Mainers know there are lots of trade-offs when you choose to live in a small, rural town. As a resident of a small town (population 2,165), I experience these trade-offs every day.

On the upside, people in our town know each other well and share a strong commitment to our community. That connection provides a tangible sense of security and support that I never experienced when I lived in large urban areas.

On the downside, access to essential services is often a challenge for rural Mainers, particularly when it comes to getting hospital, emergency department and other health care services.

As a resident of Boothbay Harbor, I watched our community go through a gut-wrenching process when our small local hospital (St. Andrews) abruptly closed its inpatient services and replaced the 24/7 emergency department with a more limited urgent care center.

Although Miles Memorial Hospital with its emergency room is just 18 miles away in Damariscotta, people in our community felt angry — and scared. It felt like a central piece of our community safety net had been shredded.

Since the closure of St. Andrews, Maine has lost Parkview Adventist Medical Center in Brunswick to bankruptcy, and the former Goodall Hospital in Sanford has just transferred its inpatient services (but not its emergency department) to Southern Maine Health Care in Biddeford.

This trend of small hospital closure isn’t happening only in Maine. Since 2010, 57 rural hospitals have closed across the nation. According to a report from iVantage Health Analytics, one of the most important predictors of closure nationally was whether the hospital operated in a state that expanded Medicaid as part of the Affordable Care Act. Rural hospitals in states that did not expand Medicaid (including Maine) were twice as likely to close.

A recent study published in the October edition of the journal Health Affairs fleshes out the story a bit more. Researchers compared the amount of uncompensated (charity) care, profitability and market characteristics of rural hospitals in states that expanded Medicaid eligibility versus those in states that did not. Hospitals in states that did not expand Medicaid provided greater amounts of uncompensated care as a percentage of revenues and appeared to be more financially vulnerable.

The closure of rural hospitals affects far more than access to health care services. In rural Maine communities, the hospital is an important large employer. Closure means lost wages and less money to support the local economy. It also has secondary effects on the need for enhanced local ambulance services, as patients require longer and more costly transports.

Many factors influence the decision to close inpatient services in rural hospitals. Patient volume is typically low, making it a challenge to keep critical skills sharp. Many rural hospitals in Maine promote creative strategies to address this issue.

In other communities, the closure of inpatient services in favor of building up primary care and other support services is viewed as a more effective way to keep people healthy and diminish the need for inpatient care. Yet keeping all these health care services in rural areas still requires a viable bottom line.

Maine’s small rural hospitals are trying to figure out how they continue caring for their communities when low patient volume and increasing charity care is straining their financial viability. Rising charity care costs threaten the significant investments that many have made in expanding and supporting primary care practices and providing ancillary services that serve the community, such as local laboratory and diagnostic testing.

The heightened vulnerability of rural providers in states that have not expanded Medicaid adds another compelling reason for Maine lawmakers to reconsider this policy decision. Besides providing needed health care coverage to Mainers with very low incomes, expansion actually could have provided more than $26 million in savings to the state budget, another recent study demonstrated.

Preserving access to health care services across a state as large and rural as Maine is a challenge that our rural health care providers are struggling to preserve. Medicaid expansion would help providers across our state continue to meet the vital health care needs that our neighbors in rural areas depend on.

Wendy J. Wolf, M.D., is president and CEO of the Maine Health Access Foundation in Augusta, the state’s largest health philanthropy.

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