When Medicaid expansion is fully implemented in Maine, those who enroll are projected to be older rural residents who are more likely to suffer from mental health and other chronic conditions and have gone years without seeing a doctor compared to other adult Mainers, according to a report released Tuesday.

Betsy Plummer, 56, of South Paris, was newly eligible for Medicaid when she signed up in April after having gone several months without insurance.

“I fell between the cracks,” said Plummer, describing how her chronic conditions, including fibromyalgia, anxiety and depression, worsened when she was uninsured. She can now get medications for all three conditions for $9 per month. “When I didn’t have insurance, I didn’t go to the doctor’s office. I was always worried about things, but I’m not worried about medical bills anymore.”

Medicaid expansion began in Maine when Democratic Gov. Janet Mills took over on Jan. 2 for former Gov. Paul LePage, a Republican. LePage opposed Medicaid expansion and refused to implement it even after voters approved it in a statewide referendum in 2017. Medicaid expansion is a voluntary program under the Affordable Care Act, with the federal government picking up 90 percent of the cost of expansion.

About 37,000 low-income Mainers – mostly childless adults ages 18-64 – have signed up for Medicaid since January, and experts predict that when fully in effect by 2020, about 70,000 to 80,000 Mainers will gain coverage under expansion. The low-cost insurance under Medicaid expansion covers those who earn up to 138 percent of the federal poverty level, or $28,676 for a family of three.

The report on the enrollee population – conducted by the nonprofit Maine Health Access Foundation and the University of Southern Maine – combines five years of Maine residents’ responses to health surveys for the federal U.S. Centers for Disease Control and Prevention with the projected expansion population.

“It helps to paint a picture of the Mainers who are gaining access to health care,” said Barbara Leonard, president and CEO of the Maine Health Access Foundation. The foundation is a nonpartisan, nonprofit organization that promotes access to quality health care through research and grant awards.

The report found that 28 percent of the expansion population reports being in “poor health” versus 9 percent of the general population. One in five Mainers in the expansion population hadn’t seen a doctor for a routine checkup in at least five years.

Other findings include:

-46 percent of the expansion population is rural, compared with 32 percent of adult Mainers.

– 29 percent of the expansion population smokes cigarettes, compared with 14 percent of adult Mainers.

– 36 percent have chronic mental, emotional or physical limitations, compared with 16 percent of adult Mainers.

– 45 percent have high blood cholesterol, compared with 32 percent of Mainers.

Erika Ziller, assistant professor of public health for the University of Southern Maine and one of the authors of the report, said the study shows that low-income Mainers, many of whom do not qualify for disability, but “are not doing well, with either their mental or physical health,” stand to benefit.

“There is a lot of pent-up demand for health services, because people have a lot of health issues that haven’t been taken care of for years,” Ziller said. “If they live in rural Maine, employment opportunities may be limited and many employers don’t offer health insurance.”

Although the study projects that 45 percent of expansion enrollees will be age 55-64, a younger population has signed up so far. According to Maine Department of Health and Human Services enrollment figures, of the 37,187 Medicaid sign-ups, 12,154 enrollees, or 33 percent, are adults ages 19-29, while 9,766 enrollees, or 26 percent, are ages 50-64.

Ziller said the age profile of Medicaid expansion enrollees could change by the time it’s fully in effect in 2020. One possible factor is that many over age 50 already had signed up for Affordable Care Act marketplace insurance and won’t be transitioned to Medicaid until 2020.

About 10,000 people in Maine fall into that category, according to estimates from the Kaiser Family Foundation, although that figure includes all adult ages, not just older adults.

Jackie Farwell, spokeswoman for the Maine DHHS, said the federal government sent out about 10,000 letters to ACA marketplace enrollees in April who would likely qualify for Medicaid, inviting them to sign up for Medicaid. It’s unknown how many of them signed up, but most will likely be transitioned to Medicaid by 2020. That’s because during the fall enrollment period to choose ACA plans for 2020, those who are eligible for Medicaid won’t qualify for the ACA subsidies that make the insurance affordable.

Maine DHHS officials expressed surprise in August at the volume of young adults who have signed up for Medicaid, as they expected an older population to be among the first to enroll.

“This claims information is preliminary and does not necessarily represent what the experience for expansion enrollees will be when the expansion is fully implemented,” the department said in an Aug. 16 update posted on the Maine DHHS website. “We may not have a full picture of the health profile of the expansion population for a number of months.”