John Gale has more than 40 years experience in health care management and policy both nationally and in Maine. He grew up in the rural community of Lebanon, Maine, and lives in Portland.

H.R. 1 – An Act to Provide for Reconciliation Pursuant to Title II of H. Con. Res. 14, also known as the One Big Beautiful Bill Act, includes extensive changes that will affect coverage under MaineCare and the Affordable Care Act Marketplace. These changes will reverse the significant progress made in the reduction of individuals without health coverage in Maine and across the nation.

This reduction in coverage will have a disparate impact on Maine’s rural residents, who are more dependent on MaineCare and the Marketplace than those in urban areas. Additional changes mandated by H.R. 1, including an increase in Medicare sequestration funding cuts and changes to the Medicaid provider tax, will have an inordinate impact on the financial stability of Maine’s already struggling rural providers.

Rural hospitals and providers in Maine and across the United States have long struggled with workforce shortages, high operating and staffing costs, inadequate reimbursement and the challenging demographics of rural communities.

Between January 2005 and July 2025, a total of 195 rural hospitals closed or converted to another delivery model, including three Maine hospitals that ceased inpatient operations but remain open as urgent or emergency care facilities (Goodall Hospital, Parkview Adventist Medical Center and St. Andrews Hospital) and one that completely closed in May 2025 (Northern Light Inland Hospital).

Two rural hospitals (Calais Regional and Penobscot Valley) filed for bankruptcy in 2019,
although both were able to restructure their finances and remain viable. Recently announced clinic closures include primary care services at Maine Family Planning sites in Ellsworth, Presque Isle and Houlton; Northern Light Waterville Walk-In Care; the Manchester Care Center; and Aurora Healthcare in Fairfield.

As the financial stress on rural providers increases due to H.R. 1, additional Maine hospitals and providers may be forced to consider closure or the discontinuation of essential services, further limiting access to care. For example, nine Maine hospitals closed their obstetrical units within the past decade, disproportionately affecting rural communities.

To mitigate its impact on rural providers, H.R. 1 established a $50 billion ($10 billion per year for five years) Rural Health Transformation Program (RHTP) administered by the Centers for Medicare and Medicaid Services (CMS). Maine will receive at least $100 million annually and potentially up to $200 million to improve the health of its rural residents and providers.

CMS released the RHTP Notice of Funding Opportunity on Sept. 15, 2025, with applications due by Nov. 5 and award decisions due by Dec. 31.

As it prepares its proposal, I urge the state to develop a vision for rural health in Maine to guide the use of RHTP funds to address the immediate needs of rural residents and providers. I recommend that a portion of Year 1 RHTP funding be used to develop an updated rural health plan consistent with the following guidelines:

• Build a sustainable rural care system that is person and family-centered, improves access, and meets the needs of rural residents.
• Provide timely access to a set of essential services (e.g., primary care, behavioral health,
  wellness, oral health, chronic disease management, specialty services such as obstetrical and cancer/oncology care, urgent care and emergency medical services) using technology and
  innovative delivery modalities based on local capacity.
• Encourage collaborative regional care systems to improve efficiency and access, while
  minimizing duplication, waste, and unnecessary competition.
• Engage community leaders and stakeholders in local and regional planning for services.
• Revise reimbursement policies to fairly compensate rural providers that reflect the higher fixed costs and lower volumes of rural providers, and realign incentives to achieve improvements in system performance.
• Implement innovative models of care, informed by national and state models, to build an aligned rural health system that better meets the needs of rural residents, reduces the costs of care, addresses population health and health-related social needs, coordinates patient care and addresses gaps in services.

The state should also use RHTP funding to provide technical assistance to help rural providers prepare for the health care environment of the future and engage in value-based and innovative models of care.

Vulnerable providers may also need support to address their revenue cycle and operational challenges, collaborate with other providers, engage their communities in local and regional planning and explore alternative delivery models such as the rural emergency hospital.

Given the expected competition for Maine’s share of RHTP funding, I suggest that the state concentrate on rebuilding the foundation of Maine’s vulnerable rural health system, providing a pathway and resources to enable rural providers to transform themselves consistent with the above guidelines, and developing a coordinated response to the needs of rural Mainers who lose coverage under H.R. 1.