Maine is the most rural state in the nation. This isn’t because Maine is bigger and wilder than Wyoming or Montana, but because Maine has a higher percentage of its residents choosing to reside outside of urban areas. Maine is a beautiful state, and its many rural and remote communities offer a vital and meaningful lifestyle. But Maine’s rustic character also makes assuring quality, affordable health care for rural residents a formidable challenge.
Both nationally and in Maine, data show that rural residents are less healthy and face greater obstacles to health care compared with their urban counterparts. They are more likely to die prematurely, suffer from chronic disease and lack insurance.
Maine’s rural rim counties have the highest percentages of uninsured residents ( 17 percent of Washington County residents are uninsured) due to a combination of factors, including lower annual incomes and higher rates of self-employment. In the meantime, Washington County was one of the few counties in the northeastern U.S. where the life expectancy of women decreased between 1983 and 1999. For the first time since the 1918 Spanish influenza epidemic, Washington County women cannot expect to live as long as their mothers did.
Because a significant percentage of working Americans earns too little to afford private coverage, the Affordable Care Act provides federal dollars for states to expand their Medicaid programs to cover low-income, working people. Expanding Medicaid offers a way to cover low-income Mainers at a minimal cost to the state budget. The state contributes nothing for the first three years, and minimal percentages until 2020, when the state will pay for 10 percent of the costs associated with expansion.
Regrettably, Gov. Paul LePage has twice vetoed the Legislature’s approval of Medicaid expansion and likely will do the same in 2014, unless the Legislature can muster a veto-proof majority.
Given the high uninsurance rate in rural areas, is the governor’s veto in the best interest of his constituents?
ACA politics are worsening the health care inequity between urban and rural Americans. Urban states, such as New Jersey and Massachusetts, leapt at the chance to accept ACA funds and inject federal dollars into their economies. More urban Americans will have health care coverage.
In contrast, most of the states with the highest rates of rural and small city residents have rejected Medicaid expansion. An estimated 1.7 million uninsured rural Americans in these states will fall into the “coverage gap” due to this choice. The media has given scant attention to the rural Americans who have been denied health care coverage by their state leaders.
Population has declined steadily in rural Maine for decades. Rural counties have higher rates of poverty and fewer people in their prime working years to fuel the economy. Given this backdrop, the politicization of Medicaid expansion further deprives rural residents and ensures the well-known disparities in health and life expectancy will persist. Beyond this, refusing to expand Medicaid also penalizes already-threatened rural hospitals.
Of Maine’s 36 hospitals, 16 are federally designated critical access hospitals. These facilities have fewer than 25 beds and are at least 35 miles from the next hospital. Critical access hospitals serve a poorer population that is more likely to be uninsured or older and eligible for Medicare. They also usually are not able to offer the more lucrative specialty services that drive revenue at large city hospitals. Critical access hospitals cannot turn away the uninsured, but treating these individuals strains already-fragile budgets.
Faced with recent cuts in Medicare reimbursements, and no corresponding expansion of Medicaid to cover their uninsured population, critical access hospitals are already undergoing layoffs, or facing closure, in some states with large rural populations refusing federal funds, including Texas and Mississippi. Leaders in these communities have tied their hospitals’ troubles directly to their state legislatures’ refusal to expand Medicaid.
Rural regions of Maine stand to benefit the most from Medicaid expansion and will be penalized most harshly if the state’s leaders continue to refuse federal funds. Maine’s rural counties already have the lowest incomes and highest rates of uninsured. In an ideological public battle over the funds, who is representing rural Maine’s interests?
Christy Daggett is a policy analyst at the Maine Center for Economic Policy.