A working group looking into ways to bring healthcare to Maine’s island communities is considering “ambulance vessels” as a possible solution.

Rob McGraw, executive director of Atlantic Partners EMS, an agency charged with appointing representatives to the Maine EMS Board, said that a regional stakeholder group of lawmakers and community members have begun discussions about emergency boats that could take critical-condition patients to the mainland. 

Martin Grimnes, president of Arcadia Alliance, which partners with international manufacturing companies to provide fast ferries for U.S. operators, said such vessels are common in his home country of Norway. They are stationed along the country’s coastline and act as mini floating hospitals.

“[Norwegians] have 60 vessels up and down the coast, doing this kind of service. And in the U.S., there’s not a single one,” Grimnes said.

Getting medical care to Maine’s islands has long been an informal arrangement for patient transport that relies heavily on the Maine Ferry Service, lobstermen, the Coast Guard, the Maine Marine Patrol, and LifeFlight.

But Grimnes has been in conversation with island authorities for a more comprehensive arrangement since 2017 — in part, he said, to preserve life on island communities.

“[The] elderly do not want to live on an island where there are uncertainties of access to medical help. Young people do not want to start a family, or God forbid, [deliver] a baby on a lobster boat,” said Grimnes, a frequent visitor to Vinalhaven.

“It would be [the Maine Department of Transportation’s] preference to get out of the patient transport business completely,” said Rick Petrie, the special projects advisor for Atlantic Partners EMS and chief operations officer for NorthEast Mobile Health Service. “We do have legislators who are willing to put in legislation to fund the operation.”

Petrie estimates the 24-hour, year-round emergency boat service to cost roughly $2.5 million in operating costs each year, plus an estimated $5 million in initial investment in the vessel.

The goal, said Petrie in a meeting in July, would be to have a funded boat transport system without relying on reimbursement. Medicare and Medicaid, the primary payers in Maine, don’t provide special reimbursement for boats.

“When you start to look at the number of calls and the reimbursement that is there we would never be able to bring in enough money for the operation of the boat.”

The group has made significant progress in the last year. The team is creating a draft to be shared with island community stakeholders for review and approval before moving forward; the group aims to establish or partner with a non-profit to be tasked with operations under the Maine Department of Transportation.

“The ferry service should be treated like any other state highway,” said Grimnes. “It is the state’s responsibility to maintain that.”

Proposal comes as rural medical care, EMS falter

The ambulance vessel proposal comes as rural care providers struggle to stay afloat. One of the state’s largest healthcare conglomerates, Northern Light, announced last week that it plans to close an internal medicine facility in Dexter, after failing to find a new location for the practice. A rural care clinic in Southwest Harbor, also owned by Northern Light, will close at the end of August. 

Rural providers say they are struggling with critical staffing shortages, funding and finding housing for employees in one of the tightest housing markets in decades. 

Maine’s EMS system is also widely considered to be in crisis. Last year, lawmakers approving $31 million in grants to help shore it up, although none of the money had been allocated as of January.

The problem is particularly acute on Maine’s islands. On Vinalhaven, for instance, the town has two ambulances and 14 individuals on the roster to assist in EMT calls. The three advanced EMTs, including Director Ryan Nizolek, are on call to work every weeknight and on weekends. 

“We do great work, we try very hard, but a lot of us are wearing a lot of different hats on any given day,” Nizolek said. “We are having to ask more and more of volunteer time that they aren’t necessarily getting compensated for.”

In addition, the nature of transient seasonal communities offers few opportunities for licensed staff to maintain their skills.

“There are examples like that in many communities where … keeping the EMS service alive is a challenge unto itself, and much less keeping the people who work in it skilled enough,” said Dr. Katherine Simmonds, the Associate Director of Health Programs and a clinical professor at Northeastern University’s Roux Institute.

The vessels could ease the demand for other emergency transportation options, including LifeFlight.

“If we’re putting more resources on the coast, that allows LifeFlight to possibly go to some of those islands that don’t have that resource possibility,” McGraw said. 

LifeFlight has seen a rise in critical transportations this summer. In the first two weeks of July, they responded to 178 calls for general emergencies, compared to less than half of that amount last year in the same period.

Maine’s only emergency air transportation service, LifeFlight, has also prepared to handle more obstetrics emergencies with the closure of maternity units throughout the state. 

“We’ve been working on this for years and in anticipation, sadly, of more and more obstetrical services being abridged in the state,” said LifeFlight Executive Director Dr. Norm Dinerman. 

Of LifeFlight’s 3,000 transfers last year, 191 were for pregnancy-related care.

“We’re trying to stay ahead of the curve,” Dinerman said. 

Nizolek, one of the few advanced EMTs on Vinalhaven, saw firsthand the challenges women face if they are pregnant on the island. One of his friends returned to the mainland towards the end of their term to avoid pregnancy complications on the island.

“That was the better option than staying here and kind of taking a gamble about what may or may not happen,” Nizolek said. “But a large portion of our population doesn’t necessarily have that ability.”

Small islands worry they’ll be left behind

Some people who work on smaller islands have concerns about the vessel service. Donna Weigle is an EMT on Swan’s Island and also ran the island’s medical center for 16 years before retiring in 2023.

She worries that smaller, more remote destinations such as Swan’s and the Cranberry Islands would not benefit from the service if only one boat is available for all of Maine’s islands.

“In theory, it sounds really great,” Weigle said. To ensure the resources are available for all islanders, she added that “you’re going to need more than one boat.”

Weigle would support the service if it is established under a state agency supported by state or federal funding. But she wants the draft to include language that allows for  expansion and for the addition of more vessels.

“I feel really good about the fact that we may be able to get this in place,” Petrie said. “This will serve all of the islands, not just the islands served by the ferry service.”

The group has discussed hosting the boat on Vinalhaven, said Nizolek, an idea the town’s Select Board is open to but cautious about, given the housing crunch on the island.

But Weigle hopes the service will ultimately live up to its intended mission.

“If I’m an EMT and I called you 10 times and I was told nine times, ‘Oh, sorry, we’re on another route’ … I think I’d be very disappointed,” Weigle said. “I think the bigger islands down in Casco Bay and down in Penobscot Bay are going to be utilizing that boat, and it’s not going to be available to us.”

A nearly $5 million federal grant recently awarded to the University of New England will be put toward efforts to improve Maine’s workforce supporting geriatric care over the next five years.

Efforts will focus on rural regions and the Wabanaki Nations, and include “dream sessions” with tribal health centers.

Maine is the oldest state in the country, and the number of Mainers with Alzheimer’s is projected to increase 20 percent between 2020 and 2025. But as of 2021, there were only 46 geriatricians practicing in the state. The need is particularly acute for underserved populations in rural and tribal communities.

The Health Resources and Services Administration awarded the grant to the UNE College of Osteopathic Medicine and Center for Excellence in Public Health. It will build on a previous five-year grant to support the work of AgingME, a geriatrics workforce program at UNE.

Dr. Susan Wehry, director of AgingME, said the grant will allow the group to develop big-picture brainstorming sessions, support hands-on rural clinical rotations and offer a microcredential for nursing students and certified nursing assistants to get additional expertise in geriatric care.

Wehry said she met with Wabanaki Public Health and Wellness — a nonprofit that provides the four federally recognized tribal nations in Maine with culturally sensitive health services — early on about how best to collaborate. They ended up having a conversation that was “transformational” for Wehry, encouraging her to think more broadly about aging care without being constrained by rigid boundaries, previous disappointments or notions of what may or may not be realistic. 

This resulted in the idea to put some of the funds toward what they’re calling “dream sessions,” brainstorming conversations with tribal health centers that consider questions such as: “What does a community look like that centers its elders? What does a community look like where tribal elders are visible, heard and empowered? What does a community look like when it is led by elder voices?”

Lisa Sockabasin, co-CEO of Wabanaki Public Health and Wellness, said her organization uses this approach for most of the work they do.

“Our work at Wabanaki Public Health and Wellness has always been how do we develop programs, systems, services that serve our people without a scarcity mindset,” she said. “Knowing that financial resources will always be limited but we don’t have to limit our minds in terms of what our people deserve to heal.”

It’s an opportunity to stop thinking small, Wehry said. 

“This isn’t about parsing out our resources and making sure that older people get their share,” she said. “It’s a different way of looking at it: If you could dream into being a community that had the condition in which all members could thrive, what would it look like?”

The grant will also be put toward ongoing geriatric training for health professionals, as well as education for students, residents, interns and fellows, with an emphasis on dementia-friendly care. AgingME also trains and supports older adults, family members, caregivers and support workers in the community like case managers with Area Agencies on Aging or community health workers, Wehry said.

To support nursing students and certified nursing assistants, some funds will go toward a geriatrics microcredential program that includes three badges: age-friendly, dementia-friendly and resilience.

Another focus of the grant will be to bolster clinical rotations in rural areas. Students will be encouraged to be more hands-on in the community at a range of rural primary care sites, including rural nursing homes. They will take a public health approach to looking at how factors like food insecurity or access to clean water can have just as much impact on someone’s health as medication, Wehry said. 

“This grant creates a mechanism for community volunteers to reach out to medical students and invite them to participate in the life of the community,” Wehry said. “We’re trying to help students see the connection between community and individual health.”

Days before winter break ended in December 2022, Bill Hansen was relieved to learn that Jordan-Small Middle School in Raymond had no traces of ‘forever chemicals’ in tests of the school’s water system.

Hansen, the Windham Raymond School District’s facilities director, was on vacation in Rockland at the time, visiting venues for his daughter’s wedding, as test results for the harmful chemicals called PFAS began rolling in for schools statewide. 

He initially thought if Jordan-Small was in the clear, then so was Raymond Elementary, just down the road. It was a promising start for the district east of Sebago Lake and its six schools. 

“We’re doing good,” Hansen said at the time. “This is awesome.”

But a couple of days later, on Dec. 30, Hansen received a bombshell. Raymond Elementary’s well water tested nearly 50 times higher than the state limit for PFAS levels. Just three days before students returned, the school learned it had the most contaminated public water system in the state. 

School and district staff members were in a bind, and they had to get to work right away. 

“There wasn’t a lot of time to turn that around,” Hansen recalled.

Raymond Elementary is one of dozens of schools, mobile home parks, local water districts and other community water systems that tested above the state’s limits for PFAS in 2022, data from the Maine Department of Health and Human Services shows. 

As some of those schools close in on the two-year mark of when their PFAS issues were diagnosed, each is in a uniquely different situation, reflecting the complexities of ridding public water sources of the tiny ubiquitous chemicals that earn their ‘forever’ moniker from the thousands of years they take to break down in the environment. 

Raymond Elementary, for example, is close to securing a new safe drinking water source around the start of the upcoming school year. But others, like Deer Isle-Stonington High School in Hancock County, are further away, delayed by funding complications or the prolonged process of planning and installing complex PFAS filtration systems.

These efforts will only grow in Maine as other water systems face newer, more stringent federal rules with deadlines unfurling over the next few years, requiring dozens more owners and operators to expunge their water systems of even smaller concentrations of PFAS. 

And although much of the current costs for public PFAS filtration systems are covered by state and federal grant money, some local officials The Maine Monitor spoke with are concerned that systems will have trouble sustaining the operations costs of their filters, and installation grant money could run out — leaving schools, communities and homeowners in a race for whatever piece of the pie remains.

DHHS, tasked with distributing funds to public water systems for PFAS filtration, doesn’t expect to have enough funds to help all the state’s public water systems meet the new federal standards, according to Lindsay Hammes, an agency spokesperson. 

“It is anticipated that the available funding will not be sufficient to meet the needs of all Public Water Systems that will exceed the federal (PFAS limits),” Hammes wrote. 

Legislative origins

School districts and other public water systems (which have varying definitions, but mostly include those that serve more than 25 people for more than two months a year) began testing for PFAS in 2022 after the Maine legislature passed a landmark law regulating the harmful class of compounds in public drinking water a year prior.

The legislation required owners and operators of public systems to notify users if their results showed combined levels of six state-regulated PFAS above 20 parts per trillion, one of the more stringent action levels in the U.S. at the time. 

The law also requires owners to pursue filtration to rid the water of the chemicals, but the state Department of Health and Human Services has not had to take any enforcement actions to date, according to a department spokesperson. But the department has sent violation letters for public water systems that have missed deadlines for submitting PFAS test results.

After receiving test results for Raymond Elementary, Hansen contacted Superintendent Chris Howell, who notified students' families. Hansen and Mike Duffy, the district’s safety support specialist, then shut off the school’s water fountains and worked to get enough bottled water to support the school’s more than 250 students and staff members.  

Principal Elisabeth Peavey handled more direct communication with parents. She said they had relatively measured reactions, likely because of all the other PFAS news swirling at the time.

“I think news (outlets) putting out that information made it so people were somewhat aware that there's potential for schools to have (PFAS) in their system,” Peavey said. 

Stories of PFAS contamination in Maine have been inescapable. The class of compounds, per- and polyfluoroalkyl substances, has been used in a wide variety of products like rain jackets, non-stick frying pans and carpets. Their use in firefighting foams have led to widespread contaminations on military bases, including in Maine. 

The effects of PFAS on human health are still being discovered, but the U.S. Centers for Disease Controls have linked the chemicals to weakened immune responses, kidney and testicular cancer, and pregnancy-induced blood pressure disorders. 

The U.S. Environmental Protection Agency and the federal standard it set for PFAS in April is supposed to account for this risk, according to the agency.

Its rules will require public water systems to limit two more common and harmful PFAS compounds to 4 parts per trillion. Though it is far lower than Maine’s 20 parts per trillion standard, the state is in the process of updating its standard to align with the EPA’s.

In pursuit of solutions

The difficulties of managing the school’s PFAS contamination set in rather quickly. Raymond Elementary’s facility staff were suddenly tasked with lugging five-gallon water jugs up and down the school’s halls, and cafeteria employees were hoisting them to prepare meals.

“The bottles are so heavy,” Peavey said, “and it was causing some physical back pain for our kitchen staff.” 

Eventually the district hired temporary employees just for transporting water — an added cost to the water itself. After initially relying on a donated supply from nearby Poland Spring, the school began paying around $350 per week for water from Gorham-based supplier H2o7.

In the background, Hansen, Superintendent Howell and other district officials worked to acquire federal money from the Small Public Water System Emerging Contaminant Grant, funding managed at the state level by DHHS’s Drinking Water Program, and made available to schools and smaller water systems. 

With $60,000 in grant funding secured, the district hired Portland-based hydrogeology firm Drumlin Environmental to begin analyzing the extent of Raymond Elementary’s PFAS contamination, testing groundwater, soils on the school grounds, and mapping the aquifer used by the school’s well.

Much of Maine’s most severe PFAS contaminations originated from the wastewater sludge once used as fertilizer and spread on the state’s farmland, especially around Fairfield and central Maine.

The source of Raymond Elementary’s contamination was not so clear-cut. Though Drumlin Environmental found traces of PFAS in the soils near the school’s wellhead, Hansen said the use of PFAS-laden fertilizer was unlikely because the school is in a wellhead protection zone and fertilizer use is restricted. 

Hansen only had flimsy guesses where the school’s high levels — 950 parts per trillion — originated. Officials with other districts afflicted by PFAS contaminations were similarly perplexed by their origins, which complicated how they came up with solutions. 

Raymond’s solution, for example, was eased by the location of the suspected source: the soils surrounding the wellhead. 

Hansen said it was likely the well’s lack of reinforced piping led to the PFAS seeping in near the surface, so Drumlin dug boreholes until identifying another area to tap into the school’s aquifer, upslope of the current well, that repeatedly tested negative for PFAS.

The district drilled a new well a few hundred feet from the original, reinforcing it with additional steel casing. But what the new well lacked in PFAS it made up for in high levels of radon, a naturally occurring radioactive gas commonly found in areas composed of granite, like Raymond and the Sebago Lake area. 

That meant the district had to purchase a special radon removal system, which Hansen predicts will be installed by the start of the school year. The cost of the planning, engineering, construction and equipment totaled around $100,000, according to Howell, with the state covering 60 percent. 

PFAS filtration systems have cost around $50,000 for smaller schools, but Raymond’s new system won’t require the routine maintenance and upkeep required of PFAS filtration systems.

Complications elsewhere

The paths for some other school districts have not been as straightforward. For Regional School Unit 76 in southern Hancock County, Superintendent Daniel Ross said he’s not sure when the district’s two schools with elevated PFAS levels — Deer Isle-Stonington High and the Brooklin School — will finish their PFAS filtration systems. 

Like at Windham-Raymond, Ross said he and his district immediately began applying for public funding after receiving test results in December 2022 that put the Brooklin School and Deer Isle-Stonington as the systems with the fourth- and fifth-highest PFAS levels in the state.

The district received a grant through the state Drinking Water Program, but because of stipulations that required domestically sourced materials and an environmental impact study, the initial estimates for the PFAS filtration systems that met those requirements was around $550,000.

State funding would cover 90 percent of the estimated cost of installing a filtration system, but that would still leave local taxpayers on the hook for around $55,000 in project costs, a steep amount for a school district of its size, Ross said. 

After a year undergoing the planning process for that system, Ross said the Drinking Water Program changed its tune and allowed the district to pursue a cheaper solution from a different company, which would cut the cost to around $60,000 per school. The entire project would be funded by the grant.

Ross welcomed the news and praised the DWP for its attentive assistance throughout the process, but didn’t understand why it took so long for the DWP to make that judgment. 

“When you are dealing with large amounts of money, it takes time to get everything through,” Ross said. “Even though (the recent update is) welcome, it would have been nice to know this a year ago so that we don't get so far into this thing only to backpedal and delay finding a solution even further.”

The DWP is not involved in the design process of public water systems’ PFAS filtration solutions, said Hammes, though it recommended a less costly but still effective design that would take less time to install.

In the meantime, the district has been paying around $1,000 per month to purchase bottled water from Poland Spring and is back to square one in planning for the PFAS filtration systems. The Brooklin and Deer Isle-Stonington school boards only recently received initial quotes for the new systems, which they are comparing before selecting a contractor.  

“We want them all to have clean water to drink, but if we’re going to have to bring in bottled water, at least having a smaller school population causes that not to cost quite as much” as larger school districts, Ross said.

Ross’ district, and Deer Isle-Stonington High in particular, are in a deeper dilemma because of the area’s fragile hydrogeology.

While Raymond Elementary had the option to dig a new well in an uncontaminated area, the archipelago that includes Deer Isle and Stonington has especially fragile freshwater sources nestled under a thin layer of granite, according to Annaleis Hafford, vice president for Olver Associates. (Olver Associates was initially consulted for RSU 76 PFAS filtration systems and is contracted by Stonington to run the Stonington Water Company, where Hafford is the operator.)

“I think that the concern is if they drill another well, it may not have any productivity and it also may still have PFAS in it,” Hafford said, as well as the elevated levels of radon that accompany granite.  

Hafford and the town of Stonington face similar difficulties in securing its drinking water system. Although the town does not have elevated PFAS levels, it is highly susceptible to drought and leaks in connections to residences.

“In the summer, every day we tend to lose water,” Hafford said. “The water tank is dropping now and it's only the beginning of July.”

The Stonington Water Company is trying to increase the system’s resilience by building a new water storage tank and identifying every leak, but that hasn’t stopped Hafford’s consistent worries over her eight years of leadership.

“Every gallon is important to us,” Hafford said.

More common solutions

While Windham-Raymond and RSU 76 may be outliers in the intricate process for schools to mitigate PFAS, the more common and streamlined approaches to filtration have still operated on relatively lengthy timelines.

By the Canadian border in Hodgdon, the town’s high school and elementary school are also looking at August completion dates after more than a year and a half on bottled water. Hodgdon’s district, Maine School Administrative District 70, received $60,000 for each school to install granular activated carbon filtration systems, according to Superintendent Tyler Putnam.

One of the more common and less expensive systems, they work by slowly pumping groundwater through a carbon media which then captures PFAS passing through, like flies in a spider web. 

Though effective, some water officials say the system also has weaknesses. The extraction process results in the filter filling up over a year or two. Unless it’s replaced, a clogged filter will hit a threshold called “breakthrough,” and begin releasing concentrated amounts of PFAS back into the filtered water. 

The Hodgdon schools’ filtration systems will have three redundant filters to account for this, according to Sienna Faessler, the Haley Ward engineer overseeing the systems’ designs. 

Schools and other public water systems are also required to test quarterly for PFAS, Faessler said, so the odds a breakthrough would go unnoticed is unlikely.

Nevertheless, breakthroughs and the upkeep of carbon filtration systems are a couple of the concerns that Sanford Water District Superintendent David Parent has with how people statewide are addressing PFAS contaminations.

Parent was introduced to PFAS relatively early when one of the water district’s wells first tested for PFAS in 2013, around the time the EPA began monitoring for the chemicals. The contamination subsided while the well was shut down after a few years, but came back at higher levels almost a decade later.

Three wells in Sanford Water District have tested for elevated PFAS levels in the past year, with the initial well of concern exceeding the state’s limit at roughly 30 ppt, even though the district hadn’t drawn from it over the years because of its manganese content. 

“We weren't putting the water in the system anyway, but then we got this hit of PFAS that was fairly high,” Parent told The Monitor. “We thought, ‘Oh boy, what is this?’”

Since then, Parent has been navigating the solutions available to him and the district, which comes at a much larger cost and scale than those of public water systems such as schools. 

As he’s seen granular activated carbon become the favored solution, Parent said he’s grown concerned that the long-term care of the systems isn’t being planned for — especially for residences, where homeowners may not be prepared for the cost of replacing the filters and the complexities of disposing of their PFAS-filled contents, which are finding their way into Maine landfills and incinerators.

“The maintenance of these systems is just very, very important,” Parent said. “For both residential and municipal systems, it’s a very expensive part of maintaining that treatment.”

Operation and maintenance costs for carbon filters contributed to one school district’s decision to pursue a different type of system, one with higher upfront costs but lower maintenance costs. 

Maine School Administrative District 6, encompassing Buxton, Standish and parts of both York and Cumberland counties, was one of the first school districts in the state to test for PFAS after the legislature’s 2021 law passed.

Adam Thibodeau, the facilities director, said he wanted to be sure the district would have its water tested before labs were backed up with samples from other public water systems rushing to test before the Dec. 31, 2022 deadline. 

Before Raymond Elementary got its results a few months later, it was MSAD 6 and Bonny Eagle Middle School that had some of the highest PFAS levels in Maine, between 600 and 800 ppt. The middle school and three other schools in the district tested above the state’s limit, with a fourth just below it.

Again, Thibodeau didn’t want to waste time, so the district authorized a study to analyze each school’s PFAS situation, and the strengths and weaknesses of each filtration system. The district not only looked for the most effective system, but one that would cost the least to maintain because operation and maintenance costs are excluded from state grants.

It eventually chose FLUORO-SORB, a proprietary filtration system that uses a clay-based media to absorb PFAS compounds, not adhere to them like carbon filters.

Altogether, planning and installation costs for all five schools’ filtration systems totaled around $700,000, far more than the other districts, though MSAD 6 is one of the largest in the state.

With $1 million provided by the Drinking Water Program, the district has about $300,000 left, Thibodeau said, which will help with Buxton Center Elementary School’s system costs — the last on the district’s list. 

The price may be high now but each system’s annual cost will be limited to between $8,000 to $20,000 for as long as the systems operate, lower than the cost of most carbon systems, according to Thibodeau.

“I plan to be here a while,” Thibodeau said. “I’m picking the best solution over time, and what that study told me is that carbon is not the way to go.”  

The FLUORO-SORB systems have been in place at two of the schools for almost a year, and Thibodeau said the district hasn’t had any problems. With a carbon system, the schools’ relatively high PFAS levels may have clogged up the filters by now, requiring replacement and disposal.

Faessler, who’s worked with other public water systems on installing PFAS filtration equipment, is less concerned about the maintenance requirements of carbon filtration systems — at least for the schools Haley Ward has consulted for.

“Most schools have a maintenance person (who is) trained or at least knowledgeable on how to operate the systems,” Faessler said. “But we're available as well, and they know that we're happy to answer any questions as they come up.”

Where Faessler and Parent’s PFAS-related worries overlap involves how the state plans to fund future PFAS mitigation projects. They suspect those fiscal needs will grow as the EPA begins enforcing its new limits for public water systems in 2029 or as more homeowners test their wells and find high PFAS levels.

Parent, specifically, questioned whether the state’s regulatory approach for public water systems like his was the most effective. 

Even though the district had relatively low PFAS levels (around 10-30 ppt) compared to Raymond Elementary, Sanford acquired grant funding for its more expensive filtration systems, which could cost up to $16 million. He thinks that money may have been better spent elsewhere, for private wells with high levels or future PFAS problems in other water systems.

“I think Maine's timing was good,” Parent said of its legislation. “But it bothers me a little bit” that Sanford Water District and its low PFAS levels receive lots of support, while the state is “buying people a system to start out with, but they're not funding the maintenance of those systems.”

There’s also the $250-$500 price of PFAS tests themselves, which aren’t always covered by the Maine Department of Environmental Protection and its program to help homeowners affected by the state’s spreading of sludge.

More than half of Mainers get their water from a private well, and the state mostly relies on homeowners to have their wells tested.

Funding also was the overarching concern from other officials The Monitor spoke with. Since the state is mandating compliance with this standard from public entities like school systems, they should pay for ongoing costs. 

Faessler, for example, had public funding questions similar to Parent’s. From her perspective, securing that funding is as pertinent as the process of removing PFAS from the sources leaking the chemicals into the environment. 

When funding becomes scarce, the state will prioritize disadvantaged communities and public water systems with the highest PFAS levels, Hammes of DHHS said.

That was one of Faessler’s primary concerns: how Mainers already stretched thin are going to afford these systems and their upkeep, especially when the funding runs out.

“Who is going to help pay for some of these installation systems?” Faessler asked.

Along the sea-smoke-covered shores of Great Wass Island Preserve in Beals, the swelter of an unusually hot June day melted away. The preserve’s ever-present maritime winds carried the chill of salt spray over granite ledges, verdant heaths and jack pine woodlands. 

A mere 13 miles away on the mainland, something less pleasant wafted through the air: the toxic pesticide imidacloprid. It is one of several popular neonicotinoids, a class of pesticides designed to mimic nicotine, whose use is banned in the European Union and restricted in 10 U.S. states.

On June 10, the Columbia Falls-based Worcester Holdings — the company behind the scrapped Flagpole of Freedom project — notified nearby Addison residents that the company would use drones to spray imidacloprid over 190 acres of its pine forest this summer.

The pesticide is being used to control balsam gall midge and woolly adelgid in the fir trees that supply balsam branch tips for Worcester Wreath, one of the company’s holdings. 

The news caused a furor on social media, with residents alarmed about the potential threat to wildlife, humans and the environment. 

But the Worcesters aren’t the only ones applying pesticides. The practice is common in forestry and agriculture. 

A recent push to ban aerial pesticide application in the state was vetoed by Gov. Janet Mills, but environmental advocates continue to push for more regulations.

“We’ve long been concerned about the impacts of pesticides,” said Heather Spalding, deputy director of the Maine Organic Farmers and Gardeners Association. “There are so many studies, peer-reviewed studies — every week more and more information comes out about the impact on human health and the environment.” 

In 2022, the U.S. Environmental Protection Agency concluded that imidacloprid and other neonicotinoids were “likely to adversely affect” endangered or threatened species, and critical habitats.  

In addition to imidacloprid, many of the more than 11,000 pesticides registered for legal use in Maine have been identified as potentially harmful.

The state sets regulations for their application via the Board of Pesticides Control (BPC), including by requiring training and licensing for applicators. In the commercial category, there are 1,648 registered and certified pesticide applicators working for 573 companies or organizations. Eleven of them hold aerial application licenses.

Despite Worcester Holdings’ track record of violations, the company appears to be following protocol. Worcester Holdings gave proper notice and is duly registered.

Surprisingly, so are five of the state’s leading conservation organizations — including The Nature Conservancy in Maine, stewards of the Great Wass Island Preserve. 

According to a Maine Monitor review of state data, The Maine Coast Heritage Trust, Friends of Acadia, Mount Desert Land & Garden Preserve, and the Kennebec Estuary Land Trust also have licensed commercial pesticide applicators on staff. 

‘Crushingly disappointing’

Among them, the five conservation groups have 17 pesticide applicators helping to manage a combined 2.6 million-plus acres, mostly along the coast.

None hold aerial application licenses, instead manually applying the chemicals from “pesticide backpacks” as part of what is called an integrated pest management approach. It Involves using pesticides to augment hand-pulling and other natural means of eradicating invasive pests and plants.

All of the conservation groups interviewed for this story blistered at the idea of using aerial application, saying their methods are much safer.

A spokesperson for The Nature Conservancy in Maine — a group founded with the help of esteemed biologist Rachel Carson — said it has several licensed applicators on staff who occasionally need to use very targeted herbicide applications to control invasive plants. TNC has conserved roughly 2.4 million acres over 193 preserves.

The other conservation groups that responded to questions from The Monitor had similar responses: They reluctantly use pesticides as part of a comprehensive approach to control invasive plants and vegetation from consuming entire habitats.

“It would be irresponsible if we called ourselves conservation landowners to let invasive plants kind of spread unchecked over the lands we’ve conserved because they greatly diminish ecological value. That’s not something we’re willing to stand by and let happen,” said Amanda Devine, director of stewardship for the Maine Coast Heritage Trust, which oversees 180,000 acres from Kittery to Calais. 

Devine, as well as Dillon Mulhern, the preserve’s manager for the Kennebec Estuary Land Trust, described their groups’ use of pesticides as “surgical.”

But some environmental advocates, like Spalding from MOFGA, say there are better, non-chemical methods to manage even extensive acreage. Spalding called the news that some conservation groups are using glyphosate and other pesticides “crushingly disappointing.”

The question of aerial application

In 2021, the legislature passed L.D. 125, An Act to Prohibit Aerial Spraying of Glyphosate and Other Synthetic Herbicides for the Purpose of Silviculture. Despite broad support, Mills vetoed the bill and lawmakers failed to override the veto. 

The governor subsequently ordered the BPC and Maine Forest Service to review the rules related to aerial pesticide application for the purpose of silviculture, the science of managing woodland. 

The agencies hired a consultant named Harold Thistle, a retired expert in forest meteorology, and paid him $30,000 to conduct a study. An additional $98,436 in federal and other funding was used for water quality monitoring. 

The 175-page report, released in 2022, draws on a number of studies that consider the impact of buffer zones, droplet size, height of pesticide release, weather and wind drift.  

Thistle found that aerial herbicide treatments produced the highest internal rate of return for the forestry industry, and alternative methods would be too costly. 

Many of the concerns about aerial application have to do with the degree to which droplets of pesticide drift through the air, potentially catching a breeze and landing outside the intended area. 

“Though aerial herbicide application as practiced in Maine is very low risk, it is impossible to assert that ‘no drift’ of herbicide occurs,” Thistle concluded in the report. “It is demonstrated that drift amounts at long ranges are minute when present.”

While drones have seen significant usage in pesticide applications in the South, they remain an emerging technology in the Northeast.

Patrick Strauch, the Maine Forest Products Council executive director, and other industry professionals believe drones can help reduce drift because they can fly close to the ground, more precisely spraying targeted invasive plants and insects. 

“The technology may offer precision treatment of browntail moth outbreaks in areas of high sensitivity,” Strauch said in an email.

‘This needs to be stopped’

Though the statewide ban failed, at least seven Maine municipalities have passed ordinances prohibiting or restricting the aerial application of pesticides. A total of 32 municipalities have ordinances that ban or limit pesticide application.

Some Addison residents are calling for town officials to enact such a measure.

“The town selectmen need to do a moratorium on aerial spraying until an ordinance can be passed,” posted one Addison resident, later adding, “We do not want spraying anywhere near our property. This needs to be stopped!!!”

One particular concern is the effect on local pollinators. Cornell University biologist Thomas Dyer Seeley, who lives in Downeast Maine part of the year and is an expert on honeybees, said although pine forests are not a honeybee habitat, aphids live among the trees and honeybees are attracted to the excrement aphids leave behind.

“Honeybees can go to those aphids and drink what’s called honeydew,” Seeley said. “So even though they’re just spraying in coniferous places… these pesticides could get into honeybees.”

Alex Cammen, a licensed forester and pesticide applicator for Worcester Holdings, said the company is abiding by the laws governing safe pesticide use, and also wants to be good stewards of the land.

“(We) are members of the communities … and care deeply about the health of our neighbors, forests, wildlife, waters and ourselves,” Cammen said. 

There are no legislative or advocacy group efforts to mount a new fight for a statewide aerial pesticide ban, according to Spalding. She said her focus is now on issues such as the clear-cutting of forests. 

Her group has also advocated against an exemption for agricultural pesticides during recent legislative discussions about banning the sale of products containing PFAS. There are at least 55 PFAS-related chemicals present in more than 1,400 pesticides registered for use in Maine, according to Spalding’s testimony.

“When you’re laying down fungicides and herbicides, insecticides, larvicides, you’re really adversely impacting the health of the soil microbiome,” Spalding said. “We need to be moving away from dousing agricultural lands and forest lands with chemicals.”

Regulators were up to their ears in trash talk on Thursday morning as they deliberated over a draft of rules intended to increase recycling, reduce the amount of material going to landfills and ultimately reduce the amount of packaging that’s coming into the state. 

It’s been five years since Gov. Janet Mills signed a resolve directing the Maine Department of Environmental Protection to come up with the rules. I remember the first meeting I sat in on where they were explained, on a chilly January afternoon at a community center in Ellsworth.

The room was packed, and then-state Rep. Nicole Grohoski, who had long been championing the concept, was trying to get residents on board.

Ellsworth was a particularly interesting place to be reporting on trash at the start of 2020. The long-awaited waste-to-fuel plant in Hampden, where Ellsworth and more than a hundred other municipalities were planning to take their waste, had finally opened after more than a year of delays (it lasted less than a year before shutting down).

The nearby incinerator in Orrington, where trash was burned to generate electricity, was still operating, but at reduced capacity, having lost many of its contracts when it raised rates and the Hampden plant came on the scene.

Meanwhile, it had been two years since China implemented its National Sword program, which banned many recyclables and put a contamination limit on others, throwing recycling markets in the United States into chaos. 

Before the implementation of the program, the Environmental Protection Agency estimated that our plastics recycling rate was roughly 9 percent, in part because we sent a lot of it to China.

After National Sword, according to research from an environmental group affiliated with Bennington College, that figure dropped by half, to around 5 percent. That means 95 percent of the plastics generated that year were put in a landfill or burned for energy. 

Meanwhile, the per capita generation of plastic waste has gone up 263 percent since 1980. 

Hancock County exemplifies many of the challenges of recycling and waste management across the state. It’s both urban — the town of Ellsworth is the service provider for the area and the gateway to Acadia National Park, which saw more than 4 million visitors last year — and decidedly rural. 

It’s also seasonal, with the volume of waste exploding in the summer and dropping off significantly in the winter. The rural nature of the region means transportation costs are higher than they are in more densely populated areas, and the seasonality makes it tough to maintain infrastructure that must handle fluctuating volumes. 

In 2019, The Ellsworth American, where I was a beat reporter at the time, chronicled the situation as town after town cut back on recycling or stopped their recycling programs entirely, citing skyrocketing tipping fees and a lack of end markets. 

“We just don’t get enough material anymore to make it worth it to keep operating,” Joyce Levesque, manager at Coastal Recycling, which served five towns before it closed in 2019, told The American. “Recycling isn’t cheap, so it’s either everybody or nobody doing it.”

The draft rules presented at the meeting of the Board of Environmental Protection on Thursday are intended to get everybody to do it. But some board members were skeptical that they would have the desired effect, at least as currently written.

“It’s not going to incentivize anybody to move their solid waste,” said board chair Susan Lessard, who also serves as town manager in Bucksport.

Under the proposed rules, communities would be reimbursed for both recycling packaging and for diverting it from landfills by choosing options higher up on the solid waste management hierarchy. 

If a municipality sends packaging material that isn’t readily recyclable to a landfill when an incinerator is closer, they’re not eligible for reimbursement, explained DEP staff on Thursday.

What if there isn’t an incineration option, wondered board members — say an incinerator is full, and can’t take any more, or it isn’t currently operational, as is the case in Orrington.

Would the municipality be dinged for an option it doesn’t have? Yes, as currently proposed, said Elena Bertocci of the DEP. 

“That is something we thought about a lot and tried to figure out if there was a good way to do something different. In many cases it’s not going there because the municipality doesn’t want to pay for it at the end of the day.”

Bertocci said it also became complicated to try and “put lines around” what not having access to an incinerator looks like.

The rules would also reimburse communities at a higher rate for incinerating over landfilling, which some board members argued meant communities in southern Maine with more options and access would get reimbursed at a higher rate than rural areas. 

Municipalities that choose incineration, for instance, would be reimbursed at two-thirds the average cost of recycling readily recyclable packaging material. Those that send it to landfills (if that’s the closest option) would be reimbursed at a one-third rate.

“Our cost is not the same as someone in southern Maine,” said Lessard. “For those of us with no option close enough… you only get one-third just because there’s nothing closer. But communities within proximity that can do that get two-thirds.”

Reimbursement at the higher rate likely won’t offset the cost of trucking packaging that isn’t easily recycled to places like the ecomaine incinerator in Portland, said Lessard. “Transportation cost alone is the killer.”

The rules are still being drafted, and there’s room for change. They’re intended to incentivize infrastructure development that will make it easier and more financially attractive for rural communities to divert from landfills, DEP staff said Thursday. But that will take time.

“I see this as good, in terms of trying to put the materials in the place they need to be over the long term,” said Steven Pelletier, a board member from Topsham. “But I see this proximity thing as being something that could really kind of shake up this particular industry… what we’re seeing on the ground now — in terms of facilities we can bring things to — in 10 years would be totally different, I would think, because of this.”

After qualifying for home care services, Pauline Kane sat on a waitlist for more than a year. In the meantime her daughter, Ann Marie Kane, who goes by her initials A.M.K., had moved in with her and was caring for her around the clock — without getting paid.

Pauline Kane, who is 86, has a neurological disorder that makes it difficult to walk or stand on her own, so A.M.K. helps with everything from making meals to showering. She’s concerned about her mom falling if left on her own in their Scarborough home, so A.M.K. brings her when running errands.

“She doesn’t go anywhere without me,” Pauline Kane said. If she didn’t have her daughter caring for her, Kane said, “I’d have to go into a nursing home. I don’t think I’d like it because there would be nobody around to talk to or for me to go out with.”

When Kane finally got off the waitlist in 2022, she was approved for about 24 to 32 hours through a state-funded waiver called Section 63, for people whose medical needs qualify for additional assistance but who have too much income to qualify for Medicaid. “I honestly don’t even know what (the number of approved hours) is right now because no matter what it is, I will do the same job every day,” A.M.K. said.

Kane now uses the funds to pay A.M.K., and realizes she is lucky to have someone who can work well beyond the number of hours she’s being paid. A.M.K. was hired by a staffing agency in her area to work as her mom’s caregiver full-time.

There are multiple home care waivers that allow Mainers who medically qualify for additional assistance (like care in a nursing home or assisted living) to opt instead to receive that level of care in their homes. But for those who do want care at home, many have been unable to find caregivers to work for all the hours they’ve been approved for.

A recent state report showed that 71 percent of around 1,500 people receiving the Section 63 voucher were not receiving all the personal support services or nursing hours they’d been approved for. 

However, the Department of Health and Human Services said there is no mechanism to know the scale of these deficits — it is unclear whether someone in this group is receiving, for instance, 30 of their 32 hours or a much smaller amount. 

The percentage of people receiving fewer hours than approved for under MaineCare or state-funded programs has increased markedly over the prior year — a problem advocates say underscores workforce shortages and increasing demand.

Gov. Janet Mills’ administration has dedicated significant resources to bolster the healthcare workforce, but advocates worry that attention to the problem is waning.

The number of people who qualify for waiver Section 19, which is for older people and adults with disabilities who qualify for MaineCare (the state’s version of Medicaid) stayed roughly the same but the proportion who are not receiving all of the hours they’ve been authorized increased from 33 percent in November 2022 to 50 percent in December 2023.

For waiver Section 96, which funds private duty nursing and personal care services, the share of people who are “partially staffed” went from 47 percent in November 2022 to 62 percent in December 2023. The number of enrollees was about the same.

Lindsay Hammes, a DHHS spokesperson, said there are a couple of explanations, including the fact that the latest report combines the home care hours that are partially and fully unstaffed, whereas this data was broken into separate categories in previous reports. She added that a nursing agency in 2022 stopped providing nursing services that supported these programs.

“As more people become eligible for the service, providers continue to struggle to hire qualified staff,” Hammes said.

Jess Maurer, executive director of the Maine Council on Aging, said the problem stems from a strapped labor market and low reimbursement rates for providers. She said DHHS and the Department of Labor have worked to attract people to direct care jobs, including by increasing wages for all essential care workers to 125 percent of minimum wage, or about $17.70 hourly.

“That’s great but it hasn’t helped,” she said. “The reality is that at some point we’re going to have to pay a market-driven rate.”

Maurer said the home care deficit could result in someone who is entitled but not receiving home-based care having an avoidable health crisis and ending up in the hospital, only to sit there for days or weeks instead of being discharged because there’s no home care nor available beds in nursing homes.

Hammes said an ongoing rate study is reviewing similar services across MaineCare sections, including home- and community-based clinical, therapy, care coordination, supportive skills building, and assistive technology services. She said the study is part of the department’s goal to address “severe state labor shortages for nurses,” which has contributed to a decline in people accessing these services.

“This effort may also help to address rate disparities across other relevant positions which are also experiencing labor shortages,” Hammes said.

How it works

To qualify for home care, a client must be assessed to see whether their medical needs qualify for additional assistance. If they do and the person opts for home care, they are connected with a care coordination agency, such as SeniorsPlus.

Betsy Sawyer-Manter, president and CEO of SeniorsPlus, said her agency serves about 3,000 people who have been approved for some level of in-home help. As a coordination agency, the group helps clients get connected with someone to provide care. But they also conduct an assessment to look at what else they might need, and connect them with the appropriate services.

While their numbers can fluctuate daily, Sawyer-Manter said SeniorsPlus has 756 completely unstaffed clients, which is slightly lower than past years. She said the demand for services is high and she expects it to only grow, especially as Maine nursing homes continue to close.

More than 23 nursing homes in Maine have closed in the last decade, with the most recent closure of Narraguagus Bay Health Care Facility reported last month.

“There is a significant amount of demand,” said Tracy Smith, the long-term services and support director for SeniorsPlus. “There are many clients who are living in areas where they don’t have family support, so this is essentially the only way they can get their needs met.”

The rural nature of the state could also be why someone has difficulty finding a caregiver, because fewer home care providers are nearby. Sawyer-Manter added that a lot of immigrants work in the field and clients are sometimes reluctant to have someone who isn’t as fluent in English provide their care. Sawyer-Manter noted that she’s seen this attitude improve recently.

Another part of the problem, Sawyer-Manter said, is the work itself is “not glamorous,” the pay is low and hours aren’t reliable. Home care workers help with bathing, dressing, cooking and transporting clients — tasks that should be valued, she said.

Sawyer-Manter said there’s been progress, including increasing the reimbursement rate to 125 percent of minimum wage and efforts to “destigmatize” the work. 

Undivided attention

Ashlee Reynolds, a certified nursing assistant who provides home care services through Allmed Staffing of New England, said she chose the work because she likes the flexibility and chance to work one-on-one with a client. When she worked in a nursing home, she sometimes had to care for as many as 12 residents in one day. In home care, she can focus all her attention on one person.

She currently works with three clients, dividing her hours with each of them into two- or three-hour shifts each day. Her services range from helping with bathing and dressing, to providing transportation and running errands.

One of Reynolds’ clients has caregivers from two agencies because the original caregiver couldn’t add more hours. 

Nate Charles, the home care manager with Allmed Staffing of New England, said his agency gets referrals for people seeking home care through waivers from care coordination agencies like SeniorsPlus. A mass email will go out to all 160 staffing agencies anytime there’s a new client.

Allmed Staffing provides personal support specialists and nonmedical staff that assist with basic house cleaning, groceries and meal preparation. If a client requires nursing care they would typically have a team of people that includes a registered nurse, he said.

Contrary to data that suggests a workforce shortage, Charles said he’s noticed a lot of demand among staffing agencies to sign new clients.

He said he has to respond within minutes to referrals for new clients or someone else will snap them up. He said this varies greatly based on where the client is located. His agency is based in Augusta and many of his care staff want to work with clients nearby. Someone in Aroostook County may have more difficulty finding a caregiver.

He’s also seen people opt not to use all the hours they’ve been allocated. This may be because they don’t want someone in their home that long or because their health deteriorates and they are approved for more hours, but want to stay with a particular caregiver who is unable to add hours.

What needs to be done

In response to the growing waitlist for Section 63, lawmakers in 2022 allocated about $6 million to get people off the waitlist so they can start receiving care. As a result, recipients such as Pauline Kane were finally able to access the funding.

As of February, there was no one on the waitlist. The number of enrollees in the program nearly doubled but the percentage of people receiving fewer than all their hours also increased from 53 to 71 percent. 

Since then, however, a waitlist was reinstituted April 1 because “current funding cannot support additional participants at this time,” according to Hammes. There are currently 280 people on the waitlist.

Eliminating the waitlist — even temporarily — is still progress, according to Arthur Phillips, the economic policy analyst with the Maine Center for Economic Policy. 

“It represents an investment in the program and that is something that we should commend,” he said.

However, Phillips said the available data offers an incomplete snapshot. Unlike previous versions of the report, DHHS did not release information on how many people have no caregiver whatsoever. And for those partially staffed, it’s unclear how many hours they are short.

“This once-annual snapshot is helpful but not nearly sufficient to measure the scale of the problem,” Phillips said.

While he applauded efforts to increase wages, and the governor’s allocation in 2022 of $120 million in recruitment and retention bonuses for home care workers, Phillips said the state has not gone far enough. He is working on a report that will look into the question of what range of wages could sufficiently draw new people into these careers.

He added that the caregiver shortages impact not only those who need the services but also their family members — like A.M.K. — who are left to pick up the slack.

“Care work should be thought of as infrastructure to allow other people to participate in the economy,” he said. “It’s really the backbone. If you don’t have access to the care a loved one needs, you can’t stay in your career.”

A.M.K. said the system has made it “next to impossible” for family caregivers because they aren’t paid like a full-time job with benefits. She has cared for her mom around-the-clock for more than 1,000 days, she said, but hasn’t made nearly what she would in another full-time career. 

To incentivize a system where older Mainers can stay at home longer, A.M.K. argues that family caregivers should be paid directly as state employees, eliminating the costs of assessments, case managers and staffing agencies. 

“People think long-term care is just if you’re an institution,” A.M.K. said. “They separate it: ‘An institution is eligible for this kind of money because they’re an institution, but if you are going to care for a loved one, oh well; we will give you a couple bucks an hour.’ ”

Hammes, the DHHS spokesperson, said the department is also starting a process to implement reimbursement for home health aide services provided by qualified parents to minor children. A state plan amendment will be submitted next month and there will be opportunities for interested parties to inform future rulemaking, she said. 

Maurer said she’s worried attention to the problem is starting to wane. She was disappointed to see a workforce bill fail during the recent legislative session. The measure would have created tuition reimbursement for a direct care worker providing in-home or community support services and could be transferred to family members, which she said would make the jobs more attractive.

Sawyer-Manter echoed her sentiment, saying she hopes there isn’t fatigue around workforce initiatives.

“There are lots of things we could certainly invest in but this is one that isn’t going to go away,” she said. “We need to take care of our older people and people with disabilities. It’s a Maine value that we take care of our people.”

As Mainers prepare to head to the polls, The Maine Monitor sat down with Secretary of State Shenna Bellows on Friday for a conversation about Maine’s electoral process and the work her office does to ensure that votes are counted accurately and information is stored securely. 

Monitor editor Kate Cough and Bellows discussed Maine’s new online voter registration system, threats to elections workers, the process for verifying signatures, the National Popular Vote Interstate Compact and more. You can watch the full conversation here: 

The state primary is on June 11, and absentee voting is already underway. 

Maine is now a semi-open primary state, which means voters who are not enrolled in a particular party can vote in the primary of their choice.

Voters who are enrolled in a party may only vote in that party’s primary. The deadline to withdraw or change party enrollment for the June primary is May 24. 

There is no in-person cut off for registering to vote — you can do so at your poll site on June 11 if needed. 

Needle disposal boxes. Handheld spectrometers. Prevention programs for middle and high schoolers. Behavioral health workers. A 58-bed recovery center.

These are some of the ways that Maine counties, cities and towns have allocated the $8 million in opioid settlement funds distributed to them over the past two years.

The money is coming from settlements that capped years of litigation against prescription drug manufacturers, distributors and retailers accused of fueling the opioid epidemic that has claimed the lives of thousands of Mainers over nearly three decades.

Maine expects to receive about $230 million across 18 years from settlements with household names such as CVS Pharmacy and Walmart, and some of the biggest pharmaceutical companies in the country, like McKesson Corporation, Mallinckrodt, Allergan and more.

Nearly every medicine cabinet across the country likely has a drug made, distributed or sold by one of the settling companies.

A memorandum of understanding between the state, and the counties and municipalities that were part of a massive multidistrict litigation case against Purdue Pharma, divides Maine’s portion of the more than $50 billion being doled out nationally, into three shares: Twenty percent to a state fund overseen by the attorney general’s office; 50 percent to a recovery fund, overseen by the Maine Recovery Council; and 30 percent to a subdivision fund paid out directly to 39 counties, cities and towns.

There is little oversight for how localities — which were party to the Purdue litigation or have a population of at least 10,000 — spend their cut of the money, which will amount to more than $66 million by 2038.

They are supposed to adhere to a list of allowable uses, but neither the memorandum nor settlement agreements require the subdivisions to report expenditures to the public or state.

Without disclosure requirements, Mainers have little way of knowing how their local governments are making spending decisions.

In an attempt to shed light on their choices, The Maine Monitor reached out to officials from each subdivision with a detailed list of questions — ultimately hearing back from everyone but Brunswick, Waterville, and Somerset and Washington counties.

Officials from the 35 counties, cities and towns that responded to The Monitor’s survey described putting the funds toward a wide variety of initiatives, some focused on prevention and awareness, others on treatment and recovery.

One theme was particularly prominent: A third of the subdivisions reported spending money on law enforcement and jail programs, including medication-assisted treatment (MAT) for substance use disorder in jails, a priority for advocates. But it also includes hiring behavioral health specialists that work with police, and purchasing handheld drug-checking devices.

Decisions to fund police programs and services technically comply with the MOU, but are at odds with how most advocates say the money should be spent.

A nationwide coalition of more than 130 public health groups, legal aid organizations and providers last year issued a list of priorities for the settlement money.

The coalition, which included Maine Access Points, Maine People’s Alliance and the Maine Recovery Advocacy Project, warned against spending on “law enforcement personnel, overtime or equipment.”

Instead the group recommended spending to expand access to medication-assisted treatment, increase housing access and support community-based organizations doing on-the-ground work.

Drug-checking devices

Saco and Falmouth purchased handheld drug-checking devices for their police departments. Saco bought the TacticID-N Plus and Falmouth got the TruNarc. These instruments, called Raman spectrometers, cost around $25,000 apiece. Saco and Falmouth each used nearly $20,000 of their opioid settlement money to help pay for them.

Experts have questioned the accuracy of the tools.

“Those handheld devices are worse than bad, they are plain dangerous,” Dr. Nabarun Dasgupta, a senior scientist researching street drugs at the University of North Carolina’s school of public health, told The Monitor.

Dasgupta called the TacticID-N Plus and TruNarc devices “garbage.”

They use a technology called Raman spectroscopy — which uses light beams to identify molecular structures — to determine which drugs are present in a sample. Dasgupta said the process works “fine” when dealing with one or two substances.

“But when you get into mixtures of substances, which most street drugs are, they’re not effective, they miss substances and they can give false positives,” he said. “They’re not scientific tools. They’re legal tools for cops to be able to arrest people.”

Saco Police chief Jack Clements and Falmouth Police deputy chief Jeff Pardue told The Monitor their departments purchased the devices because they allow officers to test a substance without taking it out of its container, which is helpful for “officer and victim safety.”

They can quickly and accurately identify substances in an overdose situation; and their results can be used in criminal proceedings.

Both named concerns about officers’ safety as a major consideration. If a drug such as fentanyl becomes airborne or gets on an officer’s skin, it can “overcome” the officer, Clements said.

In 2017, the U.S. Drug Enforcement Administration released a warning about fentanyl exposure. “Any fentanyl exposure can kill innocent law enforcement, first responders and the public,” said Rod Rosenstein, the deputy attorney general at the time.

But such “exposure overdoses” have been debunked by clinicians and medical toxicologists.

“This has never happened,” Dr. Ryan Marino, a toxicologist and emergency medicine physician who researches addiction at Case Western Reserve University in Ohio, told NPR last year. “There has never been an overdose through skin contact or accidentally inhaling fentanyl.”

The police officials also said it helps their departments’ community resource liaisons direct people toward appropriate treatment options, though they said that largely happens through the court system.

Dasgupta, who is also the co-founder of Remedy Alliance For The People — a nonprofit that supplies low-cost naloxone to harm reduction programs — said having real-time information on drugs can be helpful, especially for medical providers establishing a treatment plan, but he doesn’t think the Raman spectrometers are appropriate for collecting data.

There are more accurate options available that are already being used in Maine: Project DHARMA, a federally funded harm reduction program, has deployed portable Fourier transform infrared (FTIR) spectrometers with organizations statewide to learn more about what’s in the drug supply.

These machines, called the Nicolet Summit PRO, are made by Thermo Fisher, which also makes the TruNarc. Maine Access Points has two machines, and commonspace in Portland and Church of Safe Injection in Lewiston each have one.

At about $20,000 per machine, they are cheaper and more accurate than TruNarc and TacticID-N Plus, advocates say.

“If you’re opting for (the TruNarc or TacticID-N Plus), that tells me that you are using that during traffic stops, you’re using that during raids,” said MAP’s operating director, Whitney Parrish Perry. “And that does not feel like the spirit of the funds to me.”

Police programs

A number of subdivisions use their money to fund behavioral health liaison positions within police departments. Brunswick, Falmouth, Gorham, South Portland, York and Sagadahoc County have spent or allocated nearly $370,000 combined to fund positions. 

The town of York, for instance, allocated more than $92,000 for a contract with York County Community Action Corporation for two community health workers and one caseworker who will “help address challenges with opioids in the community,” said human resources director Kathryn Lagasse.

In a preliminary budget, Gorham town manager Ephrem Paraschak proposed creating a community liaison position within the police department that will be “100 percent funded through opioid settlement funding that is available for the next 10 years.” He requested $77,085 for fiscal year 2024-25.

South Portland spent nearly $62,000 to hire an additional behavioral health liaison for its police department, finance director Ellen Sanborn said, and allocated $106,500 to continue funding the position into the next fiscal year.

Sanford city manager Steve Buck told The Monitor that the city’s plan to use the money to “offset the cost of the police department’s mental health unit” hasn’t changed since last year. Buck’s preliminary budget proposed using $123,300 of the funds toward the mental health unit. The city spent $114,450 in fiscal year 2023-24.

Lewiston, meanwhile, spent $37,000 on a new vehicle for a ridealong program that pairs a mental health counselor with Lewiston and Auburn public safety officers.

Treatment in jails

Administrators from several counties said they expect to spend most of their funds on prevention and treatment programs in jails. 

Androscoggin County, for example, has spent or allocated more than $346,000 on “mandated substance use disorder programs in jail,” deputy county administrator Clarice Proctor said.

Piscataquis County, meanwhile, has put nearly $43,000 toward hiring a medical technician to administer medications that treat substance use disorder, pay for the prescriptions and provide counseling for jail residents, according to county manager Michael L. Williams.

Penobscot County administrator Scott A. Adkins said officials have spent $26,000 on prevention services at the county jail, and allocated another $1.05 million for these programs, but did not provide detail on what the services entail.

Programs at the jail are “currently the only projected use of funds,” he said.

Hancock County contracted Aroostook Mental Health Services to provide services at the county jail for 12 months at a total cost of $36,000, according to administrator Michael Crooker.

Kennebec County is spending its share on medication-assisted treatment at the county jail, which administrator Scott Ferguson called a “$1 million unfunded mandate passed in the legislature.”

Gov. Janet Mills signed an executive order in 2019 that directed the Department of Corrections to develop a pilot program to provide medication-assisted treatment to inmates and to “encourage every county jail to have MAT services available for incarcerated Mainers suffering from substance use disorder, and help individuals receive similar services after their release.”

A month later, a federal judge ruled that the Aroostook County Jail had to provide MAT to a Madawaska woman, which was upheld on appeal.

In 2022, Mills signed a bill that required county jails to provide medication for substance use treatment and established a County Jail Operations Fund to help pay for it. The governor’s supplemental budget for 2024-25 includes $4 million for MAT services.

Needle disposal

Bangor will spend an estimated $30,000 per year on a syringe litter pickup service, city manager Debbie Laurie said. This decision was made as the city opposed attempts by a new state-certified syringe service program, Needlepoint Sanctuary, to operate in parts of town.

Of the more than $286,000 Lewiston has distributed or allocated, the city spent just under $2,000 to replace needle disposal boxes. 

Recovery centers and housing assistance

York County commissioners approved spending all of their settlement funds — $4.6 million — to build a 58-bed regional recovery center in Alfred.

Penobscot County distributed $14,500 to Breaking the Cycle, a recovery home for women in Millinocket, for “capital improvement to their facility,” the county administrator said.

Westbrook has spent nearly $64,000 on in- and outpatient treatment, recovery housing, medical services, food insecurity and prevention costs, police captain Steven Goldberg said.

Lewiston has allocated $11,600 to A Hand Up Recovery & Re-Entry Housing, an organization working to provide housing for people transitioning out of the prison system. 

Cumberland County used $21,230 last spring to fill in a funding gap for Pathways of HOPE, formerly Operation HOPE, between state Department of Safety grant periods.

The project, formerly run by Scarborough Police and now a partnership between the Cumberland County public health department and the Portland Recovery Community Center, works to support people at high risk of overdose and criminal justice involvement by helping them find treatment and housing, according to the county’s public health director, Liz Blackwell-Moore.

Scarborough has put some of its funds toward short-term housing for individuals affected by substance use disorder while they work with a police department social worker to connect to longer-term services, Scarborough Police social services navigator Lauren Dembski-Martin said.

Community support 

Lewiston has allocated $27,400 to nonprofit An Angel’s Wing to establish a community support and receiving center; $23,000 to Recovery Connections of Maine for recovery coaching in St. Mary’s Medical Center’s detoxification unit; $18,000 to Sweetser for training to increase effective treatment options for youth and their families, and $166,400 to Tri-County Mental Health Services to contract counselors for Project Support You. Portland-based Spurwink acquired TCMHS this year.

Franklin County commissioners awarded $10,000 to Kennebec Behavioral Health, which plans to use the money for recovery coaches and gas cards, and $10,000 to Western Maine Community Action for staffing at its recovery center, county administrator Amy Bernard said.

Cumberland County has allocated $80,000 for one to two treatment programs solicited through a request for proposals that closed last month.

Research and awareness 

Cumberland County spent $4,790 to host a day-and-a-half “sequential intercept mapping” workshop in March.

Blackwell-Moore said 75 people working in behavioral health and criminal justice systems in Cumberland County “developed a comprehensive community-wide strategic plan for addressing substance use, particularly among adults involved in the criminal legal system.”

The county was one of the 11 nationwide selected to host a workshop, which was facilitated by the federal Substance Abuse and Mental Health Services Administration.

The county is also spending about $90,000 combined this fiscal year and next to partially fund a behavioral public health manager within the public health department to build relationships with, and assess efforts and opportunities for “enhancing coordination among programs and agencies that serve people who use drugs,” Blackwell-Moore said.

Lewiston put $1,000 toward its annual Rally for Recovery, while Waldo County gave $2,000 to Belfast Creative Coalition for an awareness campaign.

Prevention initiatives

Windham has spent $9,000 on substance use prevention programming at its middle and high schools, according to the town manager’s executive assistant, Tammy Hodgman.

Cumberland County has allocated but not yet disbursed $40,000 for a “preventative intervention program for families, youth and adolescents at risk for opioid use disorder, and any co-occurring substance use disorder/mental health conditions,” according to Blackwell-Moore.

The county plans to apply for federal, state and philanthropic grants to pay for the bulk of the program and use the opioid settlement money as a complement.

The story How are Maine counties and municipalities spending their opioid settlement funds? appeared first on The Maine Monitor.

Sherri Parker, assistant director of nursing at Caribou Rehab and Nursing, recalled a woman who came to her facility and was so sedated by the prescribed antipsychotic medication she had been taking at home that they couldn’t keep her awake for therapy because “she’d fall asleep in front of you.”

Parker, who handles gradual dose reductions at the nursing home, said she worked with a doctor to wean the woman off the medication. By the time the resident transferred back home two months later, “she was a completely different woman,” Parker said — able to eat on her own and be home alone while her husband went to work.

“I’ve seen a stopped antipsychotic medication on many people and sometimes I’m like, ‘Wow, they’ve actually done really well.’ That just goes to show me that it really wasn’t necessary to keep them on that,” Parker said.

But in recent years, she has seen an increase in these medications. At the end of last year, while reading referrals from the hospital for new residents, Parker said nearly every one had a prescription for an antipsychotic medication. She said it’s likely they were prescribed the medication while living at home or when they went to the hospital before ending up at her nursing home.

Statewide data shows the percentage of Maine nursing home residents receiving antipsychotic medication is increasing.

While the rate for short-stay residents, like the one Parker recalled, is relatively low, Maine’s rate for long-stay residents is higher than the national average. Short-stay residents are in a nursing home for less than 100 days, often recovering from surgery or being discharged from a hospital, according to the U.S. Centers for Medicare and Medicaid Services.

In the years after federal regulators cracked down on rates of antipsychotic medication given to long-stay nursing home residents, Maine became a success story, dramatically reducing its rate between 2011 and 2017 from 27 to 17 percent.

But since then, Maine’s rate has crept back to 20 percent, higher than the national average of 14.7 percent and the sixth-highest across all states, according to the U.S. Centers for Medicare and Medicaid Services. Among all American adults, the rate of antipsychotics was less than 2 percent. 

Antipsychotics are a type of medication, including Risperdal and Seroquel, designed to manage psychosis and delusions. They’re often given to patients with a diagnosis of schizophrenia or bipolar disorder. The side effects can be severe, including tremors, heart and circulatory problems, high cholesterol and sedation. They can be particularly problematic for older adults, even potentially shortening the lives of nursing home residents by increasing the risk of drowsiness, confusion and falling, said several experts.

CMS data on nursing home rates of antipsychotics exclude people diagnosed with schizophrenia, Tourrette’s Syndrome and Huntington’s Disease.

“Antipsychotic medications are especially dangerous among the nursing home population because of their potentially devastating side effects, including death, and the use of antipsychotic medications among nursing home residents is an indicator of nursing home quality,” a CMS spokesperson told The Maine Monitor.

Treating an episode, not a behavior

Dr. Susan Wehry, associate clinical professor at the University of New England in Biddeford and a board-certified geriatric psychiatrist, said there are times when antipsychotic medications are necessary to prevent a resident from harming themselves or others, but those occasions are rare.

“I understand an acute need for using a chemical restraint, but call it what it is: This is not treating a behavior; this is treating an episode of agitation that you can’t figure out how to address another way,” Wehry said. “You’re basically sedating the person.”

Wehry said what is often depicted as challenging behaviors from residents with dementia is actually the resident trying to communicate an unmet need. They may not have the language to say what they want, so rather than sedating the resident, it’s important to find out the cause of their frustration, she said.

Parker, with Caribou Rehab and Nursing, said she’s seen residents come off these medications and become more alert, social and talkative. And sometimes there’s no change in behavior, which she said begs the question why the resident needed to be on the medication in the first place.

As of this month, roughly 19 percent of Caribou Rehab and Nursing residents were on antipsychotics, slightly below the statewide average. Parker recalled when their rates were 5 percent and how proud she was, but said the numbers can fluctuate as admissions come in with pre-existing prescriptions.

“I tried really hard with my antipsychotic numbers to be down, and then just slowly they crept up again as we took admissions,” Parker said. “I would love to see my numbers come down and I know those are some things we have to work on.”

Multiple experts and advocates point to a number of explanations for Maine’s rising statewide average, such as staffing shortages and reliance on temporary agency staffing, diminished attention to the problem, MaineCare underfunding for nursing homes, and the all-consuming nature of the COVID-19 pandemic, which demanded more attention on infection control.

Staff who are overwhelmed with duties or haven’t had time to build relationships with residents may turn to medication rather than spending time on de-escalation techniques when residents have challenging behaviors.

“It’s a disappointment to see the rates have increased because I know we can do better,” said Brenda Gallant, Maine’s long-term care ombudsman who advocates for nursing home residents and their families.

Gallant was part of the coalition in 2012 that led the effort to reduce Maine’s rates of antipsychotics, with Wehry and numerous other advocates, providers and organizations.

Multiple people involved in that effort said the success was due to the commitment of a broad coalition that involved statewide trainings, workshops, mentoring programs, grants for innovative programs like Music and Memory, and resources such as a handbook for providers.

The guidance urged providers to take a holistic approach to treating dementia patients, which included education for family members on the risks associated with the medication, staff training programs that identify specific areas of competency and a collaborative transition process with hospitals.

“Initially, we were leaders,” Gallant said, adding that at one point Maine was ranked the seventh-most improved state in 2016, according to federal data cited at the time by the Maine Partnership to Improve Dementia Care in Nursing Homes.

Nationally, the rates during that time decreased from about 24 percent in 2011 to 14.3 percent in 2019, while Maine’s crept back up. But this data also can lag slightly: the collection period for the current data on this quality measure was Oct. 1, 2022 to Sept. 20, 2023.

“The tip of the iceberg”

In recent years, some experts have become concerned about an overreliance on medication for older adults, including Dr. Jabbar Fazeli, who has served as medical director for multiple nursing homes and assisted living facilities in Maine. He said antipsychotics could be the “tip of the iceberg,” and that facilities also use mood stabilizers and sleeping pills as a way to sedate residents.

Fazeli served as co-chair of the Maine Partnership to Improve Dementia Care in Nursing Homes and has been outspoken about reducing overreliance on medication for older adults. Before the federal government decided to focus on the issue, it was difficult to push back against a “pervasive” culture of using antipsychotic medications, Fazeli said.

Durgin Pines in Kittery, where Fazeli served as medical director for more than a decade until last month, maintained a rate of antipsychotic medication that was always below 5 percent, he said. Currently the facility has a rate of 4.2 percent, according to the Centers for Medicare & Medicaid Services. Fazeli said the success was dependent on a joint effort with the director of nursing, assistant director of nursing and the administrator to try all other options before resorting to an antipsychotic medication.

In recent years, lawmakers and the federal government have also become concerned about nursing homes “erroneously” claiming residents had schizophrenia as a way to “mask the facilities’ true rate of antipsychotic medication use,” the agency said in a release last year. CMS conducted onsite surveys to look at schizophrenia diagnoses and conducted audits of how nursing homes coded these residents.

An oversight organization said this does not appear to be a problem in Maine. The nonprofit that provides quality improvement organization services in New England, Healthcentric Advisors, said it has “thoroughly analyzed” Maine data and determined the state is not seeing an increase in schizophrenia diagnoses.

Fazeli added that in his 26 years in geriatric care, Maine is better than most other states, including those he worked in like Missouri, Massachusetts, Connecticut and New Hampshire.

But after a lot of initial energy in Maine, attention on the issue slowed, especially during the pandemic, Gallant said.

Many said the pandemic was all-consuming for nursing home providers, making it difficult to keep the focus on reducing antipsychotics while keeping up with evolving regulations and caring for residents who were forced to be quarantined.

Wehry, the geriatric psychiatrist, said it was understandable for rates to climb back up in the first months of the pandemic, but “that’s no longer an adequate excuse.” She said a lot of nursing homes reverted back to institution-centric care that forces residents to conform to their environment rather than create an environment that works for them.

“I think it’s broader than just the individual person who’s getting the antipsychotic. I think the culture change, which people worked so hard to introduce, also backslid in the pandemic,” Wehry said.

Ruta Kadonoff, who worked for the national nursing home industry group during the 2012 effort to reduce antipsychotic medication, and traveled across the country providing education on the issue, said Maine’s biggest challenge is workforce shortage.

Staff need adequate training on how to “get inside the world of a person with dementia,” time to work with a resident who is upset or struggling to communicate a need, and support to provide person-centered care that allows them to build relationships with residents. None of that is possible in a facility that is understaffed, has high turnover or relies on temporary agency staffing.

“Until we address that, I don’t think it’s realistic to think we’re going to address other quality issues,” Kadonoff said. “It’s a bandaid to try to address other things without dealing with the underlying fact that we just don’t have the people to provide this care and to do it well.”

Healthcentric Advisors, the quality improvement organization, said it has been meeting with the long-term care ombudsman and the Maine Health Care Association, which represents the state’s nursing homes, about refocusing attention on this issue. They plan to update and reintroduce training modules that condense the most useful tools and resources, which will be rolled out in late fall.

The Maine Department of Health and Human Services said it has identified the increasing use of antipsychotics in nursing facilities and encouraged the stakeholder group to reconvene along with nursing facilities administrators and medical directors. In January, DHHS published a stakeholder group report, Improving Quality in Maine’s Nursing and Residential Care Facilities, and noted that “this metric is likely to be among those tied to reimbursement as part of nursing home payment reform,” spokesperson Lindsay Hammes said.

Gallant, the ombudsman, said it’s important to return attention to this problem “if we want to make progress and get back to the place that we had initially in terms of really being leaders. I think that should always be our goal: to do the very best that we can for residents in our nursing homes.”

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The state will establish two new public defender offices covering Aroostook, Piscataquis and Penobscot counties, and change the name of the Maine Commission on Indigent Legal Services to the Maine Commission on Public Defense Services. 

Gov. Janet Mills signed the emergency bill, L.D. 653, into law Thursday after it passed unanimously in both houses. The legislation creates positions for 10 new public defenders and 12 other staff members, bringing the total number of public defenders in Maine to 25. 

“This legislation creates new public defender positions across communities in rural Maine and advances my commitment to improving the delivery of legal services to low-income people to ensure their constitutional right to counsel,” Mills said in a statement. 

The state’s first public defender office opened in Augusta late last year; it covers Kennebec County and will expand to include Somerset County when staffing levels increase. It followed the establishment of a Rural Defender Unit that has five trial attorneys who travel around the state.

The commission hopes to open four more offices in the next two years. One would cover Hancock and Washington counties; one covering Androscoggin, Franklin and Oxford counties; one covering Sagadahoc, Lincoln, Knox and Waldo counties; and one covering Cumberland and York counties. 

The public defender offices have been designed to handle about 30 percent of adult criminal cases in a given region, employing somewhere between three and eight attorneys with support staff. Their work will be supplemented by private lawyers in a hybrid system. 

Until recently, Maine was the only state with no public defenders, instead appointing private lawyers overseen by the Maine Commission on Indigent Legal Services to represent poor defendants. 

A nine-month investigation by The Maine Monitor and ProPublica published in October 2020 found that the commission repeatedly hired attorneys with criminal backgrounds, including a registered sex offender who was convicted of possessing child pornography, and a lawyer who exposed himself to a client.

The investigation found that the commission did not have enough money or staff to supervise these lawyers, many of whom had been disciplined for professional misconduct.

The ACLU of Maine sued the state in 2022 on behalf of poor defendants, claiming that the commission was failing to provide them with adequate counsel and thus violating their constitutional rights. 

The case is ongoing, and two attempts by the parties to resolve the matter have been dismissed by a judge. Last month, Superior Court Justice Michaela Murphy rejected the second proposed settlement agreement, saying it failed to address the constitutional crisis of individuals going without legal representation. 

Maine is facing a critical shortage of defense lawyers who will accept new indigent cases, and there are hundreds of people awaiting court-appointed counsel across the state, many of whom are in jail. 

“Standards and accountability mean very little when very few attorneys, or no attorneys at all, have been made available by (the commission) for judges and justices to appoint,” Murphy said when she denied the settlement.

She scheduled a trial to begin in late June.

In a State of the Judiciary address to lawmakers last month, Maine Supreme Judicial Court Chief Justice Valerie Stanfill said the courts have made progress in shrinking the pandemic-induced backlog of cases, but not enough, pointing to the lack of available lawyers on the commission’s roster. 

“We have people sitting in jail every day — frequently a dozen or more in Aroostook County alone — without an attorney because there is no one to take their cases,” she said. “I hope that adding some public defenders will help, but it will be a while before we really see results. And in the meantime, I fear the system will indeed collapse.”

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