As birthing units continue to close, potential solutions emerge
Editor’s Note: This story is the third in a series exploring maternity care in Maine.
In the United States and across the world, birth rates are falling.
Fertility rates in the United States reached a historic low in 2023, and have dropped more than twenty percent in the past three decades, to 1.6 births per woman of reproductive age. In Maine, where fertility rates have long been lower than the national average, that figure was 1.47 births per woman in 2022.
The reasons are complex, driven in part by dramatic reductions in teen pregnancies and fewer unplanned pregnancies. But the change — coupled with a nationwide shortage of physicians, low reimbursement rates for care and people entering pregnancy with more complex medical needs — is the primary force behind a cascade of birthing unit closures in Maine and across the nation.
Fewer babies being born means it is difficult for providers to maintain their skills and harder to sustain services financially; once a unit closes, it becomes more difficult to attract young families to an area, pushing fertility rates into a downward spiral.
As birthing units shutter and some rural hospitals close their doors entirely, providers around the state are looking to make it easier to train physicians in rural areas, cross-train staff who are already in rural hospitals in obstetrics and make better use of highly-trained nursing staff and other providers to lessen the burden on physicians and prop up the birthing units that remain.
The state already has a range of services in place designed to support families, including services for parents struggling with substance use disorder, telehealth programs for patients to access mental health care and remote blood pressure monitoring, which allows patients in rural areas to avoid frequent office visits.
“The state is taking this seriously,” Anne Marie van Hengel, a retired obstetrician from Portland, told The Maine Monitor in early March. “No one is looking at this and saying, ‘oh, no big deal.’ These birthing unit closures, they are really an issue.”
Leveraging existing providers
One of the most approachable solutions to the rural health care crisis, said several experts, and one that can be implemented immediately, is making better use of providers who are already part of the community.
That’s what hospital administrators did in Washington County. Two years ago, faced with a nearly $1.5 million gap between projected costs and nursing staffing charges, a declining number of births and the very real prospect of closing the sole remaining maternity unit in the county, hospital administrators at Down East Community Hospital in Machias decided to cross-train nurses from the medical/surgical department in obstetrics.
Med/surg nurses were trained in resuscitating newborns. Staffing shifted slightly to have just a single dedicated obstetric nurse on shift rather than two, allowing the hospital to reduce its reliance on costly traveling providers. A labor-trained medical-surgical nurse fills in the staffing gaps, and a multi-disciplinary team, including emergency department staff, anesthesiologists, a pediatrician, a nursing supervisor and a respiratory therapist, are on call.
The transition was not seamless. Some nurses, uncomfortable working with highly specialized obstetrics cases, reportedly left the hospital, according to nursing union representative Roberta Alley, who told The Monitor last year that the decision to cross-train nurses was “highly unusual.”
In an email this February, DECH spokesperson Julie Hixon said the flex arrangement was still in place and “has helped considerably with closing the gap. Even though our births were down in 2023, we feel good about the future of our OB program because we believe our flex approach will only improve over time.”
Surgeons trained to perform C-sections can also provide care in places where a dedicated obstetrician is not available.
That was once the case at Mount Desert Island Hospital in Bar Harbor, where Linda Robinson, a certified nurse midwife, worked for decades.
“Midwives used to provide all of these services. It was never an issue,” said Robinson, who recently taught a class on the history of midwifery in the U.S. at the College of the Atlantic. “The one thing [hospitals] absolutely need an OB/GYN for is a C-section, which can be done by a general surgeon.”
With low birth rates making it financially unsustainable to retain obstetricians in certain areas and challenging to keep them trained, Robinson advocates for hospitals training surgeons to perform complex births while nurse-midwives assist or, in some cases, take the lead during deliveries.
“There’s a younger generation of doctors coming forward [and] many of them have been trained by midwives, so they appreciate our skill,” said Robinson.
Allowing specially-trained nurses to take first call, bringing in a physician only if a case becomes complex or requires a C-section, can also help alleviate the burden of being constantly on call, said several providers. Sharing personnel across hospitals within a system can also reduce the strain.
Cross-training family medicine physicians, who outnumber obstetricians more than ten to one, has also been proposed as a way to boost obstetric care in Maine.
According to a 2024 paper published by the Maine Rural Graduate Medical Education Collaborative, Maine graduates about four obstetric residents annually, all out of Maine Medical Center in Portland. By contrast, the state graduates around 35 family medicine residents each year out of programs in Portland, Lewiston, Augusta and Bangor.
The authors suggested that Maine explore establishing a family medicine obstetrics fellowship to train family medicine physicians in obstetrics. Twenty-eight states offer such fellowships, including Massachusetts.
“In Maine, where Family Medicine physicians are more widespread through the State, it would be beneficial to cross-train rather than rely on recruitment,” the authors wrote.
Cross-training providers who are already part of the community is often much easier than hiring those who have few or no connections to a place.
“No question about it, recruitment is extremely challenging,” said Mike Towey, a speech pathologist who recently retired from Waldo Hospital. “It’s all about… developing a sense of community to attract and recruit people.”
Rural hospitals in Maine face significant challenges with recruitment due to scheduling, fluctuating patient numbers and internal hospital dynamics, according to a 2024 Roux Institute report.
But, according to the same report, rural hospitals in Maine see “high retention of employees from the community,” and solid partnerships and communications with other providers, such as EMTs, community midwives, and other types of community-based care and services.
“When they’re trying to recruit medical professionals for these rural areas, nobody wants to move there, nobody wants to put their kids in the schools, and they don’t make enough money,” said Robinson. “These people are already part of the community.”
Incorporating midwives, doulas, training EMS
Hospitals in Maine are also incorporating more nurse-midwives — registered nurses with a master’s degree in nurse-midwifery — into their practices.
Maine’s largest hospital systems, MaineHealth and Northern Light Health, offer midwifery services at several hospitals. Nurse-midwives are licensed to attend births in hospital settings as well as at birth centers and at home, although the vast majority practicing in Maine are affiliated with larger providers.
A nationwide blueprint published by the Biden Administration for addressing the maternal health crisis calls in part for expanding access to licensed midwives, doulas, and freestanding birth centers and encouraging insurance companies to improve reimbursement for and coverage of nurse-midwives and perinatal supports, such as doulas and nurse home visits.
Other countries rely far more heavily on midwives than the United States — in most countries, midwives far outnumber obstetricians. In some cases, research has suggested that midwifery-led care models provide care that is comparable or better than obstetrician-led care, according to the CommonWealth Fund.
“Outside the U.S., midwives are often considered the backbone of the reproductive health system,” wrote the authors.
But midwifery training in many of those countries is far more standardized than it is in the United States. It is also often far more integrated into the health care system, with greater coordination and support for midwifery-led care teams, said several midwives.
“Midwives are the answer to maternity care in America. But just putting that burden onto us without giving us the infrastructure to do it is not sustainable and does not actually create a better care structure,” said Ariel Bernstein, a certified professional midwife who recently graduated from Harvard with a master’s in public health.
According to the National Academy for State Health Policy, 18 states and Washington, D.C., reimburse non-nurse midwives (whose titles and certification vary) under Medicaid; nurse-midwives are covered under Medicaid in all jurisdictions. MaineCare, Maine’s version of Medicaid, covers nurse-midwives but does not reimburse for services by midwives without a nursing degree.
Hospital administrators and state officials interviewed by The Maine Monitor said they had no plans to incorporate independent midwives (those who are not trained as nurses but instead licensed as certified professional midwives) into their practices, in part for liability reasons.
Some in Maine are pushing for increased access to doulas, non-clinical providers who provide educational, physical and emotional support to families and people who are pregnant and postpartum. A bill sponsored by Sen. Denise Tepler (D-Dresden), would require MaineCare to cover doula services.
The bill, however, faces an uphill battle, as lawmakers in Augusta fight over a supplemental budget and a budget shortfall for MaineCare, the state’s insurance program for low-income residents. MaineCare covers roughly 37 percent of all births in Maine.
A recent grant awarded to the Maine Department of Health and Human Services, however, requires the state to cover doula services within the first three years, according to previous reporting by The Monitor.
A dozen states and Washington, D.C., have implemented Medicaid coverage for doula services, according to the National Health Law Program.
Rural emergency medical service providers are also increasing training for their staff, who are being called upon more frequently to handle out-of-hospital births and newborns.
“We’ve also seen a tremendous increase in the number of births that happen outside of the hospital, triple the numbers from prior to the COVID pandemic,” said Mark Minkler, program manager of EMS for Children, speaking to Maine Public in late February.
“If [a nearby hospital doesn’t] have the internal capacity to admit patients that are having complications, EMS is the workforce that moves those patients to other locations, and that can put a tremendous strain on both systems,” said Minkler, “and on the patients that have to be transported and their connection with their families and homes.”
Maine also has CradleME, a free program that began in 2017 in which public health nurses make home visits to anyone who is pregnant or postpartum, or anyone caring for an infant, to help with parenting, breastfeeding, nutrition and any other concerns.
Decades of research have shown that sending nurses into people’s homes is one of the most effective ways to reduce pregnancy complications, pre-term births, infant deaths, child abuse and injury, violent crimes and substance abuse.
“You do not have to have a problem,” said van Hengel, who likened the program to support offered in much of Europe, where “Someone comes by and says, ‘so, how’s it going? What’s up?’”
But CradleME has struggled for years to reach as many families as the state has hoped. Many patients and providers are unaware the program exists, or may offer information as families are leaving the hospital after giving birth, as parents are overwhelmed and exhausted.
The Monitor was unable to reach CradleME representatives before press time.
“For a lot of people, including myself as a provider, I did not really realize that that was something that was accessible for anyone,” said van Hengel. “The context really needs to be ingrained early, so that providers or women or families know about it ahead of time.”
Training future providers in rural areas
Residency programs, where physicians spend time training in various specialties after medical school, are mostly hosted in largely medical centers, where doctors-in-training have access to a host of specialist attending physicians and exposure to a variety of cases.
While that’s valuable, said Dr. Jane Carreiro, dean of the University of New England College of Osteopathic Medicine, Maine’s only medical school, it doesn’t reflect the environment that rural physicians end up practicing in, one with limited specialist access where complex cases will be transferred to larger facilities.
Starting a new residency program is nearly impossible for small hospitals, said Dr. Carreiro, because it requires not only funding but also access to highly specialized staff certified in a range of fields, including maternal-fetal medicine, urogynecology and reconstructive pelvic surgery, gynecologic oncology, and reproductive endocrinology and infertility.
Criteria for residency programs are set by the Accreditation Council for Graduate Medical Education, she said, “which is biased towards large academic medical centers.”
But most doctors in community hospitals won’t ever need or have access to that level of care once they’ve started their careers.
“It’s throwing the baby out with the bathwater,” said Dr. Carreiro of the requirements for starting new residency programs. “You want this high, high standard, but 90 percent of people don’t need that. And so you eliminate the opportunity for those 90 percent of people to have any care because you’ve created so many obstacles.”
MaineHealth currently operates the state’s only obstetrics residency program, at Maine Medical Center in Portland.
While establishing dedicated obstetric residency programs in small rural hospitals may be a significant lift, hospitals are working together to expose more doctors-in-training to rural obstetric medicine, in the hope that they’ll stay in the area after graduation.
The Maine Rural Graduate Medical Education Collaborative recently received a three-year, $667,330 federal grant aimed at developing obstetrics education programs focused on rural community needs.
The program has been in place for several years in a range of other specialty areas, allowing budding physicians to train at partner hospitals around the state, and offering housing stipends to eligible residents. Of the ten residents who graduated in 2024, six chose to practice in rural settings, two of them in Maine, according to a paper published earlier this year in the Journal of Maine Medical Center.
“It creates an opportunity for students in rural residency rotations to learn important skills to support pregnant patients and their families,” said Dr. Kalli Varaklis, designated institutional official at MaineHealth, in a statement in January announcing the collaboration.
Financial reforms
Experts The Monitor spoke to said one of the most impactful ways to support rural birthing hospitals would be for MaineCare to pay more for their services. Thirty-seven percent of all births in the state are covered by MaineCare, and Maine recently expanded postpartum coverage to 12 months after the end of pregnancy, which research has shown is the deadliest time for new mothers.
On average, private insurance reimburses providers in Maine $23,595 for a C-section and $14,630 for a vaginal delivery, according to research by the Health Care Cost Institute. MaineCare, however, reimburses providers just a fraction of the cost of providing care — $4,607 for a vaginal birth and $6,847 for a C-section.
Significant reimbursement reforms are unlikely in the current budgeting environment, however. The program is facing a $118 million budget shortfall; the state began temporarily holding payments to some participating providers on March 12.
Maine is examining the payment model for maternity services under MaineCare as part of a $17 million, ten-year grant announced earlier this year, said Dr. Amy Belisle, chief child health officer for the Maine Department of Health and Human Services. A plan for the grant calls for the state to implement a new “value-based” payment model by 2028.
Under that model, payments would be tied in part to the implementation of evidence-based best practices that address issues like mental health, hypertension and sepsis in pregnant people.
“How do we make sure that we’re getting good outcomes? So we’re not just paying for care, but we’re paying for quality care,” said Dr. Belisle.
The $17 million grant also has funding to support birthing units at risk of closing, said Dr. Belisle, although those funds do not kick in for several years. The first three years of the grant are focused on planning; the remainder are for implementation.
Whether the grant will survive the cuts being made by the Trump Administration is hard to tell.
“We’re actively monitoring what the situation is and if things change then we’ll think through that at that time,” said DHHS spokesperson Lindsay Hammes. “But given that there’s not been an indication that that funding is going to be frozen, the work continues.”
Farmers Still Owed Hundreds of Millions in REAP Payments After Federal Freeze
Kevin Leavitt was just days away from getting reimbursed by the U.S. government for $48,000 when the Trump administration signed an executive order freezing federal funding and stopping payments to farmers across the country.
Leavitt, who owns Farmer Kev’s Organic in West Gardiner, Maine, was authorized to receive money through the U.S. Department of Agriculture’s Rural Energy for America Program (REAP). The funding was approved to help with costs attached to a $140,000 project to generate efficient electricity on the small vegetable farm.
The project has been up and running since December, and Leavitt told the Daily Yonder he was on track to get his reimbursement at the end of January. The U.S. Department of Agriculture, or USDA, requires a 30-day waiting period between project completion and reimbursement to verify that the project has been completed, Leavitt said. Since the executive order was signed, he has not heard anything from the USDA about when he can expect to receive the payment.
“It’s getting to be over a month now, and every day that passes, we lose faith in the money coming through,” Leavitt said.
Leavitt is one of approximately 2,252 farmers waiting to be paid by the government for 2024 REAP awards. The amount owed totals $410 million, according to data compiled by Jeremy Fisher using information from USA spending, a government website that tracks federal dollars. Of that outstanding $410 million in REAP payments, just under $300 million is set to go to Republican-led Congressional districts, according to Fisher, who works as a senior strategy and technical advisor with the Sierra Club’s Environmental Law Program.
“This isn’t something that shakes out cleanly along blue or red lines,” Fisher said. “And, this is not large corporations who are making these decisions, these are individual farmers, small businesses that have to put their own money down on the table in order to be able to make this happen.”
If the REAP money Leavitt is expecting doesn’t come through, he will have to foot the bill for the entire project. He said that doing so could put his farm in a vulnerable position to continue operating.
On February 20th, Secretary of Agriculture Brooke Rollins announced that the USDA would release $20 million in contracts that had been paused due to a review of funding in the Inflation Reduction Act (IRA), the legislation Congress passed in 2022 that appropriated billions of dollars for clean energy projects across the country. That $20 million represents less than 1% of all USDA funding, according to the National Sustainable Agriculture Coalition.
REAP predates the IRA by several decades, though Congress added $1 billion in funding to the program when it passed the piece of legislation in 2022. The purpose of REAP, according to its landing page, is to guarantee loan financing and grant funding to agricultural producers and rural small businesses for energy efficiency improvements and renewable energy systems. Legally, farmers and small businesses are entitled to the money that has already been obligated to them by the USDA for REAP projects.
“These are programs that are meant to save people money, make their lives easier, provide stability and certainty,” Fisher said. “People are entitled to the money that Congress has allocated to this purpose, irrespective of what the administration thinks about any particular recipient.”
Funding from the USDA also supports smaller farms and younger farmers trying to get into the industry, like Leavitt, who is 33.
“To be able to start producing food and do something sustainable, you do need some assistance — farming is a very capital-intensive industry to get into,” Leavitt said.
REAP is just one program under the USDA’s Rural Development umbrella, which encompasses billions of dollars appropriated by Congress for federal spending for rural programs in the form of grants and low-interest loans.
Across the country, Fisher said grant and loan recipients are waiting to hear from the USDA on payments for projects approved under other programs, including the Empowering Rural America (New ERA) program.
As farms are preparing for spring planting, many farms are facing uncertainty on receiving reimbursements for USDA contracts. (Photo courtesy of Maine Organic Farmers and Gardeners Association)
Payments Across USDA Programs
Established by the Inflation Reduction Act in 2022, the New ERA program provides $9.7 billion in loan and grant financing for rural electric cooperatives to transition to clean, affordable, and reliable energy. It is the largest investment in rural electrification since President Franklin D. Roosevelt signed the Rural Electrification Act into law in 1936.
Before the USDA’s funds were frozen, approximately $9.4 billion had been obligated to rural electric cooperatives in 24 states. Overall, the Sierra Club estimates that about 40% of all rural electric cooperative customers in the U.S. are in line to receive funding through the New ERA program. Those dollars have yet to be released by the USDA.
Since the New ERA funds account for around 25% of the total cost of any given project, Fisher said the total investment for rural cooperatives to transition to more efficient and affordable energy is much higher.
“It’s spurring $35 billion, at least, worth of investments across these cooperatives, and in each of those circumstances, substantially reducing costs for customers,” Fisher said.
Beyond USDA programs supporting energy and electricity, the USDA has a host of other programs that go toward supporting farmers and others in rural communities across the country. Sarah Alexander, executive director of the Maine Organic Farmers and Gardeners Association (MOFGA), is seeing money frozen for those programs, too.
“The $20 million that was released is just a very small drop in the bucket compared to the national amount that those programs would normally be funding at this time of year,” Alexander told the Daily Yonder. Right now, many of the farmers who MOFGA supports, like Kevin Leavitt, are being told that their grants are under review in accordance with the statement made by Secretary Rollins on February 20.
Alexander said that cuts to the federal workforce, including in local USDA offices, are affecting access to information for farmers trying to track down answers to their funding questions.
“Some folks are calling the office and nobody’s answering. There’s nobody to pick up the phone, or the person that they were in contact with may no longer be there,” Alexander said.
In West Gardiner, Leavitt said that the federal funding he was expecting helps reduce the price of food, like the vegetables he grows. Without it, prices may go up in the coming season.
“If these payments don’t come through, that’s going to add a pretty significant burden to these farms, and it’s hard to see how that wouldn’t end up ultimately impacting consumers,” Alexander said.
Maine’s childhood vaccination rates have benefited from the elimination of nonmedical exemptions
Editor’s Note: The following story first appeared in The Maine Monitor’s free health care newsletter, Health Monitor, that is delivered to inboxes every other Thursday. Sign up for the free newsletter to stay informed of Maine health care news.
As the nomination of Robert F. Kennedy Jr. for health secretary heads to a final vote, and the national conversation around vaccines intensifies, it’s worth examining Maine’s childhood vaccination rates.
During the last school year, vaccination rates among kindergartners across Maine were around 97 percent for all four mandatory vaccines. The rates have increased steadily since 2019, when the state passed legislation ending nonmedical exemptions. But some public health advocates worry that vaccine hesitancy could increase under the Trump administration.
Under state law, all kindergarten students in a public or private elementary school must have the following vaccines: Diphtheria/Pertussis/Tetanus (DTaP), Poliomyelitis, Measles/Mumps/Rubella (MMR) and Varicella (VAR).
In 2019, Maine passed a law that eliminated religious and philosophical exemptions in response to dropping rates of vaccination among schoolchildren. At the time, Maine was one of only 17 states that allowed exemptions if a parent or guardian cited a personal reason, according to reporting from the Bangor Daily News.
Since then, annual vaccination data shows that exemption rates have dropped across the board for the four required vaccinations. The exemption rate for the polio vaccine dropped from 5 percent in 2019-20 to 0.6 percent last year.
Before the law went into effect, Maine had one of the highest opt-out rates in the country: it was 5.3 percent in 2017-18 when the national median was 2.2 percent. Last year, Maine’s opt-out rate was 1 percent compared to the national median of 3.7 percent.
A student who isn’t vaccinated can still be enrolled in school under certain conditions: a parent or guardian provides written assurance the student will be vaccinated within 90 days; a licensed physician, nurse practitioner or physician assistant provides a written statement noting that immunization may be medically inadvisable; or students have an individualized education program that began before September 2021 that included a philosophical or religious exemption.
Last year, 19 schools had kindergarten exemption rates above 5 percent (it’s worth noting that in some of these schools class sizes are quite small).
Ashwood Waldorf School, in Rockport, had the highest vaccine exemption rate for kindergartners last year at 33 percent – four out of 12 students.
Jeremy Clough, school director, said all four of the exemptions last year were temporary and at least two of the students are now caught up on their vaccines. These temporary medical exemptions often apply to new students who were previously homeschooled and are behind on their vaccinations.
Clough said most of the conversations he’s had with families about vaccines involve explaining the law.
“There’s really no pushback that the families can have because it’s like, ‘Here’s the law and … you either need to be caught up or you need to talk to your health care provider,’ ” he said.
He said it’s helpful that there’s no gray area in the law. “We’re not doctors,” he said. “I feel like we have no idea what is appropriate medically for anyone. What we know how to do is educate children. So yes, I think it is helpful to have something that’s very clear.”
Jay Corbin, teaching principal of Penobscot Community School, agreed that the law makes conversations more straightforward. He said there wasn’t much resistance from families when the nonmedical exemptions were eliminated and he doesn’t anticipate more pushback going forward.
Penobscot Community School had among the highest exemption rates last year at 14 percent, but that was due to one exemption out of seven kindergartners. Corbin said the school has historically had high vaccination rates.
The county with the highest exemption rate for kindergartners last year was Piscataquis County at 3.7 percent.
Sue Mackey Andrews, who was a national consultant to health and education departments for 25 years and now is active in public health efforts in Dover-Foxcroft that include childhood vaccine initiatives, said she was surprised the exemption rate wasn’t even higher in her county because Piscataquis has historically had low vaccination rates.
One factor Mackey Andrews pointed to is the lack of access to health care. The closest pediatrician may be in Bangor, which could make it hard to keep kids up-to-date with their vaccines. She said she has also seen the anti-vaccine movement grow in her area due to a “phenomenal” amount of misinformation and fears it could increase under the Trump administration.
In the years since the start of the COVID-19 pandemic, Mackey Andrews said there’s been a “dramatic increase” in homeschooled families in the region.
“I suspect that some of it, at least, is vaccine related,” she said.
Mackey Andrews said she would urge people who have concerns about vaccines to listen to their doctors and ask questions.
“That’s a lifelong, perhaps critical, decision that you’re making,” she said.
Concerns raised about Maine’s ‘crisis pregnancy centers’
Editor’s Note: The following story first appeared in The Maine Monitor’s free health care newsletter, Health Monitor, that is delivered to inboxes every other Thursday. Sign up for the free newsletter to stay informed of Maine health care news.
Maine has at least 11 so-called crisis pregnancy centers, facilities that offer prenatal services with the goal of deterring people from having abortions. These centers have come under scrutiny nationally for providing inaccurate information and have seen an uptick in funding since Roe v. Wade was overturned.
These anti-abortion centers are not regulated the same as health clinics. Many are not licensed or staffed by medical professionals but offer free services like pregnancy tests or ultrasounds. And because they are not medical facilities, these centers are not bound by HIPAA to protect patient confidentiality.
During a recent summit hosted by the Maine Public Health Association, abortion-rights activists warned public health leaders that these centers circulated misinformation about “abortion pill reversals” that aren’t supported by any studies.
Grandmothers For Reproductive Rights (GRR!), a Maine-based organization, added that because the centers are unregulated, they may provide testing for sexually transmitted diseases but are not required to report the results to the state Center for Disease Control and Prevention.
Maine is among a handful of states that has fewer of these facilities than abortion clinics, according to reporting from The Independent. In neighboring New Hampshire, for instance, there are more than 13 crisis pregnancy centers and only four clinics that offer abortions.
In 2022, the year Roe v. Wade was overturned, crisis pregnancy centers nationally pulled in about $1.4 billion in revenue — and at least $344 million of that was in government funding, according to reporting from the Guardian. At least 16 states have allocated more than $250 million from 2023 through 2025 for programs intended to dissuade people from abortions.
The Charlotte Lozier Institute, which advocates for these centers, reported that in 2022, the centers consulted with 974,965 new clients, distributed 703,835 free pregnancy tests and performed 546,683 free ultrasound tests.
“Now, in the wake of the reversal of the infamous Roe v. Wade, the demands upon centers are increasing daily. Many states are responding with new funds and new policies to support the centers’ work,” Chuck Donovan, then president of the institute, said in its 2024 annual report.
Three states — Michigan, Minnesota, and Pennsylvania — have stopped publicly funding these anti-abortion centers, according to Equity Forward, an abortion rights group.
Abortion access in Maine is less restrictive than in many other states. Abortion is banned at fetal viability, which is about 24 weeks of pregnancy, but a recent law allows doctors to perform abortions after the cutoff when deemed medically necessary.
Maine lawmakers passed a “shield law” protecting people who travel to Maine for abortion or gender affirming care from legal action taken from other states. It also protects the health professionals who provide the services.
Maine’s yellow flag law in three charts
Use of Maine’s yellow flag law has grown dramatically since the Lewiston mass shootings: law enforcement agencies completed more than 500 weapons restriction orders in the past 14 months, up from fewer than 100 in the three years prior to the tragedy.
Since August, when an amendment to the yellow flag law went into effect, officers have had the option to apply for a warrant when trying to bring people into protective custody, which is the first step for a weapons restriction order.
Sagadahoc County Sheriff Joel Merry told The Monitor in August that he thought it would be a “good and relevant tool.” Yet few agencies have used it so far.
The amendment, part of a larger bill to “strengthen public safety by improving Maine’s firearm laws and mental health system,” was a reaction to the October 2023 shootings. Maine’s yellow flag law has come under scrutiny since it was revealed that deputies from the Sagadahoc County Sheriff’s Office were aware of the shooter’s threats of violence and access to firearms, and had attempted welfare checks on him, but never pursued a weapons restriction order.
The deputies testified before an independent commission that they had no right to enter the home of an uncooperative Robert Card in order to bring him into protective custody, where he would have been evaluated by a mental health professional for his risk of harm to himself or others. If the evaluator agreed that Card posed a threat, the order would then go to a judge for final approval and Card’s weapons would have been confiscated. But that never happened.
The Maine Monitor found that law enforcement officers often lack direction for how to conduct welfare checks, and their training on mental health lags far behind the reality that cops are usually first to respond to a person in crisis.
Merry, the Sagadahoc County sheriff, said after the scrutiny his agency received post-Lewiston, he and his command-level staff discussed how they could use the yellow flag law more effectively and “take no chances” when threats are made.
Sagadahoc County deputies completed their first weapons restriction order on Nov. 8, 2023, exactly two weeks after the Lewiston shootings. The sheriff’s office has completed 23 more orders since then, the third-highest total in the state as of Jan. 6, 2025.
“If a person makes a threat that they’re going to do harm to themselves or do harm to another person, that’s probable cause to take that person into protective custody,” Merry told The Monitor this month. “I think we were aggressive in doing that.”
Most of his deputies have completed a week-long crisis intervention training course from NAMI Maine, considered the gold standard of mental health training for law enforcement. Some have also completed a training course focused on adolescents in crisis and others have taken a mental health first aid refresher course.
Mental health liaisons
Many law enforcement agencies are incorporating mental health liaisons — trained clinicians who can accompany officers on calls and help connect people to services — into their departments.
Sanford Police launched a new mental health unit around the same time that the yellow flag law went into effect, which helped officers develop a “really strong grasp” of the law, Sanford Police Deputy Chief Matt Gagné said.
“We were one of the few agencies in the beginning to really utilize (weapons restriction orders) more than most other agencies,” said Gagné, who was previously the major in charge of the mental health unit. “I attribute that to the fact that we had a dedicated unit that was leading the way.”
On the eve of the Lewiston shootings, Sanford Police had completed seven weapons restriction orders, the second-most behind State Police. As of this month, the department has completed 27 — again second to State Police.
The Sagadahoc County Sheriff’s Office shares a mental health liaison with all the police departments in the county, along with Brunswick Police. The liaison, who is on contract from the nonprofit mental health group Sweetser, started just days before the Lewiston shootings.
Merry said the liaison, Michael Maudlin, is “overworked” — a sign that the departments regularly use his services.
Sanford and Sagadahoc County officers have yet to obtain a warrant for protective custody. It hasn’t been necessary, Gagné and Merry said. While Gagné can’t say for sure that Sanford’s mental health first responder, Shannon Bentley, has helped officers avoid the need for a warrant, he said having a trained clinician available has been “incredibly beneficial.”
“She is a trained professional. That is her job,” he said. “Whereas police officers, we are well-trained in crisis intervention in the moment, and of course with criminal law and things like that. But we don’t have advanced degrees and master’s degrees in that field. So I think it’s greatly beneficial that our agency has somebody like that who can intervene.”
Key takeaways
The Monitor has been following the use of the yellow flag law since the Lewiston shootings by regularly requesting records from the attorney general’s office, which tracks completed orders. Here are some key takeaways:
As of Jan. 6, 2025, 95 law enforcement agencies from across the state have completed 628 weapons restriction orders since the law went into effect four-and-a-half years ago. The agencies hail from every county in the state, with the most orders in Cumberland and York counties and the fewest in Washington County.
Between July 1, 2020, when the yellow flag law went into effect, and Oct. 25, 2023, the day of the Lewiston shootings, agencies had completed just 80 orders — an average of two orders per month.
Since then, agencies have completed 548 orders, for an average of 38 orders per month. Forty-five percent of those — 247 orders — occurred on or after Aug. 9, 2024, when the protective custody warrant amendment went into effect. Thirteen agencies, including police from the University of Maine at Orono and the Maine Warden Service, filed their first order in the past five months.
Only five agencies — Bath and Cumberland police departments, and the sheriffs’ offices in Lincoln, Somerset and Waldo counties — have obtained a warrant to bring someone into protective custody, according to the data.
Men were the subject of the vast majority of orders, with men aged 25 to 54 constituting more than half of all orders. Officers cited a person’s attempts or thoughts of suicide in about three-quarters of all cases.
A year since the region saw disastrous flooding, western Maine officials say they’re better prepared
The arid conditions that choked Maine into a drought this fall stand in stark contrast to the blanket of precipitation that inundated the state a year ago.
When an atmospheric river threatened to bring a deluge of rain and snowmelt to Maine earlier this month, parched waterways helped shield valley towns from the flooding they saw last December.
It wasn’t just luck. Farmington town manager Erica LaCroix said the modest infrastructure projects and emergency response protocols that the town has completed in the flooding’s aftermath gave her confidence that her community was better prepared for a potential disaster.
Weak, undersized culverts have been expanded, and emergency resources have been moved out of flood zones. LaCroix and other inland Maine town officials have strengthened their communication protocols to share resources and streamline their emergency response plans.
Over the past twelve months, Farmington and other Franklin County towns have participated in a number of county-led disaster response exercises and have created contingency plans for various worst-case scenarios, all with the expectation that more severe floods are imminent.
“We all have an eye towards where we can partner with each other, try to mitigate the cost for our taxpayers and also have a better response,” LaCroix said. “We can all have our separate services, but a lot of times, because of geography, the closest response could be in another town.”
But after a year of ruminating on what went wrong in 2023 and recovering from the $20 million in estimated damages, some western Maine towns have reached the limit of what they can achieve on their own.
The state has doled out $60 million in storm recovery funds to businesses, working waterfronts and infrastructure projects — including $1.05 million to strengthen Norridgewock’s water main against flooding.
But federal disaster aid has been slow to trickle down and many towns lack the technical expertise required to bolster their infrastructure to the levels they’re striving for in the face of climate change.
Even larger towns like Farmington need help fronting costs and navigating federal permitting processes. A year later, LaCroix says the town still hasn’t seen a cent of the $482,875.13 promised by the Federal Emergency Management Agency for recovery costs, causing Farmington to carry a deficit until Maine forwards the funds to the town.
In smaller communities, limited town budgets could put those projects out of reach.
“Supporting that kind of additional cost on a major project is burdensome, particularly for town-meeting towns,” LaCroix said. “When you’re telling people you need to do a project that costs several million dollars, and you’re going to have to borrow a lot of it, it’s hard to get past town meetings.”
Pushing forward
The towns aren’t the only ones grappling with how to move forward. State agencies, too, have spent the year reflecting on last winter’s devastating flooding. In November, the state released a climate resilience playbook and a roster of state officials that can get Maine there — it’s just a matter of funding and execution.
Many of the recommendations outlined in the Infrastructure Rebuilding and Resilience Commission’s interim report address the barriers that Farmington and other towns have identified: the prohibitive cost of resilience projects, complex grant applications and highly technical permitting processes.
One robust section details how Maine can help communities prepare for disasters by pointing to examples from other states, and outlines the creation of a new state office focused on municipal planning.
Born out of a legislative mandate and recommendation from Gov. Janet Mills’ administration, the freshly minted Maine Office of Community Affairs intends to be a “one-stop shop” that can provide coordinated and technical assistance to towns and tribal communities throughout the state.
Though many of its 30 or so anticipated staff members come from reorganizing other state agencies, part of a $69 million federal grant will fund four new positions that will form the state’s Resiliency Office, according to Samantha Horn, director of the Office of Community Affairs.
That includes a resiliency coordinator who will be a direct tie between regional planning offices and state government, linking communities to the resources they need for their larger infrastructure projects.
In Farmington, that kind of assistance could help the town realize its dream of raising a low-lying commercial hub that was under six feet of water last year when the Sandy River spilled over its banks. Some businesses there took months to re-open, while one shuttered for good.
“That’s the only thing that will fully mitigate that area, is raising it,” LaCroix said. “If we could get some help at the state level to even help us through permitting, and maybe not financially help us, but give us some extra guidance, some training, then maybe some of this we can do with our own personnel in-house.”
The state commission’s interim report highlighted a program in Vermont that provides free technical assistance to qualified flood-impacted communities, a service similar to what Horn hopes her office can provide in the near future.
“I think what is needed at this point is some connective tissue so that communities have an easier time navigating resources,” Horn told The Maine Monitor. “That way they spend more time doing the projects and less time finding the grants and technical assistance they need.”
Norridgewock Town Manager Richard LaBelle is concerned that residents may have rebuilt in the same flood-vulnerable areas that could be knocked out again in the next storm. Photo by Garrick Hoffman.
In Norridgewock, town manager Richard LaBelle has seen his community largely recover since the Sandy and Kennebec Rivers wreaked havoc on buildings along their banks, but he’s concerned that residents may have rebuilt in the same flood-vulnerable areas that could be knocked out again in the next storm.
“Our local regulations don’t deal with that necessarily,” LaBelle said on the eve of this December’s projected storm. “I think folks are maybe operating under the misconception that that’s never going to happen again in our lifetime, and unfortunately, we’re looking at it 12 months later.”
LaBelle sees floodplain ordinances, which would prevent new development in the highest risk areas and reduce flood risk in floodplains, as the only way to guide future sustainable development. Horn said her office will be able to guide towns like Norridgewock through this process.
The state plan acknowledges that housing options in Maine are limited but is encouraging communities to pursue smart growth.
“The governor has just pushed so hard to make sure we’re making resources available to communities so that they can do preventative measures as well as recover,” Horn said. That way “when they build back, they build back in a way that’s going to last for a long time.”
Expecting the unexpected
As deputy director of Franklin County’s Emergency Management Agency, Sara Bickford concedes that it’s impossible for Franklin County to plan for every curveball thrown by unpredictable storms like last December’s, but that hasn’t stopped the county from trying.
This July, the county partnered with the National Weather Service to drill towns on how they’d respond to a tropical storm hitting Maine with high winds and extreme flooding — all during the week of the Farmington Fair. When participants thought they had a situation under control, organizers would throw a wrench into their plans and keep them on their toes.
“We had really really good participation, without that our efforts aren’t as valuable,” Bickford said. “There’s something to be said for all of us going through the flood and then coming together even stronger.”
One national expert believes Maine and New England could be uniquely positioned to demonstrate model emergency management policies for the rest of the country.
Not yet burdened by the same amount of climate change-fueled storms as places like Louisiana, New England has more resources and a depth of knowledge to get ahead on planning, according to Samantha Montano, an assistant professor of emergency management at Massachusetts Maritime Academy.
“We have the breathing room right now and the potential resources and knowledge to make really significant reforms to how we’re doing emergency management,” Montano said, which will “set us up for when those bigger disasters come and also potentially be a model for other parts of the country.”
The deputy director of Franklin County’s Emergency Management Agency concedes that it’s impossible to plan for every curveball thrown by unpredictable storms like last December’s. Photo by Annie Twitchell of The Daily Bulldog.
Potential reforms include increasing the number of professional emergency managers at the municipal level (roles often occupied by town managers today), redesigning communities to accommodate flooding and undertaking a massive public education campaign on what to do when disasters strike.
Whether supported by state or local funding, expanding the number of emergency managers embedded within municipal governments will also provide a full-time staff member to pursue hazard mitigation grants and ease communities through technical planning processes, Montano said.
Many of these recommendations align with the commission’s proposals. As Horn met with her team for the first time on Thursday, she recognized the significance of the mission ahead of them.
“We’re going to continue to face severe storms,“ Horn said, and “there is an all-out effort to address these issues so that that type of damage doesn’t happen again.”
Maritime officials fear ‘catastrophic’ outcome if mariner shortage worsens
Russell Marinari, 23, graduated from the Maine Maritime Academy in Castine in May and is now working as third mate on Deepwater Titan, an offshore drillship in the Gulf of Mexico. Marinari works three weeks on and then has three weeks off.
“I summered in Boothbay and knew I wanted to work on the water,” he said. “I have a full-time salary and I only work 50 percent of the year. I think that’s pretty cool.”
The excitement of working at sea for months and exploring new places has long attracted people to nautical careers.
But a number of factors, including the pandemic, have left the United States with a marked shortage of merchant mariners, who largely work on commercial ships that at times transport weaponry and supplies to the U.S. military, provide disaster relief and support international trade.
Thomas Lord, a 1987 Maine Maritime Academy graduate and now executive vice president of Seiden Krieger Associates, said the shortage of mariners has been a major topic of discussion recently, and that many mariners have postponed retirement so the true magnitude of the situation has yet to be felt.
“The crisis is with the mariners, the shipboard folks,” said Lord. “They are raising the alarm that we need more mariners.”
A 2021 report from the Baltic and International Maritime Council and the International Chamber of Shipping described a shortage of around 26,000 officers certified to work on ships in international waters and predicted it would triple by 2026.
The report forecast that there would be a need for an additional 89,510 officers by 2026 to operate the world’s merchant fleet. BIMCO said there were at the time 1.89 million seafarers operating over 74,000 vessels around the globe.
Ann Phillips, a retired Navy rear admiral who heads the Department of Transportation’s Maritime Administration, told a Congressional committee last year that the mariner shortage was exacerbated by COVID-19 but has been a problem for several years.
During the pandemic, hundreds of thousands of mariners were stranded at sea during the peak of the crisis, with many ports refusing to allow crew ashore. Some were at sea for 20 months, according to reporting by The Washington Post, even as demand for their services skyrocketed.
Ninety percent of the world’s goods move by sea, a figure that became glaringly evident during the pandemic, as containers stacked up in ports, waiting to meet insatiable consumer demand.
Phillips cited a 2017 study that found the U.S. did not have enough mariners with unlimited tonnage credentials to sustain a full activation of the Ready Reserve Force, which has around 50 vessels and supports the deployment of U.S military forces worldwide. The study found a deficit of 1,839 mariners.
“This optimistic scenario assumed that all qualified mariners would be both available and willing to sail as needed,” she said.
Recruitment efforts
Roland Rexha is secretary treasurer of the Marine Engineers’ Beneficial Association, a union that dates back to 1875 and represents U.S. Coast Guard licensed officers in foreign and domestic trade.
He said the shortage has become acute since the pandemic. To appeal to new recruits, he said, the industry needs to offer higher wages, internet access onboard, better food and a schedule that makes it possible to raise a family.
“If we don’t have enough people, it then becomes an issue with our supply for our sailors and our soldiers,” Rexha said. “It would be catastrophic. We deliver tanks, helicopters, ‘bullets and beans,’ as they say.”
George Tricker, vice president for contracts and contract enforcement for Seafarers International Union, said his group has an active recruiting effort and is streamlining its application process.
“As an industry, we have to make ourselves more visible,” he said. ”Back in the day you were on ships that stayed in port for several days so that you could sightsee. Now you are in and out of the port so quickly. It’s less of an adventure and more of a job.”
Zach York, 23, graduated from Maine Maritime Academy last spring and spent the summer working for a ferry company part-time and joined a union in August. He shipped out in late September as third mate on Major Richard Winters, a cargo ship.
York, who is from Sewell, N.J., said going out to sea ran in his family, noting that his dad attended the United States Merchant Marine Academy at Kings Point and he has been racing sailboats since he was six.
“It’s a big learning curve,” he said of his new job. “It’s not a training ship. It’s not the same culture. You’re learning a lot every day and trying to put the pieces together, as they say.”
Each job comes with its own contract. York had the option of a 60-day posting or a 120-day posting and opted for the longer one because it will allow him to be home for 115 days.
Industry shifts
Craig Johnson, interim president of the Maine Maritime Academy, graduated from the academy 30 years ago and sailed with the Merchant Marine for seven years before coming ashore.
Johnson said the academy does its best to give students a taste of life at sea. During their four years at the school, they go on three 75-day training cruises — two on an academy vessel and one on a commercial ship.
He said the industry knows it has to make life better for mariners, starting with connectivity, noting that most ships now have Starlink satellite internet. Not long ago he was on a training vessel and received an alert that his son’s blood sugar was low. His son was miles away, yet Johnson was able to address the issue immediately. This is a big change from before.
“When you went out to sea, you were very disconnected from the world,” Johnson said. “Thirty years ago you lined up at a payphone with 20 other sailors to make calls. In the Nineties came the cell phone that you could use when in port. But now you can do your business at any time.”
He is a member of a working group looking at the mariner shortage and said it’s clear the issue is no longer simply about wages, but amenities.
“This shortage of qualified mariners is something I have never seen before,” Johnson said. “It’s a defense crisis for us too. This is a huge problem worldwide.”
Johnson said at the end of the day, one has to have stamina to work at sea.
“You’re working seven days a week, 12 hours a day. You’re really on call all the time. That’s why people on shore love the mariners,” he said. “They are problem solvers. You can’t call AAA when you’re out at sea. You have to solve problems in real time.”
Maine proposes major staffing changes for assisted living and residential care facilities
In the first major update to assisted living and residential care regulations in more than 15 years, the Maine Department of Health and Human Services has proposed significantly increasing staffing requirements, among other changes.
Advocates have applauded this step as necessary to meet residents’ increasing medical needs and address gaps in care, but facility representatives say the associated costs could lead to “catastrophic outcomes.”
During a public hearing earlier this month, the department proposed big changes to the current staffing ratios, including doubling the number of direct care workers at residential care facilities overnight and setting stricter rules in memory care units that go beyond the state and federal staffing requirements at nursing homes.
The new expectations, which are not accompanied by additional funding, came as a surprise to most in the industry, who thought the regulations would be limited to the licensing structure.
Assisted living programs — which the state currently categorizes in 10 tiers — serve older Mainers, adults with intellectual and developmental disabilities and people with mental illness. These facilities offer less medical care than nursing homes but have expanded in recent years as people opt to live in more home-like and independent settings.
At the same time, the needs of residents in these facilities have “increased significantly,” said Brenda Gallant, Maine’s long-term care ombudsman, the state’s advocate for residents and their families. This is in part because nursing homes have closed and been converted to assisted living facilities, and because people are aging at home for longer, waiting until they’re older to move into a facility.
“Current regulations for assisted housing have not kept pace with the increasing needs of residents,” Gallant said. “This is an opportunity to improve the quality of care for residents that should not be missed.”
Facility owners and administrators, however, warned that increased staffing requirements will be difficult to meet due to workforce shortages. During the Nov. 13 public hearing, one resident services director in Saco said they have been trying to hire a nurse for more than two years. Another administrator said their last opening took two months to fill and when they finally hired, the candidate had “no qualifications” and required months of training.
Staffing levels
When the proposed changes were announced on Oct. 23, DHHS summarized them as simplifying the licensing process. As it stands, there are 10 different levels of assisted housing that vary depending on the number of beds, the needs of the population they serve and whether they accept MaineCare.
The proposal simplifies these 10 levels into two: assisted living facilities and residential care facilities. Assisted living facilities offer private apartments whereas residential care facilities are closer to nursing homes, with private or semi-private bedrooms.
“This simplified structure is designed to improve licensee understanding of and compliance with the rule,” DHHS said in its announcement. “The provisions of the proposed rule have been updated to reflect current best practices in assisted housing.”
It was these updates that took the facilities by surprise. The current staffing ratios for residential care facilities with more than 10 beds require one direct care worker for 12 residents during the day shift; one for 18 residents during the evening; and one to 30 overnight. Facilities with 10 or fewer beds must have at least one responsible adult present.
Brenda Gallant, the long-term care ombudsman, said staffing problems in residential care rank third among the most frequent complaints her program receives. Photo by Rose Lundy.
Under the proposed regulations, facilities with more than 10 beds would need to have one direct care worker for eight residents during the day and evening shifts; and one for 15 residents overnight. Facilities with 10 or fewer beds would need to have at least two responsible adults on duty at all times.
The proposed staffing requirements for memory care units are stricter: one direct care worker to five residents during the day and evening shifts; and one worker to 10 residents on night shifts. These staff ratios would be more than what is required in nursing homes.
The update stipulates that memory care units must also have one additional employee during the day shift “who is delegated to provide direct observation of residents and who does not have additional assigned duties.” At the public hearing, providers expressed confusion about the role of this employee and said it would be a challenge to keep the responsibilities so narrow.
Experts and advocates have told The Monitor that residents with Alzheimer’s disease and other dementias are among the most vulnerable because they can have a tendency to wander. During the course of TheMonitor’s investigation one facility owner called the current staffing requirement “scary,” “unsafe” and “completely inadequate.”
Gallant, the long-term care ombudsman, said staffing problems in residential care rank third among the most frequent complaints her program receives.
“The staffing numbers are a starting point and I expect there will be more discussion,” she said. “But the providers have to understand that they are taking care of more complex residents and staffing needs to reflect that.”
The proposed regulations also add a definition and required assessment for risk of “elopement,” or an incident in which a resident is “leaving a secure facility without authorization or supervision.” The Monitor and ProPublica found that there were at least 115 reported elopements at Maine residential care facilities from 2020 to 2022, according to state inspection records and a database of incidents reported to the health department.
Numerous providers said they were concerned that these regulations marked a step away from assisted housing as a “social model” towards a “medical model” more closely aligned with a nursing home. Yet some acknowledged that the needs of residents in these facilities have increased.
Gallant said the state estimated in recent years that between one-fourth and one-third of residents served in residential care would qualify for a nursing home — at least 26 of which have closed in Maine over the last decade.
Mark Kaplan, a physician who has patients in assisted housing facilities, said he has seen the residents’ needs grow. Within one week, he saw a resident with end-stage liver disease waiting for a liver transplant, another who was on dialysis, and another who had COPD and heart disease.
‘Significant new costs’
The changes came as “quite a shock,” said Angela Cole Westhoff, president and CEO of the Maine Health Care Association, which represents nursing homes and assisted living facilities across the state.
“The lack of communication contrasts starkly with the open dialogue with the department with respect to nursing facility rate reform, where comments, both positive and negative, have been welcomed as a vital part of the regulatory process,” Westhoff said in her testimony.
DHHS held a listening session on assisted housing changes last December and considered suggestions from the long-term care ombudsman. But aside from the listening session, Westhoff said there had been “zero communication with the affected providers about this rulemaking.”
Westhoff and facility administrators said they would be happy to participate in focus groups with the state to find solutions that would pose less of a financial burden. At the hearing, they repeatedly asked the state to “hit pause” on the process.
DHHS is required to present the proposed regulations to lawmakers by Jan. 10 in order for them to be reviewed and approved during the upcoming legislative session. A DHHS spokesperson did not respond to questions about what would happen if it missed that deadline in favor of more discussion.
The staffing requirements will mean adding about 2,000 more direct care workers, according to estimates from MHCA.
The long-term care ombudsman recommended creating a standard practice to follow up on plans of correction when facilities are cited for deficiencies. Photo by Tara Rice for ProPublica.
“This industry is not financially positioned to incur significant new costs without a corresponding increase in MaineCare spending and private pay pricing,” Westhoff said. “With the increased staffing and other costs that the new rule would impose, assisted living and residential care facilities will be further financially strained.”
During the three-hour public hearing, providers strongly disputed DHHS’s assertion that the rule was expected to have “minimal fiscal impact on licensed providers.”
DLTC Healthcare & Bella Point, which owns and operates 17 residential care facilities, estimated the change would cost an additional $108,000 for each 30-bed facility.
The director of finance and human resources for Schooner Retirement Community, Schooner Memory Care and Fallbrook Woods estimated the three facilities would need to add 68 full-time-equivalent employees, totaling $4.5 million.
Woodlands Senior Living, which operates 16 facilities in Maine, said it would need to hire more than 300 staff members across its facilities, totaling nearly $13 million.
Many providers said they would likely have to pass these costs on to residents unless the regulations came with an increase in MaineCare reimbursement from the state.
DHHS spokesperson Lindsay Hammes said the department could not comment during the rulemaking process and noted that the proposals could change based on public comments, which are being accepted until Nov. 25.
Encroaching regulations
Island Commons, a 7-bed non-profit facility on Chebeague Island, said it already runs a deficit of $150,000 annually due to low MaineCare reimbursement, which it offsets by fundraising every year. The facility estimates that increased staffing requirements would add another $190,000.
Four of the facility’s beds typically go to MaineCare residents, and the other three are private pay, said Amy Rich, the administrator. The added costs would likely increase the private rates by 30 to 40 percent to about $325 a day. This would be “untenable” for those residents, said Nancy Olney, the community outreach manager.
Increasing rates would cause private-pay residents to spend down their savings faster, which would put them onto MaineCare sooner, Rich said. She added that many facilities are already dropping MaineCare beds because of the costs.
Left: Karyn Miller, a certified residential medication aide, does a puzzle with resident Rita “Peachie” Stevens at Island Commons, a residential care facility on Chebeague Island. Right: The dining room at Island Commons, which has space for seven residents. Photos by Rose Lundy.
Rich said the proposed regulations are “encroaching” into the nursing home realm. Her facility would be required to have a license for its adult day care program; a registered nurse would be required to help write training policies; and she would need to add another direct care worker around the clock.
She sees the proposed regulations as moving away from allowing facilities to rely on what she called a universal worker: someone who is a cook or cleaner but also a certified residential medication aide who can help out when needed.
“It’s so clinical,” she said.
While she acknowledged that some facilities are having trouble addressing residents’ growing medical needs, she doesn’t think the solution is for DHHS to introduce significant changes without provider input.
A better approach, she said, would be to require facilities with repeat problems to increase their staffing, rather than changing the ratios across the board for facilities like Island Commons, which hasn’t been cited for any deficiencies in recent years.
When asked about whether doubling the staff would impact her, Helen Nannery, a resident at Island Commons, said it could mean more activities. Janet Martin, another resident, added: “It’s better. You’d have more workers.”
Rich acknowledged the work day is easier when they have more people on duty: “It is great. It’s just not feasible because of the financial impact.”
‘The stakes here are high’
While testimony at the public hearing consisted largely of facility owners and administrators who opposed the proposed regulations, Gallant, the long-term care ombudsman, and a representative from Legal Services for the Maine Elders both testified in support. AARP Maine told The Monitor it also planned to support the rule changes.
A survey of direct care workers in assisted living and residential care facilities across the state found that most workers would like to see increased staffing, said Nicole Marchesi, who works in the ombudsman’s office. Increasing staff ratios can help prevent burnout and turnover, she said.
“Staff tell us they do not feel they are leaving their shift providing quality care because of the current staffing ratios,” Marchesi said. “These staff continue to express the frustration around caring for residents who are nursing home level of care in assisted living. When staffing is insufficient, resident safety is jeopardized.”
The long-term care ombudsman and Legal Services for Maine Elders also recommended having license renewal and survey inspections completed annually, rather than every two years, and creating a standard practice to follow up on plans of correction when facilities are cited for deficiencies.
In our investigation, The Monitor found that DHHS rarely sanctioned facilities in cases where residents unsafely wandered away — in the vast majority of cases, investigators never inspected the facilities, conducting only a desk review or no investigation at all.
Gallant, the ombudsman, also asked DHHS to publish survey results on its website and make the website more user-friendly so residents and families can better access the information and compare facilities.
“The stakes here are high,” wrote John Brautigam on behalf of Legal Services for Maine Elders. “These rules have the potential to prevent neglect, improve health outcomes, and foster environments where residents feel valued and safe. We owe it to them to ensure these protections are as strong as possible.”
Who donated to Jared Golden and Austin Theriault?
On Tuesday, residents of Maine’s 2nd congressional district will vote for their representative to Congress.
Austin Theriault, a former NASCAR driver, won the June primary to clinch the Republican nomination. A relative political newcomer who just finished serving his first term as the state representative for a large swath of Aroostook County, including his hometown of Fort Kent, Theriault will face three-term incumbent Jared Golden, the Lewiston Democrat and Marine veteran.
The fight for the 2nd district will be closely watched across the country and will help determine the balance of power in the U.S. House of Representatives.
The race has attracted a large amount of spending, both from within Maine and from out of state. As of Oct. 16, Golden’s campaign had raised about $6 million in individual contributions, while Theriault had raised $2.7 million.
The Maine Monitor analyzed the most recent campaign finance reports filed with the Federal Election Commission to learn more about where the money came from. Here’s what we found:
In-state vs. out-of-state fundraising
Of the around $6 million Golden raised, $5 million was itemized; of the $2.7 million Theriault raised, $2.4 was itemized. The majority of itemized individual contributions to Golden’s campaign, $4.2 million, came from about 2,700 out-of-state donors, compared to $825,000 from about 1,000 Maine donors.
Contributions to Theriault, on the other hand, are split: He raised $1.3 million from 588 out-of-state donors and $1.1 million from 535 Maine donors.
(The FEC does not require campaign committees to itemize — disclose individual donors’ names, addresses, occupations and employers — for aggregate contributions under $200. However, contributions received through conduits such as ActBlue or WinRed are itemized regardless of contribution size.)
Donors gave big
Donors overall gave big: Less than one percent of the total money raised came from donors who gave less than $200 throughout the election cycle, though more than half of small contributions came from Maine donors.
About 200 donors to Golden’s campaign gave the maximum contribution allowed under federal law — $3,300 in the primary and $3,300 in the general — compared to 149 donors to Theriault’s campaign.
Executives, business owners, retired people
Individuals who said they were retired, not employed, business owners or executives were among the top 10 occupations of donors to both campaigns.
Among the top 10 employers of people who gave the most money, Golden’s campaign was largely dominated by national companies or companies based outside of Maine, while the top 10 employers of contributors to Theriault’s campaign were mostly Maine-based.
Methodology& Support
The Maine Monitor, working with Stanford University’s Big Local News, analyzed Federal Elections Commission data on itemized individual contributions to Jared Golden and Austin Theriault’s campaign committees for the 2023-24 election cycle through Oct. 16.
Because the FEC typically takes weeks to process recently filed campaign finance reports, which involves categorizing and coding receipts, processed data was only available through June 30. In order to append the raw data, which was available through Oct. 16, to the processed data, The Monitor filtered out duplicate records and kept only records from individual and organization entities, and contributions from individuals other than political committees and transfers from authorized committees, found on lines 11(a)(i) and 12, respectively, on FEC form 3.
The Monitor’s sum totals also account for held or refunded contributions. The Monitor’s data went through several rounds of checks, including with the FEC.
This story was produced with support from the Institute for Nonprofit News’ Rural News Network and the Google News Initiative.
Bucking national trends, a third of Maine towns still count ballots by hand
When polls close at 8 p.m. on Nov. 5, six trained election clerks in New Vineyard, a town of about 700 in Franklin County, will start counting ballots by hand. There are 13 questions on New Vineyard voters’ ballots: eight races for county, state and federal positions and five state referendum questions. Each of these votes will have to be tallied independently — not once, but twice.
Election clerks will divide into groups of two (generally one Democrat and one Republican), and each group will count batches of 50 ballots at a time. Working concurrently, the two clerks will review the same ballot and state aloud the race or question and the choice — “State Senate, Jane Doe; Question 1, Yes” — and each will record the voter’s selection on their individual tally sheets.
As each batch of ballots is completed, the teams will compare their tally sheets to ensure that they match. If they don’t, the team has to recount the race or question that was off. Once everything is settled, the clerks sign the certification on the tally sheets and one sheet goes to the warden and the other stays bundled with the ballots.
Michelle Beedy, New Vineyard’s town clerk, said she would like to get voting tabulation equipment, such as the hand-fed optical scanners the majority of Maine municipalities use to count ballots.
“It just would make counting a lot easier,” Beedy said. “There’s a lot to counting those ballots.”
But the town enjoys its traditions, hauling out an old-fashioned wooden ballot box for each election.
New Vineyard is one of 150 towns, or about a third of all voting jurisdictions in Maine, that counts ballots by hand. Each of the towns has fewer than 750 registered voters, though the average number of voters among the towns is much lower, at 251.
In Maine, unlike most of the country, elections are run by municipalities. Nationwide, elections for 90 percent of registered voters are run at the county level. Only half of a percentage of those voters’ ballots are exclusively hand counted. By contrast, Maine jurisdictions that hand count ballots represent 4 percent of registered voters, or about 37,000 people.
(Not all Maine voters’ polling places are in the same jurisdiction as where they’re registered to vote, especially in unorganized territories. The 241 registered voters from Connor Township in Aroostook County, for example, will go to Caribou to vote in the upcoming election.)
Maine’s other 330 cities and towns use devices called hand-fed optical scanners, which scan hand-marked paper ballots and tabulate the votes cast, storing the data on a memory stick-like device. If something on the ballot is incorrect or unclear, like too many choices filled in for a single race or a partially filled in bubble, an alert displays on the screen and offers to return the ballot for correction.
Since 2012, Maine has had a contract with the company Election Systems & Software, which makes optical scanners. Municipalities can opt in to receiving the DS200 ballot scanning device at no cost to them, Secretary of State Shenna Bellows told The Monitor.
In the 12 years since Maine entered into that contract, the number of cities and towns that opt to hand count has gone down significantly: in 2012, only about one-third of towns used a hand-fed optical scanner to tabulate their ballots, while the remaining two-thirds hand counted.
More than 2,300 voting jurisdictions from 39 states or territories, including Maine, use this particular make and model of ballot scanning device, according to Verified Voting, a nonpartisan organization that researches the use of technology in elections.
Per state law, it is up to municipalities to decide if they want to use state-approved tabulation equipment, which besides hand counting is the only other state-approved tabulation method. Bellows said her office strongly suggests large municipalities do so.
“The data demonstrates that hand counting increases the possibility of human error, and it takes a lot longer to count ballots when you’re doing it by hand,” Bellows said.
A peer-reviewed study published in the Election Law Journal compared the election night hand count and the statewide recount for two Wisconsin elections and found that vote counts done by scanning devices were more accurate on average than those tallied by hand.
But she gets why small towns like New Vineyard stick to hand counting.
“We understand that they prefer the old-fashioned hand count, recognizing that it’s really important that they be as scrupulous as possible in ensuring the accuracy of that count,” she said.
GOP lawmakers and supporters in some states have made a push to go back to hand counting ballots, including in New Hampshire where Trump ally and MyPillow founder Mike Lindell, peddling unfounded conspiracy theories of fraud related to voting tabulation devices, like optical scanners, helped orchestrate a campaign to get rid of them earlier this year.
But Pam Smith, the president and CEO of Verified Voting, said the number of voting jurisdictions that have gotten rid of their equipment in favor of hand counting remains small nationwide. In New Hampshire, the effort failed — just one small town voted to ban voting machines, and the decision is unlikely to stand.
Smith said the DS200 optical scanners used across the state are secure and accurate, particularly because all Maine jurisdictions, regardless of how they tabulate votes, use hand-marked paper ballots. This ensures there is a paper trail in case of a recount or audit. (A law allowing the Secretary of State to conduct post-election audits goes into effect on Jan. 1.)
“It’s important to have that evidence because then you can use it,” Smith said. “If your system was purely electronic and there was no separate record that the voter could see and confirm, then you don’t have that same benefit and that equipment is not securable in the same way that a scanner is.”
All but 1.4 percent of voters in the U.S. will have a paper record of their votes in the upcoming election, including hand- or device-marked paper ballots or receipt-like print-outs called Voter Verified Paper Audit Trails.
All Maine jurisdictions also have ballot-marking devices called ExpressVote from the same manufacturer that makes the optical scanners, which allow people with disabilities to vote “privately and independently,” according to Verified Voting’s equipment database.
The device generates a printed ballot when the voter is finished, which is then tabulated by a scanner or by hand. (Some Maine voters with disabilities also have the option to vote absentee via a secure online portal.)
Photo by Caitlin Andrews.
Smith said the security and accuracy of hand counted ballots depends on how many voters there are: the larger a jurisdiction gets, the more difficult it is to “cautiously and carefully” tabulate votes in a timely manner. And the larger the jurisdiction, the more expensive and time-intensive the process — a point Bellows echoed.
“Mainers are accustomed to receiving results on election night, and the tabulators advance the speed of the results as well as the accuracy,” Bellows said.
Beedy, New Vineyard’s town clerk, said she’ll have two election clerks counting absentee ballots throughout the day, and four more clerks counting ballots cast on election day once the polls close. Each clerk is paid minimum wage, $14.15 an hour. Beedy and the election warden will be there the entire time. It will cost the town — which only has about 530 registered voters — about $700 for just the six election clerks and more than 14 hours to count every vote.
“We’re responsible for every single ballot,” she said. “You miss one number and your whole tally sheet is off. So you could be back trying to find one ballot out of 800.”
Beedy figures the election clerks will be counting until at least 11 p.m.
“If all goes well,” she said.
This story was produced with support from the Institute for Nonprofit News’ Rural News Network and the Google News Initiative.