfway between New Hampshire and the state's eastern border with New Brunswick, Canada.
They run a computer business and rely on herbal teas and locally grown greens to stay healthy as they fall in and out of Medicaid eligibility. LePage restricted Medicaid eligibility for adults with dependents, like the Arrudas.
"There have absolutely been times when my husband or I have put off getting something looked at that we probably should have because we didn't have coverage," Arruda said.
In Miller's view, her son would still be alive if LePage had signed one of the Medicaid expansion bills sent to him by the legislature.
When Kyle turned 21, he was one of thousands who lost MaineCare coverage under the governor's reforms. She said he juggled construction jobs but couldn't afford his $80 subsidized monthly premium for private insurance.
He struggled to pay medical bills from emergency room visits, Miller said.
Before Kyle died last November, he had landed a steady job at a plastics factory that promised health insurance. He didn't live long enough to get the coverage, falling into a diabetic coma.
"He started rationing his insulin so he could buy food," his mother said. "And it cost him his life."