At MaineHealth, we are proud that we are able to provide our patients with excellent care and that we continue to improve the health of the 1.1 million people who live in our health care system’s service area, which includes the 11 southernmost counties in Maine and Carroll County, New Hampshire.

That pride exists in no small part because we are making progress even as the health care landscape grows more difficult to navigate. An unstable public-policy climate, challenges in delivering wondrous but often expensive new treatments, and a looming shortfall of qualified doctors, nurses and other care providers all create a good deal of uncertainty for health care systems.

Yet, within this larger context, a disturbing divide is forming. The challenges that hospitals and health care providers face are growing particularly acute in rural communities, and that is a big concern here in Maine. And it’s also a big reason why Maine people should support expanding the Medicaid program here – known as MaineCare – under the federal Affordable Care Act by voting “yes” on Question 2 on Nov. 7.

Rural providers in Maine and elsewhere are being stressed as they care for populations that tend to have higher rates of under-insurance or no insurance at all. Those same small hospitals are also seeing surgeries and other complex procedures migrating to larger medical centers that are better able to leverage new technologies, and to highly specialized providers who can deliver improved outcomes. And our rural providers have more patients with government insurance – either Medicaid or Medicare – that doesn’t cover the full cost of providing care to those patients. That problem is exacerbated by the fact that the Affordable Care Act cuts Medicare payments in Maine to help pay for Medicaid expansion, which benefits other states but is something not taken advantage of in Maine.

As a result of these trends, many rural hospitals and health care networks are struggling. For the 2016 fiscal year in Maine, 19 of the state’s hospitals lost money. Notably, taken together, Maine’s 36 hospitals had a combined operating margin of $29.4 million that year, but if you take out the two largest, Maine Medical Center in Portland and Eastern Maine Medical Center in Bangor, the remaining Maine hospitals lost $50.7 million.

Expanding Medicaid under the Affordable Care Act would help to stabilize the finances of all Maine hospitals, and it would be especially helpful for rural providers. According to statistics from the Maine Center for Economic Policy, the four least-populous counties in Maine – Franklin, Lincoln, Piscataquis and Washington – would see an average of 6.2 percent of their residents covered under expansion. In the four most populous counties – Cumberland, Kennebec, Penobscot and York – an average of 4.9 percent would gain coverage.

We know from experience that this would offer immediate relief to struggling hospitals. Memorial Hospital, a MaineHealth member in North Conway, New Hampshire, saw a reduction in uncompensated care of $1.4 million in the first year of Medicaid expansion in that state. That is a significant positive impact on a small rural hospital, and we can expect the same in Maine.

Expanding Medicaid eligibility would also lift the underlying economy. Again, this impact would be felt disproportionately in rural Maine, where a larger percentage of the population would become eligible for coverage. With the federal government paying no less than 90 percent of the cost of expansion, nearly $500 million a year is expected to flow into the state, creating 6,000 new jobs.

It is true that the state government would eventually have to pick up 10 percent of the cost of expansion – about $55 million once the federal share falls to 90 percent in 2021. That amount is equal to about 5 percent of the state’s current Medicaid spending and less than 2 percent of the overall state budget.

The return on that investment, however, is thousands of jobs and help for our rural health care providers, and that’s important.

Expanding MaineCare under the Affordable Care Act won’t solve all the problems facing our rural health care providers, but it would be an important step.

Importantly, with so much out of our hands when it comes to the forces affecting health care, this is something we can actively control to help our patients and providers while growing our economy.

Please join us in voting “yes” on Question 2 on Nov. 7.