Enacting a bipartisan bill to provide Medicaid coverage to all low-income people in Maine is a challenge not unlike that faced – and overcome – by other states.

Times have changed since Maine’s last unsuccessful effort to expand Medicaid. Six states where the expansion controversy was as intense as the debate in Maine are administering “private option” Medicaid programs. Those programs buy private insurance, require premiums and cost sharing and, in one state, disenroll those who fail to meet their premium payments after a grace period.

Some programs penalize excessive, inappropriate use of emergency departments. Others have included voluntary initiatives connecting unemployed enrollees to job training and job banks. And they encourage healthy behaviors by waiving payments for those who commit to work on improving their health and participating in disease management and related programs.

Most of these states have provisions to end the expansion if the federal government does not maintain its level of funding. The federal government remains committed to funding for the program and has shown its willingness to meet the states halfway, approving these unique state proposals among the 31 states that have now expanded Medicaid.

Medicaid expansion must cover individuals sometimes referred to as the “working poor” — those with an annual income under $15,654 for an individual or, for a family of four, those earning less than $32,253.

Those below poverty level who are medically fragile — that is, they require medical intervention for everyday living — are covered by traditional Medicaid. But all the others can be covered by commercial insurance.

And who are they? Keep in mind that these are people with some income. They work. In fact, according to the Kaiser Family Foundation, among the states that have not expanded Medicaid, Maine leads in the number of uninsured low-income people attached to the workforce; 88 percent live in families with a worker.

Yet those jobs often do not pay enough to afford coverage. They are part-time positions, and they are in fields like agriculture and service industries where coverage is not offered or is often not affordable — even with the subsidies provided through the federal health insurance marketplace.

But there are too many people in Maine who have trouble getting or holding down a job, often because they struggle with illness or substance abuse. They are caught in a vise — unable to work and unable to afford the treatment that would help them recover and gain employment.

With Medicaid expansion, adults could seek and receive that needed treatment — and that may be especially important for those with substance addictions. For Maine’s criminal justice system, the toll of these addictions is evidenced by repeated criminal behavior and incarceration.

And illicit drug use is correlated with high rates of HIV/AIDS and hepatitis C, diseases that are infectious and costly to treat. National studies show that two-thirds of inmates have substance-use addictions and that a majority of inmates in states that have expanded Medicaid eligibility now qualify for coverage under the program.

The cost of incarceration and health care for prisoners is borne with state dollars. Medicaid, with its federal dollars, could pay for the health care provided in Maine’s hospitals to incarcerated adults if they are enrolled in the program — for which most are ineligible without expansion.

Colorado, Michigan and Ohio are reporting significant savings ($5 million to $13 million a year) in their state spending on criminal justice as a result of Medicaid.

And think of the incarcerated adult who ends his substance abuse while in prison and receives treatment there. Released from jail and unable to pay for his continued treatment, he relapses into addiction, and into the crime to pay for it. But if he were eligible for Medicaid through the expansion, he could continue that treatment.

With lessons from six other states to guide it, Maine has a chance to reframe the debate and develop a new approach to Medicaid expansion. Maine could make a significant contribution to address the scourge of opioid addiction and other substance use disorders. The federal government has shown its willingness to work with states to craft Medicaid expansions that address each state’s needs.

Some may take a Yogi Berra view of state Sens. Tom Saviello and Roger Katz’s proposal to expand Medicaid as “déjà vu all over again.” In fact, they present the bill in a changed environment where a new path forward and a focus on reducing substance abuse could find compromise and approval from both Maine and federal policymakers.

Trish Riley is executive director of the National Academy for State Health Policy, with offices in Portland and Washington.

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