I was recently admitted to a community hospital in southern Maine. What I experienced was eye-opening and disturbing.

Initially admitted to the facility’s overcrowded emergency department (ED), I observed patients sleeping in hallways amid glaring lights and the unrelenting din of ED activities. Later I was transferred to an inpatient unit located deep within the hospital’s interior that was bleak and devoid of natural light or glimpses of outside life. Patients were crowded into small quarters, separated by curtains that provided minimal privacy, allowing sensitive nurse-patient conversations to be overheard.

Despite these conditions, the unit staff with whom I interacted were competent, conscientious – and as dispirited by their challenging environment as I was.

The conditions I experienced reflect the funding disparities and inequities facing community hospitals nationwide. According to the Boston Globe, while Medicare and Medicaid pay less than market rates, private insurers pay even less to community hospitals and far less than they pay large, academic medical centers. Is it surprising that smaller hospitals, providing the same services, struggle mightily to upgrade their facilities and meet rising labor costs?

About 30 million people are admitted annually to U.S. community hospitals. Most nonmaternal admissions are people over age 65, and 97% are paid for by Medicare and private insurance, such as Medicare Advantage plans (MAP). These popular, heavily marketed plans generate significant patient volume, now insuring 54% of all Medicare beneficiaries and accounting for 48% of all Medicare inpatient days.

MAPs are privatized versions of Medicare that differ markedly from traditional Medicare. The Kaiser Family Foundation reported that these plans frequently require prior authorizations before covering prescribed services, like inpatient hospitalizations (98%) and skilled nursing stays (99%). Prior authorizations are defended as reducing unnecessary care and costs but impose expensive administrative burdens and frustrating treatment delays on health care providers and patients.

MAPs also demand that beneficiaries use specific provider networks or pay more in “out-of-pocket” costs. According to KFF, hospitals and medical groups have raised concerns about the deleterious impact of MAPs’ policies on their finances once they join an insurer’s network. As occurred in Maine in 2022, hospitals and other providers nationwide have terminated or threatened to terminate, in-network contracts over delayed, payments, restrictive coverage determinations, and payment rates.

The situation facing rural communities is particularly dire.

Most residents rely on small, local hospitals and clinics, characterized by low volume and older, poorer and sicker patients. According to KFF, MAPs have increased their market share of rural beneficiaries from 18% in 2015 to 40% in 2022. At the same time, the Center for Healthcare Quality and Payment Reform reported that, due to financial losses, 64% of Maine’s rural hospitals were rated as either “at risk” or “at immediate risk” of closing. The report emphatically concluded that the reasons for such losses were not service inefficiencies or low Medicaid and Medicare payments, but inadequate payments from private insurance plans such as MAPs and employer-sponsored plans.

Exacerbating the prospects for rural communities are private equity companies that have aggressively been buying distressed rural hospitals and clinics cheaply, reaping quick returns by administrative reorganizing, cutting staff and services, and placing struggling community economies and their health care services at the mercy of profit-driven firms.

While community hospitals are clearly the primary drivers of U.S. health care spending, clearly other players contribute to, and perpetuate our costly and dysfunctional system. At every level there is much at stake and much to do, beginning with federal legislation to bolster Medicare’s financial stability and make it less complicated, less expensive and more comprehensive.

There are also meaningful actions that individuals and small groups of citizens can take that are neither complicated nor time-consuming. We can tell our personal health care stories to local, state and federal legislators, friends and neighbors and the wider community. We can support progressive health care legislation and the legislators who sponsor it. We can contribute resources to health care advocacy groups that need donations, volunteers, and/or our support to secure additional funding. And we can regularly assess the quality and efficacy of our individual health care and drug coverage during the annual open enrollment period.

This is the time (between Oct. 15 and Dec. 7) when Medicare beneficiaries can evaluate and change their health and drug plans, yet only 30% do so. Assessing the quality and efficacy of our current health care coverage, and urging our neighbors to do likewise, will both help us more closely scrutinize the quality and conditions offered by our community providers, and hopefully reduce the chances of anyone else having a disturbing hospital experience like the one I had.