In Maine, the 340B drug program was meant to be a structure of care — a policy designed to help the hospitals that serve people with the least. But over the past decade, it has become something else.

By the numbers, charity care in Maine’s 340B hospitals tells a revealing story. On average, it accounts for just 0.6% of their total operating costs — well below the national average of 2.5%. The intention of the program changed, transformed by years of institutional incentives absent transparency.

There have only been 27 federal audits of 340B hospitals in Maine since 2015. Twelve of those revealed violations — including the illegal distribution of discounted drugs. A system designed to support access for low-income patients instead becomes a vehicle for untracked expansion.

Patients are the real victims when hospitals consolidate. Prices go up, local autonomy goes down, patients wait longer and often travel farther. All of this serves to ratchet up the financial pressure those seeking care face. This year, Prime Healthcare, a California-based system, is set to acquire three Maine hospitals. Also on the table is a cancer care center — a calculated choice. In the economics of 340B, cancer treatment is highly profitable. Expensive drugs are purchased at discounts and billed to insurers at full price.

A report out of North Carolina outlined this phenomenon in detail: rather than reducing inequity, 340B often aligns with hospital expansion strategies that displace smaller clinics and raise costs. In states like Maine, the same incentives are showing up in regulatory paperwork — even in certificate of need (CON) applications.

Maine is a CON state. Hospitals must prove that new projects are necessary for public health. But in 2023, when Maine Medical Center (MMC) and Southern Maine Health Care (SMHC) applied to merge licenses, their justification wasn’t just care-based, but instead financial. They wrote openly that the project would qualify SMHC for 340B eligibility, saving an estimated $8 million per year.

SMHC doesn’t qualify for the program on its own. It doesn’t meet the criteria as a “disproportionate share hospital” — a designation intended for facilities serving large numbers of low-income or uninsured patients. But by merging licenses with MMC, which meets the 11.75% threshold, it can acquire eligibility retroactively.

Both hospitals, it should be noted, are operating above the state’s financial average. There is no immediate financial crisis. The merger isn’t about survival. It’s about access to a government benefit not originally designed for institutions like these.

To their credit, lawmakers have passed a bill requiring hospitals to report on their use of the 340B program. But the data has yet to be fully collected, and no one — not the public, not the state — knows how deep the inefficiencies or abuses run. And yet, there’s a push to lock the program in place, to codify it without clarity.

Through my work with the Coalition for Headache and Migraine Patients, I’ve seen how decisions about 340B ripple far beyond balance sheets. For those living with chronic conditions, access depends on accountability. Policy decisions affect which patients are seen and which are referred elsewhere. They influence what kind of health care system we inherit: a public trust, or a private strategy with a charitable logo on the front.