Maine has the fifth-highest rate of emergency department visits in the country, which hospital officials say could get worse with cuts to Medicaid and further contraction of services.

Hospitals in the state saw 555 emergency department visits per 1,000 people in 2023, according to recent data from the American Hospital Association analyzed by KFF. The only states with higher rates were West Virginia with a rate of 596 per 1,000 people, North Dakota with a rate of 591, Louisiana with a rate of 589 and Mississippi with a rate of 567.

Nevada had the lowest rate of 226, followed by Alaska at 258 and Arizona at 281 visits per 1,000 residents.

Steven Michaud, president of the Maine Hospital Association, said Maine has had a high rate of emergency department visits for decades, which he said is largely because it is one of the most rural states and has limited access to primary care doctors, which can drive Mainers to the emergency department if they can’t get timely access to primary care.

“A lot of it is not an emergency,” he said. “They’re using it as their primary care, which you just don’t want to do because it’s inefficient, it’s expensive and all that.”

While the trend is not new, this all comes at a time when Maine hospitals are merging, reducing services and even closing.

Northern Light Inland Hospital in Waterville stopped its services on May 27. A California-based nonprofit announced plans to take over three hospitals through its purchase of Central Maine Healthcare. Northern Light Health reported a $156 million loss last year.

Mount Desert Island Hospital announced it would close its birthing unit in July. MaineGeneral planned to end its pediatric psychological services last month. And on May 29, two Aroostook County hospitals said they would merge their management for a year to “remain viable.”

Michaud said these are “unprecedented times,” and that these closures are happening across the state, even in smaller communities where they don’t grab as much attention. For example, he said Penobscot Valley Hospital also had to end behavioral health services due to financial losses and paused payments after lawmakers failed to initially pass the supplemental budget.

All these closures may not be the primary driver of the trend of emergency visits, but they’re definitely a factor, he said.

“What happens when people get into a behavioral health crisis? Where do they go?  The emergency departments,” Michaud said.

Hospitals have tried to address the issue by creating walk-in clinics, he said, but that requires additional staff.

Dr. Jay Mullen, CEO of BlueWater Health and a practicing emergency physician with experience in hospitals around the state, agreed with Michaud that the highest use of emergency departments is in the “most rural areas where access to primary care, dental care and urgent care services are the most limited.”

He added that Maine has a higher proportion of older adults and people with chronic conditions, which can contribute to emergency department visits.

High use of emergency departments can strain resources, leading to longer wait times and potentially delayed care, Mullen said.

“For patients, this can mean fragmented care and less continuity, especially when (emergency department) visits are used in place of primary care,” he said. “However, it’s important to note that (emergency departments) in Maine are doing their best to meet these needs — often serving as the only accessible point of care for vulnerable populations.”

And in some communities, Mullen said there can be benefits. High rates of emergency department visits can actually be a “financial stabilizer” for rural hospitals by providing critical revenue to support broader hospital operations.

“Rural (emergency departments) operate with high fixed costs — staffing, infrastructure, and compliance requirements remain constant regardless of patient volume,” he said. “When visit volumes are low, these fixed costs are spread across fewer encounters, making each visit disproportionately expensive. But when volume increases, even modestly, it helps offset those fixed costs and improves the financial viability of the department.”

Both Mullen and Michaud said another factor contributing to high rates of ED visits is that many Mainers have coverage from MaineCare, the state’s version of Medicaid. Nearly a third of all Mainers were enrolled in MaineCare last year, including two-thirds of nursing home residents and half of all children.

This isn’t limited to rural areas, Mullen said. Urban areas with a lot of people on MaineCare also see higher rates of emergency department visits, suggesting “that both geographic and socioeconomic factors are at play.”

People on MaineCare often struggle to find primary care providers who will accept them due to low reimbursement rates, Michaud said. As a result, they might end up in the emergency department.

Michaud said expected federal cuts to Medicaid will only make this worse: “Any time you reduce coverage, you exacerbate this.”

U.S. House Republicans narrowly forwarded a bill last week that would reduce Medicaid spending by at least $600 billion dollars over 10 years and is expected to reduce enrollment by about 10 million Americans.

Another factor impacting emergency department visits is that Maine sees high numbers of visitors, many of whom don’t have doctors, so hospitals in destination towns along the coast often see surges in the summer, Michaud said.

While Maine’s rural nature may explain its high ranking for emergency department visits per capita, there were some rural states that had low rates. In particular, Michaud said he was surprised to see Alaska among the lowest rates. And Massachusetts, which has near-universal healthcare, still had the 14th highest rate of emergency department visits.

Michaud said there are many factors that contribute to these trends and it’s difficult to tell what might explain each state’s ranking. It might be that some states have robust public health networks, unlike Maine, which has only two city public health departments in Portland and Bangor.

“Hospitals in Maine serve as the public health infrastructure,” he said.

This story was originally published by The Maine Monitor, a nonprofit civic news organization. To get regular coverage from The Monitor, sign up for a free Monitor newsletter here.