Maine Attorney General William Schneider announced this week that Maine would soon join at least 20 other states challenging the constitutionality of a key provision in the federal health care law.
Several local groups oppose the lawsuit, including the Maine Medical Association, AARP and advocates of a single-payer system.
But embracing the law has been difficult, even for those who might welcome reform.
The legislation was passed in a way that a lot of Americans found distasteful, and the complexities of the health care system and the legislation itself are difficult to understand.
The result, according to Andrew Coburn, a professor of health policy and management at the University of Southern Maine Muskie School, is debate — and decisions — based on politics, not health care policy.
"People don’t understand the system," Coburn said. "People are afraid of government. It makes it very hard to come to a consensus when there are these blind spots in how we understand the health system can be improved."
Coburn highlighted the debate over the constitutionality of the individual mandate, the basis for the Florida lawsuit that Maine is expected to join. He said the argument has "virtually nothing to do with how the health insurance system functions."
The more important discussion, he said, is whether the individual mandate would improve health care delivery, an issue recently taken up by three doctors in The New England Journal of Medicine. The doctors defended the provision and said it contributed to the success of the Massachusetts health care law advanced by former Gov. Mitt Romney.
Coburn acknowledges flaws in the law. However, he said, it's "important to keep the ball rolling in reform." He said that if lawmakers feel the legislation is wrong, "then let’s either fix this bill or tell me what the alternative is."
Coburn's perspective is shared, albeit reluctantly, by Jim Wellehan, owner of the Lamey Wellehan shoe stores.
Wellehan is disappointed that the law didn't do more to drive down insurance costs for small business owners. He blamed Congress, which he said, "caved in to the insurance companies and the drug companies."
Despite the law's shortcomings, Wellehan doesn't favor repeal, or the lawsuit Maine will soon be joining.
"I think (the law's) objectives are critical," he said. "We cover everyone. I think (the Affordable Care Act) needs major reform, but the thing that troubles me is that I think the people who are looking to repeal it have no intention of reforming it. They just want to get rid of it."
Peter Geiger, executive vice president of Geiger, said he too was concerned that the law didn't address costs for employers. However, he wasn't ready to "throw the baby out with the bathwater."
"I'd like things to be rejigged or made better, rather than just throwing things out," said Geiger, who was part of Gov. Paul LePage's transition advisory team.
Peter Gore, a lobbyist for the Maine State Chamber of Commerce, said businesspeople in general are "apprehensive at best" about the law.
"There's nothing in the law that will make providing insurance less expensive," Gore said. "But the business communities recognize that it is the law right now."
"There really is a huge fear among businesses that if Maine doesn’t do it, the feds will come in and do it for us, and that is not something Maine businesses are interested in," Gore said.
The state must begin setting up the insurance exchanges this year for the 2014 deadline or the federal government will do it.
The chamber hasn't taken an official position on the lawsuit, but Gore said he would advise supporting it. He said the law could be costly and burdensome for businesses, citing the requirement that they submit a 1099 IRS form for services or purchases of more than $600.
The provision is unpopular with both Democrats and Republicans. On Friday, U.S. Rep. Mike Michaud, D-Maine, submitted legislation to repeal the requirement. The vote could take place next week.
Despite vows to adjust or improve the law, Gore and other groups are wary of its impact, not because businesses didn't want to insure employees. Employer-provided insurance helps with recruitment and retention, he said.
The real concern for employers is cost-containment, he said.
"That apprehension is having an impact on how businesses plan for the future in terms of job creation," Gore said.
David Clough, who heads the Maine Federation of Independent Business, said the law is the product of misplaced congressional priorities, access over cost.
"That was not the issue for small business owners," said Clough, who added that his organization represents about 3,700 businesses each employing about five people. "Their issue was choice and affordability."
Earlier this week, the group urged LePage and Schneider to join the lawsuit.
Chip Morrison, president of the Androscoggin Valley Chamber of Commerce, said he hadn't surveyed his membership to see where they stand, but he suspected they had mixed feelings about it.
Hospitals have taken a cautious approach to the law.
Jeffrey Austin of the Maine Hospital Association said the bill was a "mixed bag" for hospitals. On one hand, he said, the law increased access to insurance. On the other, Maine hospitals could face significant cuts in Medicare payments.
Medicare reductions are no small matter for hospitals. However, taking a firm position against the law is difficult because it's generally supported by doctors. The American Medical Association has endorsed the law.
Locally, the 3,500 doctors in the Maine Medical Association urged LePage to stay out of the litigation effort and begin implementation. It recently wrote an op-ed in the Portland Press Herald outlining the law's benefits, including ending out-of-pocket costs for Medicare recipients for preventive care procedures such as physicals and screenings for diabetes and cancer; eliminating lifetime caps by insurance companies; and denying coverage to patients with pre-existing conditions.
"We are strongly opposed to joining the lawsuit," said Gordon Smith, executive vice president of the MMA. "We think there's a lot in the law to the benefit of Maine people and providers, as well."
The AARP has also championed the Affordable Care Act.
The law closes the so-called "doughnut hole," the point at which prescription drug reimbursement ends once a Medicare patient spends $2,000. Kate Bridges, the communications director for the Maine chapter of the AARP, said the doughnut hole was particularly tough on Maine seniors because the threshold was based on retail costs, not out-of-pocket expenses.
Bridges said 10,000 Mainers hit the doughnut hole each year.
AARP surveyed Mainers of voting age last summer and found 70 percent felt that health care should be a top priority for the next governor, Bridges said.
"The lawsuit is not the way to reach that goal," she said.
But Schneider's intent to join the Florida lawsuit appears to have the full backing of the Republican-controlled Legislature.
If the GOP effort is successful, Coburn, the USM professor, said he's anxious to see their alternative.
"What I’d like to be seeing in this debate over implementation is what alternatives there are," he said. "If we’re not going to implement this bill, what are we going to do?"