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.

They are located throughout Maine, from Sanford to Fort Kent:

• Open Arms Pregnancy Center, Augusta

• First Step Pregnancy Resources Center, Bangor

• Care Net Center of Mid-Coast Maine, Brunswick

• Hope House, Lewiston

• ABBA Women’s Resource Center, Portland

• Pregnancy Care Center of Aroostook, Presque Isle, Houlton & Fort Kent

• Zoe, A Women’s Center, Rockport

• Alpha Pregnancy Resource Center, Sanford

• Resolve Life Center, Waterville

There are an estimated 2,500 of these anti-abortion centers nationally, compared to about 765 abortion clinics, according to The Guttmacher Institute, a leading research and policy organization focused on reproductive health.

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.

There were about 2,500 abortions in Maine in 2023, the vast majority of which happened before nine weeks of pregnancy.

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. 

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.

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.”

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.”

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.” 

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.”

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.

The proposed updates come after an 18-month investigation into the state’s largest residential care facilities published by The Maine Monitor and ProPublica found dozens of resident rights violations including abuse and neglect incidents, more than a hundred cases where residents wandered away from their facilities and hundreds of medication and treatment violations. Experts, advocates and providers said requiring higher staffing levels, better training and more nursing care would help address these problems.

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.

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 The Monitor’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.

“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.

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.”

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.

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.

Bellows referred to other reports on elections in New Hampshire and Nevada that found hand counting to have much higher error rates than scanners.

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.)

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.

Eighth-generation farmer Ben Edwards hustles from his family’s seaside Machias farmhouse at Schoppee Farm each morning, often with one of his two toddlers on a hip, his lanky legs moving swiftly, first to the greenhouse where he cares for tender organic hemp plants, and then to the fields to bring in the harvest and put in cover crops for winter. 

Down the road at Welch Farm in Roque Bluffs, sixth-generation farmer Lisa Hanscom and her seven-year-old grandson survey the family’s guest cabins and iconic wild blueberry barrens as they reach full splendor after the harvest, the cool ocean air transforming the tiny green leaves into shimmering hues of crimson, copper, and magenta. 

In neighboring Aroostook County, trees are splashed with another blaze of carnival color, framing thousands of acres of rolling potato fields, dotted with tractors as farmers and laborers toil from dawn to dusk harvesting the last of this year’s crop.

But some of Maine’s bucolic landscape might soon be ceded to help meet the state’s desperate demand for housing. 

A new bi-partisan bill introduced in late September by U.S. Senators Angus King (I-ME) and Jerry Moran (R-KS) would pour an additional $200 million into an existing federal program to incentivize rural property owners to build rental housing on their land, such as an attached apartment unit or a small home nearby.

The Farmhouse-to-Workforce Housing Act is just one piece of a patchwork effort to create a flurry of housing around the country after decades of lagging construction, aging stock, zoning restrictions and local resistance to building collided with a dramatic change in migration patterns post-pandemic, leaving rural communities in particular struggling to deal with a lack of places for people to live.  

A study commissioned by Gov. Mills and MaineHousing found that Maine will need upwards of an additional 84,000 new housing units by 2030. The state currently has about 741,803 housing units, nearly a quarter of which were built before 1940.  

In a press release, Sen. King said the bill aims to make it cheaper and easier for Maine people and residents across the country to renovate their homes or build new ones on their land.

“Maine is one big, small town connected by long roads, and when I drive those long roads, I see potentially available properties in the same communities that are facing crisis levels of housing availability,” King said. 

The biggest push to increase residential and workforce housing is in Washington and Aroostook counties, where the need is greatest due to historically lower housing production, coupled with an influx of wealthier new residents and property investors buying up already meager housing stock.

According to housing trends based on permits issued, the MaineHousing study found that Washington and Aroostook counties — two of the state’s four poorest counties — will need to add an average of 50% and 40% more housing, respectively, over each of the next five years to keep up with existing and future needs and hit the state’s lofty goals. 

In Aroostook County that means adding 390 housing units each year, a roughly 333% increase over current production. In Washington County, it will require a truly herculean feat — 830 new housing permits will have to be issued each year — a 1,283% leap in production each year over what the county currently manages. 

At a multi-day housing workshop held in Machias last month, about two dozen municipal leaders from ten rural communities gathered to learn about programs, strategies, and available funding to help increase housing and manage growth. The workshop is the second in a three-year series being facilitated by GrowSmart Maine, a non-profit community planning advocacy group. The program is funded in part by a $304,636 USDA Rural Community Development Initiative grant.

Sen. King’s proposed legislation, which is currently under review by the Senate Banking Committee, taps into an existing, under-funded USDA rural housing preservation grant program that was originally intended to help rural property owners renovate their homes. This fiscal year’s funding for the program is $12.2 million. 

According to Senators King and Moran, the program is underused and receives limited funding. If adopted, the legislation would expand the national program for rural housing creation by increasing its funding by $200 million, a more than 1500 percent jump, and expanding eligibility for rural homeowners willing to yield some of their land to create more housing on their property — such as an attached apartment unit or a small home nearby — to be available for rent, according to King’s press release.

Low- or medium-income rural property owners with a primary home that is 25 years or older would be eligible for two grants of up to $100,000 each to construct rental housing in the home or on their land.

King’s proposal follows legislation passed by Maine lawmakers in 2022 that effectively eliminated single-family zoning in certain areas by requiring municipalities to ensure local regulations allow the creation of different types of housing units, including multi-family dwellings and so-called accessory dwelling units.

That prospect of incentives to develop housing on farmland makes Edwards, from Schoppee Farm, more than a little worried.

“Anything that erodes the ability of farms to continue somehow or another as actual farms, I don’t see the long-term gain in that,” said Edwards. “Not get too grandiose about it, but I really think it’s just overall bad for our culture and our communities, period.”

Data from the American Farmland Trust shows that Maine’s already sparse farmland is under significant threat. According to the AFT, from 2001 to 2016, 17,000 acres of Maine’s agricultural land were developed or compromised, converted to residential or commercial use. The analysis found that the converted land could have generated $10 million in annual revenues had it stayed as farmland.

About half of Maine’s remaining agricultural land is considered “Nationally Significant Land,” classified by AFT as the nation’s best land for long-term production of food and other crops, according to the report..

Edwards said he’s witnessed farmland slipping away as many farmers, struggling under the rising costs of farming and roller-coaster revenues, buckle to developers. He’s concerned the proposed incentives for farmers to build housing on farmable land would add one more threat, and points to solar farms, built on agricultural lands, as an example of how fast an industry can gobble up valuable, historic farmland.  

The proposed legislation by Sens. King and Moran could add fuel to the debate over farmland conversion. New federal housing incentives and the already hotly contested solar issue also could pit the state’s climate action plan goals against its housing goals. 

Details of the proposed federal rural housing legislation are yet to be determined, including how funds would be allocated to each state and each county, said Rhiannon Hampson, Maine State Director for USDA Rural Development, in a written response to questions from The Maine Monitor.  

Hampson added that Maine benefits greatly from the Rural Development Housing Preservation Grant program, a total of $169, 658 in fiscal year 2023. The funding was split between Penquis Community Action Agency and Western Maine Community Action to rehabilitate low- and very-low-income, owner-occupied homes.

“It’s a way in which we can strengthen the work of our partners, such as Community Action Partnership agencies like Penquis and others, to do the direct work for folks to create more and safer housing options.”

Maine is suffering growing pains as it struggles to balance agricultural, energy, and housing needs. There has been a flurry of recent legislative actions at the state and local level to either expand or curtail regulations on everything from expanding the areas where modular housing can be built to reining in how much solar and wind power can impact farmland, wildlife and fisheries habitat.

Down on Englishman Bay, wild blueberry farmer Lisa Hanscom sees the issues a little differently than her neighbor, Edwards. Hanscom believes there needs to be a balance.  

Sixteen years ago, Hanscom erected rental cabins on her family’s still-productive blueberry farm, diversifying into agricultural tourism. Her great grandfather fueled the farm with a wind tower and Hanscom would like to add some solar panels to help curb her energy costs. She hopes lawmakers strike the right balance.

“Don’t take away the ways that farmers can make money, to make sure that they can stay there and survive — so they don’t have to sell off the farm to developers.”

Frustrated with used needles littering city streets, some local officials have called for renewed restrictions on syringe service programs, which they say contribute to the recent rise in needle waste.

But harm reduction experts say the needle waste — and high rates of infectious disease among injection drug users in Maine — is evidence that these programs should be expanded, not restricted.

Syringe service programs offer supplies, including sterile needles, naloxone and fentanyl, and xylazine test strips, to people who inject drugs, with the goal of reducing overdose deaths and disease outbreaks.

The programs also help connect people to services and serve as a critical “touch point for people who are otherwise marginalized from the health care system,” said Dr. Robin Pollini, an epidemiologist and harm reduction expert at West Virginia University.

Maine’s first syringe service program, The Exchange, operated by Portland’s public health department, opened in 1998 and remains the only municipally run program in the state. The Maine Center for Disease Control and Prevention certifies the programs and the sites where they can operate. Although program operators must provide notice of their intent to file for certification, municipalities do not have a role in the certification process, which has led to complaints from some city leaders that programs pop up in their towns with little to no consultation.

As of last year, 13 of the 32 certified programs were in operation statewide, according to the Maine CDC’s latest annual report. While some programs have been in operation for over a decade, the majority — eight of the 13 that are active — opened within the past four years.

For more than two decades, state rules limited programs to a 1-for-1 exchange, meaning they could only provide one sterile syringe for every used one a person brought in. In late March 2020, Gov. Janet Mills suspended that rule and made it so that programs could adjust their hours without state approval and operate anywhere within the county in which they were certified. The rule change also allowed them to mail supplies.

Mills’ executive order acknowledged that the public health emergency posed “substantial barriers” for clients to access syringe service programs and cited a desire to maintain a continuity of services during the COVID-19 pandemic.

The change was hailed by the American Medical Association, which urged other states to adopt similar policies. At the time Maine had 11 certified programs operating in 10 cities — Portland, Ellsworth, Bangor, Machias, Belfast, Calais, Augusta, Waterville, Sanford and Lewiston. Most programs quickly relaxed their rules. Maine Access Points, which at the time operated programs in Sanford and Calais, started a mail-order program. But Portland doubled down on the 1-for-1 policy and refused to loosen its rules for more than a year.

In September 2022, shortly after Mills’ order expired, the Maine Department of Health and Human Services adopted a 1-for-100 rule that allows programs to distribute up to 100 more needles than a person turns in. If someone turns in 20 used needles, for example, they can get 120 sterile needles. If someone doesn’t have any used needles, they can still get up to 100 sterile needles. 

But in the past few weeks Portland Mayor Mark Dion and Sanford city manager Steve Buck called for a return to the 1-for-1 rule.

In a Sept. 12 op-ed in the Portland Press Herald, Dion said “needle waste is a public safety hazard of our making” and that he would introduce a resolution to the city council next month to go back to 1-for-1. (Dion previously supported loosening restrictions on The Exchange in 2021.)

Over the past decade, enrollment in a syringe service program has almost doubled. Last year nearly 8,400 people were enrolled in a program, a 25 percent increase from the previous year. Accompanying this boom was a dramatic increase in the volume of syringes that the programs distribute and collect every year.

In 2023, the 13 programs distributed nearly 3.7 million sterile syringes — four times the amount they distributed in 2019 and seven times the 2013 amount. They collected about 3.2 million used syringes, or 86 percent of what they distributed. Before the pandemic and the rule change, programs typically collected the same number of syringes they gave out every year, or more.

Dion and Buck said the high volume of syringes that programs distributed and the discrepancy between the number collected explains the uptick in needle waste on city streets.

Portland’s two programs, The Exchange and commonspace, distributed nearly 1.4 million syringes last year. That was more than double the next-highest total distributed in a single city, though the number of people enrolled in either Portland program accounts for 43 percent of the enrollees statewide.

Together, The Exchange and commonplace collected about 294,000 fewer syringes than they gave out.

Residents have complained about improperly discarded syringes in public spaces for years, even before the city loosened its 1-for-1 rule. At a March 2021 health and human services committee workshop, Marie L. Gray wrote, “As a longtime resident of the Parkside neighborhood and an avid walker, the issue of randomly discarded needles is a major concern. Unfortunately it is almost impossible to take a walk through the neighborhood and not see several discarded needles.”

At a West End Neighborhood Association meeting earlier this month, Rich Bianculli, echoing complaints from other residents, said the situation is, “kind of a nightmare,” the Press Herald reported.

Buck, the Sanford manager, in a memo to the city council earlier this month, estimated that after the city sweeped a homeless encampment in mid-June, workers collected about 14,700 used syringes. The encampment, which had been there for about a year, was located next to the syringe service program operated by Maine Access Points.

Last year, MAP distributed 460,720 sterile syringes and collected 441,998 — a difference of roughly 20,000. Buck claimed most of those missing needles were found in the encampment clean-up.

He attached several photos taken in August that showed needles strewn about at public parks around the city.

“The City recognizes a public health crisis exists due to the extraordinary number of inappropriately discarded contaminated needs that puts people at risk of becoming infected by the very pathogens the program seeks to reduce,” Buck wrote.

But some advocates say the problem shows there’s not enough access to syringe service programs.

“To me, what that says is there is not enough access,” to programs, where people can hand in their used syringes and learn more about safe disposal techniques, said Zoe Brokos, Church of Safe Injection’s executive director.

“It doesn’t mean reduce access to syringe service programs or cut off somebody’s safe supply of sterile equipment because the only thing that does is increase disease transmission.”

A 2019 study found that improperly disposed needles in publicly accessible areas of Miami decreased by 49 percent after a syringe service program was established there — in part, researchers suggested, because people injecting drugs had a safe place to dispose of used needles. Several other studies linked syringe service programs to less needle litter and a higher inclination to practice safe disposal among the people who use the programs.

According to the U.S. Centers for Disease Control and Prevention, new users enrolling in these programs are also far more likely to enter treatment and stop using drugs altogether compared to those who don’t enroll. Last year, syringe service programs in Maine made more than 26,100 referrals to various services, such as primary care and housing assistance, more than double the amount in 2022.

Gregg Gonsalves, a Yale University epidemiologist and public health policy expert, suggested approaching needle waste as its own issue, rather than as a symptom of syringe service programs.

“The cost of instituting a clean-up program in these jurisdictions, in these cities and these towns, is far, far less expensive than paying for the lifetime medical costs for somebody who is HIV positive or HCV positive,” he said. “The economic argument is just unequivocal.”

“The point is that (needle waste) is a resolvable issue. We can resolve it in a pretty simple way by enhancing sanitation efforts.”

The executive directors of Maine Access Points, Church of Safe Injection and Wabanaki Public Health and Wellness all told The Monitor that their staff regularly does syringe clean-up in their communities.

There are no sharps containers — metal boxes where people can drop used syringes — in Sanford, said Anna McDonnell, MAP’s co-founder and interim executive director. That’s why MAP is installing its own sharps container that is accessible 24/7.

Closing or restricting syringe service programs only means more infections at a time when infectious diseases, particularly among people who inject drugs, is at an all-time high in Maine and around the nation, advocates say. Maine had the highest rates of new hepatitis A and C cases in the country in 2022, the latest year federal data is available. It had the third-highest rate of new hepatitis B cases, according to the U.S. CDC.

There is an historic cluster of HIV infections in Penobscot County that was first identified last October. Two of the three initial people diagnosed in the cluster reported they were unhoused and shared or reused equipment to inject drugs. As of Sept. 21, a total of 13 people were diagnosed with HIV; all of them were also diagnosed with hepatitis C and all of them reported recent injection drug use. Eleven were currently or recently unhoused.

“I think one of the things that really gets confused is the conversation around syringe litter. It’s really a conversation about housing, about housing access and about supporting people who are unhoused,” McDonnell said.

“We serve a lot of folks who are housed and who don’t have an issue with safely disposing of their syringes. And so the conversation really shouldn’t be about the efficacy of the syringe service programs or how well we’re able to do our job. It’s really about the conversation around people who are homeless, being displaced and not having anywhere to kind of have their belongings or deal with their waste safely.”

Over the past five years, Penobscot County averaged two new HIV diagnoses per year, one of which was a person who uses drugs, according to the Maine CDC.

As the number of cases grew earlier this year, a third syringe service program in Bangor, Needlepoint Sanctuary, was certified to operate up to three sites in the city, as well as one each in Waterville and Milo, according to the executive director, Willie Hurley.

But the city has repeatedly rejected the organization’s proposed locations, most close to homeless encampments, or in or near public parks. They have yet to reach a solution and the program is limited to doing mobile outreach within the city’s homeless encampments, which it has already been doing for years, Hurley said.

“The last thing you want to do is restrict” syringe service programs while in the midst of an HIV outbreak, said Pollini, the West Virginia epidemiologist. Limiting the number of syringes a program can distribute is “virtually ensuring that people are going to share or reuse syringes, and that doesn’t serve any of us.”

Although more and more people visit Maine programs, the number a person typically makes has stayed roughly the same for 15 years, at three to four times per year.

In 2023, enrollees in a Maine program exchanged an average of 102 used needles for 118 sterile ones at each visit. Ten years ago, people exchanged an average of 38 needles.

Dion, in his op-ed, suggested that providing 100 needles simply provides multiple “changes for addicts to taunt the finality of their own lives.”

But experts — including from the U.S. CDC — say a needs-based program is best practice, especially since fentanyl has proliferated the state’s drug supply.

“Fentanyl has a very short half-life and people are injecting a hell of a lot more than they ever used to,” said Whitney Parrish-Perry, MAP’s former operations director. One person could easily go through five to 10 needles in one day.

“People assume that if you don’t give people who inject syringes, they won’t inject drugs. And that’s patently false. People are going to inject whether you give them sterile syringes or not,” Pollini said.

“The question is not, will they inject or not inject? The question is, will they inject with a sterile syringe or a used syringe?”

Providing people with sterile syringes has not been shown to increase overdose risk. And each time a syringe is reused or shared, the risk of acquiring blood-borne infections increases, as does the potential to develop serious and life-threatening bacterial infections, Pollini added. Xylazine, an animal tranquilizer that has been growing in prevalence in Maine’s drug supply, is also known to cause necrotic wounds, which can lead to infections.

Advocates say these programs also help by reducing health care costs: nationwide, hospitalizations and lifetime medical costs for infections associated with injection drug use cost hundreds of millions of dollars annually.

Those deaths — “where someone sits in the hospital for three months and slowly dies of sepsis,” Brokos said, “those get completely forgotten in these conversations.”

Seven years after a Maine Cancer Foundation study identified transportation as a major barrier to treatment for cancer patients in the state’s most rural areas, the same communities are still struggling with long travel times to treatments. 

Since 2017, Maine has lost several cancer treatment centers, including the closure of the oncology practice at St. Mary’s Regional Medical Center in Lewiston in July 2023. The state has just a handful of radiation treatment sites, mostly in southern Maine.

The number of practicing oncologists has stayed roughly steady, with 76 practicing in 2017 and around 71 in 2024, according to state licensing data, and services are still concentrated in the southern region.

Aroostook and Washington county patients must travel on average more than 100 miles for inpatient cancer care, and two of the counties with the highest rates of deaths from cancer — Washington and Somerset — are without a single oncology practice. 

“You’re fighting just to survive to get to your treatment,” said Angela Fochesato, the director of the Beth C. Wright Cancer Resource Center in Ellsworth.

Mainers are at a significantly higher risk of developing and dying from cancer than the national average, with rural residents most at risk, according to a recent report on cancer in Maine. 

While the rate of Mainers dying from cancer decreased over the past decade, from 170 deaths per 100,000 people in 2014 to 161 in 2024, according to the Centers for Disease Control and Prevention, rates are still higher than the national average and anywhere else in New England.

There are many factors, including obesity, alcohol, tobacco use and exposure to environmental hazards such as ultraviolet rays, radon and arsenic.

Longer travel times to care can delay early detection of the disease, which has been linked to a higher likelihood of death. 

Traditional treatment plans often require therapies like radiation once a day, several times per week.

For those farther from care locations, these barriers translate to hundreds of dollars in transportation costs and hours of driving. Patients who don’t have access to a vehicle, or those too sick to drive, face additional hardships.

That was the case for Kathleen Bell, who was diagnosed with stage three breast cancer in February 2013 after a mammogram screening following a skiing accident. 

Bell’s husband had passed away two years earlier. She was alone and without the finances to make various appointments in Bangor from her home in Lincoln, a roughly two-hour drive round trip. 

Bell underwent four rounds of chemotherapy every three weeks, lasting 5 1/2 hours each time, and received 36 radiation treatments by the end of the year. 

“My keys were always in the nightstand next to me,” said Bell. “But I was so sick, I knew I couldn’t even move.”

Friends from a local book club drove her for a while. Eventually she was connected with Penquis Transportation Services, an agency with an office in Bangor contracted with the state to provide rides for certain patients with insurance through MaineCare.

“I would not have survived without Penquis,” Bell said. “Without them I would have died.” 

Penquis, one of the primary transportation providers for MaineCare beneficiaries in northern and eastern Maine, made 672,339 trips last year, according to the Bangor Daily News.

More than half – around 350,000 — were part of Penquis’ Accessing Cancer Care program, according to figures provided by Steven Richard, the nonprofit’s director of transportation. 

Penquis spent more than $25 million on transportation services last year alone, roughly 33 percent of its $75 million annual budget. 

“Every pot of money that we manage to find, we’re able to spend pretty quickly,” said Richard. 

Many rides require specialized equipment because the organization works with patients who have mobility issues or require certain medical aids.

“Sometimes they need wheelchair accessibility, sometimes they need us to actually be able to secure additional bottles of oxygen if they’re on a high consumption rate for it,” said Richard. “So those are some of the concerns (we consider).”

The Maine Cancer Foundation provides a large portion of funding for such initiatives. The director of programming, Katelyn Michaud, said the requests for grants have not slowed in her 10 years there.

“We have been investing a significant portion of funds toward transportation for cancer patients,” said Michaud, adding that Mainers would benefit from a more cohesive, statewide approach, particularly for patients who need to leave the state for care. 

“It’s one thing to get a patient from Washington County to Brewer, but then it’s another to get a patient from Washington County to Portland, perhaps, or to Boston,” she said.

Staffing issues at rural hospitals also have posed challenges.

In 2022, Northern Light Cancer Care announced it would not accept new patients at its oncology and treatment center due to staffing shortages. The center, in Brewer, is a vital resource for cancer patients in eastern and northern Maine.

Northern Light Health officials said it’s back at full capacity for oncology services and recently added three medical and two pediatric oncologists.

“We’ve been very successful so that we can support and offer the (cancer) programs and additional capacity,” said Ava Collins, the vice president of oncology services for Northern Light Health. Collins directly oversees the center and cancer care programs. 

“We continue to evaluate the need to strengthen our services and the care we provide to ensure we meet our mission of caring for our community,” Collins said in an email.

But the hospital system still faces deep financial challenges, with the Northern Light Eastern Maine Medical Center president, Gregory LaFrancois, telling employees in an email last month that it is “headed into very choppy waters,” according to the Bangor Daily News. Northern Light has cut back on services in rural areas in recent years, including closing a clinic in Southwest Harbor and shutting down a primary care practice in Orono. 

Advanced trials and collaboration pioneer possible solutions 

Advancements in cancer treatment options have also paved the way for patients to receive care closer to home — or even at home — by increasing access to clinical trials, which can offer expert medical care and cutting-edge treatments.

All of the state’s oncology practices receive guidance from the Maine Cancer Genomics Initiative (MCGI), a collaborative network of providers led by the Jackson Laboratory, a nonprofit medical research center in Bar Harbor.

The initiative, which began in 2017, aims to provide highly targeted cancer therapies to patients statewide. 

“The biggest goal of MCGI is really to help patients get the best care as close to home as possible,” said the program director, Leah Graham.

While the initiative does not replace the need for cancer treatment centers, where patients work with oncologists to create a plan, the matchmaking process can allow some to receive treatments from home. 

“The drugs that target a certain gene mutation that’s found in the cancer are oral therapies,” Graham said. “A lot of the treatments are new. Some physicians have never prescribed them before.”

An observational study by MCGI found that patients who received matched treatment through the initiative were nearly a third more likely to survive the following year than those who did not.

“The great thing about targeted therapy is there tends to be less terrible responses,” Graham said. “They’re less toxic in some ways.”

The American Cancer Society’s Road to Recovery transportation program, which has operated for over 40 years and is another option for cancer patients needing transportation to appointments, has been slow to return to normal capacity and regain lost volunteers after the pandemic.

There are also places like the Beth C. Wright Cancer Resource Center, which recently opened a second location in the small town of Baileyville in Washington County, that coordinates rides to and from appointments. The new center, which does not provide treatment but does offer wraparound services, is aimed at reaching people in the far eastern part of the state, which has some of the highest rates of cancer diagnosis and deaths. 

“That is a hot spot. That’s where a lot of our patient population comes from,” said Fochesato. 

Many, she added, will skip treatment if they think they can’t afford to make it. 

“Some (people) will go without eating to pay for their medication … it’s not pretty,” Fochesato said. 

Despite the closure of treatment centers, Cora Fahy, a breast cancer survivor and MCGI board member, said she feels more optimistic about the future of cancer survivors because of the number of local organizations working to pull together different resources across the state.

“In the nine years, even since I was diagnosed, there’s so much more offered out there,” Fahy said. “I’m very, very, very optimistic about survivorship.”