Mainers for Health Care rally outside the State House prior to Gov. Paul LePage's State of the State address, Tuesday, Feb. 13, 2018, in Augusta, Maine. Credit: Robert F. Bukaty | AP

Does the expansion of eligibility for MaineCare bring to mind a gate opening and a line of people instantly walking through? It’s a nice image, but the reality is more complicated.

A recent data brief developed by the University of Southern Maine’s Muskie School of Public Service in partnership with the Maine Health Access Foundation highlights the characteristics of the people who are eligible to sign up for expanded MaineCare. It also illuminates how the complicated nature of health insurance eligibility and coverage interact with people’s health and life circumstances.

The majority of individuals eligible to enroll in expanded MaineCare are older adults aged 55 to 64, and live in some of the most rural parts of Maine. They are much more likely to have chronic physical and mental health conditions that could have been prevented or controlled if they had been identified early and supported through regular medical and mental health care. They are also more likely to have dental health issues that similarly could have been addressed with regular access to services. We also learned, the expansion population is twice as likely as other Maine adults to lack a primary care provider or to have gone without a check-up for five or more years.

So why aren’t the older members of the eligible population signing up? While lack of rural internet access is one possible reason, there are other issues like beliefs and perceptions that will take more than a technical fix.

Health care insurance of any kind can be complicated to understand and use, and for individuals who work seasonally or part time, eligibility may change from month to month or year to year. Imagine if you had a long-term chronic condition like heart disease or arthritis, or both, and in addition to coping with those conditions, you had to figure out how to get insurance coverage before you could get regular services.

We know from the data that one in five people in the likely expansion population reported poor health and poor mental health on over half of the days each month. This can make signing up for coverage such a big barrier that limping along without may seem easier. And, some older members of the newly eligible population may have gone so long without a stable source of coverage that they are resigned to wait for their Medicare coverage to begin at age 65.

To complicate matters, MaineCare has been portrayed in ways that can make those who have coverage through the program feel stigma, and those who are eligible reluctant to sign up. That stigma can come from friends, family, and even health care providers and their staff.

In the public square, this critical health insurance program is sometimes portrayed as a form of welfare. MaineCare is a kind of government subsidized health insurance, as are Medicare and the VA health program, and the coverage available through the Affordable Care Act. It’s important not to demonize any kind of health insurance coverage, because in order to maintain the infrastructure of hospitals, health centers, and mental health providers for everyone, we need to have as many people with health insurance coverage in the system as possible.

And this population, whether already enrolled or eligible and not yet enrolled, will need additional supports. Assistance must start at the beginning, navigating the enrollment process. After enrollment those who gain coverage may benefit from integrated health and mental health services to cope with years of chronic physical and mental illness. Peer support and community health workers will play a vital role in meeting treatment goals.

If we build it, will they come? We all — providers, funders, communities — have a role to play in the creation of a successful new system of expanded coverage. Together we can create a system much closer to an open gate for those seeking care, with support at each step of the way.

Zachariah T. Croll is a research associate on population health and health policy at the Muskie School of Public Service. Barbara Leonard is president and CEO of the Maine Health Access Foundation.