Jessica Rogers has tried for two years to find a mental health counselor who can take her on as a new patient. But she continues to struggle on her own with the grief that followed her adult son’s death in 2020.
“It’s been pretty much impossible,” said Rogers, of Augusta. “I ended up giving up. Every place I called had a long wait list or weren’t accepting patients.”
Sara Kinrade, of Naples, can’t schedule a dentist appointment for her 5-year-old son, even though she knows he has a cavity. It’s maddening to know he’s in pain and that there’s not much she can do.
“I have called every dentist within 50 miles, and I can’t get him in,” Kinrade said. “I’m just so frustrated I can scream. It makes me feel like I’m a bad parent.”
Alex Petrovich, of Woodstock, said that despite many efforts, he can’t get in to see a mental health therapist, and he knows it’s holding him back.
“It’s like I can see the finish line, and I know what needs to happen, but I’m stuck,” the 27-year-old said. “I can’t take that first step forward to get better.”
Maine is experiencing a crisis in access to health care services. While a record number of Mainers now have health insurance, many are finding it difficult or impossible to get help from a broad range of providers – primary care doctors, medical specialists, mental health counselors, dentists. It can take months – even more than a year – to get an appointment with a health professional, frustrated patients told the Portland Press Herald.
While the severity of the problem may vary, other states also are struggling with access. The U.S. will need 4.2 million additional health care workers to meet the demand over the next five years, according to Kaiser Permanente, a national managed-care organization.
The reasons for constricted access to health care are myriad, but experts say the pandemic worsened access in two significant ways. People delayed care during the early years of the pandemic, and as restrictions were relaxed, patients flooded the health care system seeking services for untreated or chronic health problems. Meanwhile, the health care workforce shrank during the pandemic, leaving fewer health care professionals to see an increasing number of sicker patients.
Maine’s population also has grown – by slightly under 2% since 2021 – outpacing the rest of New England. Maine’s population had only grown 2.6% from 2010 to 2020. The population increase is driven by people moving to Maine since the pandemic, including an influx of people from other states and the immigrant population.
Delayed care leads to sicker patients with more complex conditions, research shows.
More people will need hospitalization to treat mental health crises, for example, when they may not have reached a breaking point had they been seeing counselors. And what could have been an easily managed chronic illness can grow serious if left untreated – hypertension, for instance, developing into a significant heart condition.
Petrovich’s wife, Roxy Kai-Petrovich, said she’s been trying to get a primary care doctor for more than a year, ever since her doctor moved away. Her physician had been a convenient 15-minute drive away, a rarity in rural Maine. She has chronic conditions, including attention-deficit/hyperactivity disorder and migraines, and she’s had a difficult time managing them without a doctor.
“Every place I call, there’s such a long wait list with no end in sight, or they say they’re completely full and don’t even have a waitlist,” Kai-Petrovich said.
Kristin Jackson, of Brunswick, said it took about 10 months to get an appointment with a dermatologist so she could properly diagnose and treat a skin rash. And trying to schedule a preventive colonoscopy screening is also a monthslong process that she is still in the middle of trying to navigate.
“It’s just really frustrating. America is an advanced country with a supposedly advanced health care system. It can make you feel really helpless,” Jackson said.
Medical professionals say they understand the frustration and sympathize.
“Every new patient we see tells us, ‘I’m so glad we’re here. I waited so long to get here.’ It really breaks my heart,” said Dr. Brigitte Salembier, a primary care doctor with MaineHealth in Westbrook.
Dr. Andy Mueller, CEO of MaineHealth, the largest health care provider in Maine and the parent organization of Maine Medical Center in Portland, said everyone is feeling the strain, from health professionals to patients.
“There’s not enough availability compared to demand,” Mueller said. “We have patients seeking care, and we know they are having difficulty finding it. We are still dealing with a lot of deferred care from the pandemic.”
Glenda Dwyer, vice president of clinical operations and chief access officer for Northern Light Health, said bottlenecks delaying care cause a host of problems in the health care system, so solving the access problem is paramount.
“If we don’t get people in through the gate, they just get sicker and sicker,” Dwyer said.
While the uninsured rate in Maine declined from 8% in 2019 to 5.7% in 2021 – the most recent data available – having insurance coverage does not guarantee being able to get a doctor’s appointment.
Experts say the global pandemic continues to reverberate through the health care industry, exacerbating what already had been a persistent access problem, especially in rural areas of Maine.
The ability to see a health care provider historically has varied in Maine depending on whether patients were in rural, suburban or urban parts of the state, and whether they were covered by MaineCare, Medicare or private insurance. But patients around the state are now struggling to find care.
Statewide labor statistics tell part of the story. Maine’s health care practitioner workforce is significantly leaner than before the pandemic.
As with workers in many other sectors, health care professionals retired early or left the workforce for other careers faster than they could be replaced. The stress and strain of caring for patients during the peak of the pandemic added to the exodus. And now a shortage of staff across the health system may be causing more to leave. Between 40% and 70% of health care workers say they feel burned out, according to national data.
Workforce numbers vary widely in the many sectors of health care, but the number of health care practitioners – which includes doctors, nurses and numerous other medical positions – has declined overall.
In 2019, the year before the pandemic began, Maine’s health care practitioner workforce totaled 42,390, according to the U.S. Bureau of Labor Statistics, a peak after several years of mostly slow and steady growth. By last year, the number had declined to 41,110.
Because the state’s population grew during the period – a trend also fueled by the pandemic – the decline was more significant on a per capita basis, with 67.32 practitioners per 1,000 population in 2022, the lowest level in more than a decade.
The decline was evident in key areas, such as primary care, where demand for services is especially strong. The number of family medicine doctors in Maine decreased from 710 in 2019 to 580 in 2022. Nurse practitioners declined in number from 1,380 in 2019 to 1,300 in 2022, while the pool of physician assistants fell from 840 in 2019 to 770 in 2022.
The number of registered nurses increased slightly, from 14,490 in 2019 to 14,610 in 2022, in part a result of aggressive efforts to build the nurse workforce. But there is still a shortage of nurses compared to the need, especially in hospitals, health officials have said. Workforce gaps are often filled by expensive traveling nurses, straining hospital budgets.
At the same time the state’s workforce declined, demand for services climbed.
People put off seeking care for health issues during the early years of the pandemic. Then demand exploded. And patients now tend to have more complex problems because they went a long time without screenings or treatment, health professionals say.
Patients who are now coming in for primary care or specialized services have greater needs in large part because their untreated chronic conditions have become more severe. Fifteen-minute consultations take twice as long. Each patient takes longer to care for.
The situation is especially critical in mental health.
“We are having a mental health crisis in this country,” said Jayne Van Bramer, president and CEO of Sweetser, a Maine mental health provider. “We have high levels of suicide, anxiety and depression, especially in our youth. But we have a waiting list at Sweetser of over 2,000 people.”
Van Bramer said Maine’s reimbursement levels under MaineCare are too low and the state needs to step in and fix the system. MaineCare is the state’s name for Medicaid, a state-administered program funded with state and federal dollars.
“We pay our therapists much less than in any state I’ve worked, including Oklahoma,” said Van Bramer, who also worked in New York.
Without care, patients who otherwise might be stable end up in crisis in hospital emergency departments.
“When a person goes to the ER, that’s far more expensive for the system than paying mental health therapists,” Van Bramer said. “We are being penny wise and pound foolish.”
Dr. John Campbell, senior physician executive at Northern Light Acadia Hospital in Bangor, said it’s not just the increased ER crisis care. Some in need of help self-medicate with alcohol and drugs.
“We’re not anywhere near as effective as we could be,” he said.
Dental care is also facing staff shortages and overwhelming demand, said Kalie Hess, associate director of the Partnership for Children’s Oral Health, and both those with private insurance and MaineCare are affected.
“Access is definitely a problem. There are fewer providers to serve more people,” Hess said. “We definitely still need more dentists and more hygienists.”
Dental disease is the most prevalent chronic disease in childhood, and preventive care is key, she said: “It’s really horrible the number of kids in Maine who are not getting any preventive care.”
In 2019, Maine had 590 dentists, according to the U.S. Bureau of Labor Statistics. That total dipped to 521 in 2021 before rebounding to 560.
But in 2022, Maine created a new adult MaineCare dental benefit covering about 200,000 Mainers, many of whom had gone decades without care.
That’s created a crushing demand, only made worse because not all dentists accept MaineCare, in part because reimbursement rates are lower.
Kinrade, whose 5-year-old son has a cavity that needs care, said their MaineCare insurance doesn’t help.
“Some of these waiting lists go into 2025,” she said. “He’s not going to even have the same teeth by then.”
LACK OF ACCESS HARD TO MEASURE
Workforce statistics gathered by the health care industry and state and federal governments tell only part of the story.
The number of primary care physicians in Maine per capita is one of the highest in the country, for instance, even with the dip since the pandemic.
But the numbers don’t reflect how the need has changed since the pandemic, with patients requiring more care and time. Maine also has the highest median age in the nation – 45 – and older patients typically have more health problems and take longer to treat. And doctor totals don’t take into account other health care workers – physician assistants, nurse practitioners, front-office staff – who are essential to making a practice run smoothly.
Meanwhile, there is no comprehensive data to track wait times for medical appointments around the state and therefore no way to measure the unmet demand or to compare Maine’s access crisis to other states.
MaineHealth is in the middle of updating the way it tracks how long it takes to get in to see a doctor, said spokesman John Porter.
Dwyer, of Northern Light Health, said their health system does not have a statistic that shows, over time, the changes in wait times for patients, but access has definitely been a problem.
In Northern Light’s service area, which includes Bangor, Portland, and many parts of northern and Down East Maine, Dwyer said, there are 37 vacancies for advanced practitioners in primary care – doctors, nurse practitioners and physician assistants. That number has sometimes been as high as 50.
Before the pandemic, vacancies would typically be in the 15-20 range, she said.
Some data points to the demand for mental health care. A comprehensive report by the nonprofit Mental Health America found that when looking just at “access to care” including therapists per capita, Maine ranks 11th among the states. But when looking at a number of factors, such as unmet mental health needs and prevalence of substance use disorder, Maine’s ranking plummets to 31st.
SEARCH FOR SOLUTIONS
Maine’s health care systems are trying to increase efficiency by various means: changing how patients are scheduled, expanding telehealth, assigning patients to teams of providers instead of just one doctor, increasing the number of graduates in health care and providing incentives for them to stay in Maine. The University of New England, MaineHealth, Northern Light and others have expanded student enrollment in various health care fields in Maine recently, including nursing, primary care, dentistry and other health care fields.
Telehealth, which boomed as a pandemic necessity, is now being used for some of the simpler health needs, such as medication management, that used to require in-person appointments.
More MaineHealth practices are using a team-based approach. Salembier works on a care team with Caitlin Costigan, a nurse practitioner. They manage 1,800 patients and give them care based on needs. Some patients may just need to see a nurse or have a telehealth consultation, they said.
Costigan said in specialty care practitioners can consult “econsultants,” apps linking physicians in specialty areas, such as dermatology. Primary care doctors used to often have to call specialists with questions and wait for responses, which could take time if the specialists and primary care doctors were booked up with appointments. But the apps’ doctors focus solely on responding to queries from other doctors.
Mueller, the MaineHealth CEO, said there are some common sense ways to improve efficiency, such as streamlining responses to patients’ online messages to their doctors. A doctor doesn’t need to respond to all of them, and MaineHealth now funnels some questions to others, including nurses and front-office staff.
Hess, of the Partnership for Children’s Oral Health, said they are looking for ways to provide baseline care when dentists aren’t available, such as in-school clinics where hygienists can provide cleanings and fluoride coatings.
Northern Light, Dwyer said, is trying to reduce patient no-shows by 10% with increased communication with patients to ensure they show up to appointments.
In all health care sectors, suggestions of ways to help fix the access problems include increasing MaineCare and Medicaid reimbursement rates, loan forgiveness for college graduates in health fields and increasing the number of college graduates in health fields including mental health, primary care and dentistry.
Northern Light Acadia Hospital in Bangor is starting a postgraduate residency program to help boost the number of psychiatrists in Maine, said Dr. John Campbell, senior physician executive. The number of psychiatrists practicing in Maine fell from 220 in 2015 to 110 in 2020. And with the average age of Maine psychiatrists at 55, many will soon be retiring.
With four residents per class, the Northern Light program will have 16 residents in four years, Campbell said, helping alleviate shortages. He said it’s hard to know how many psychiatrists will remain in Maine after completing their residencies, but typically it’s about half.
Van Bramer said Sweetser has also expanded non-clinical mental health care, such as peer support and call lines that allow people to discuss their challenges anonymously. Sweetser also has a system in place to call and check in on the people on its waitlist – and it refers some to outside services.
Lindy Graham, CEO and founder of Wellspace, a Portland- and Yarmouth-based outpatient mental health clinic, said Wellspace is always working at improving patients’ access by “shortening the time between when they reach out to us and get an appointment.”
The new Wellspace@Work program, she said, provides mental health services to workers at companies, which gives people faster access.
“When people are in a place of distress and it takes enormous hoops for them to jump through to get to a clinician, that’s really traumatic,” Graham said. “At a time when someone needs help, it should be a seamless process.”
Jessica Rogers, whose 23-year-old son Hunter died of a fentanyl overdose in October 2020, said the fight to find a mental health counselor has been exhausting and painful.
“It’s a lot of effort just to be told no,” she said. “I called Augusta, Portland, Bath, Brunswick. Every place I called, they said, ‘Try back in a few months.’ No one was even taking names for a waiting list.
“It’s frustrating, and it’s hard to understand.”