Two days after giving birth, Brianna Lareau wasn’t eager to strap her newborn daughter into the car seat and crisscross the state for 120 miles worth of driving. 
But her baby’s health needs, and her distance from her doctors, required it.

It started with a drive of more than 30 miles from Lareau’s home in Piermont, New Hampshire, to her pediatrician in Plymouth for her baby’s checkup.

As soon as she finished, Lareau, 36, got an urgent call from Dartmouth Hitchcock Medical Center in Lebanon, where she’d given birth. The hospital wanted to see her immediately about the high blood pressure she’d had near the end of her pregnancy. So, Lareau drove more than 60 miles to Lebanon, with a stop back home in Piermont along the way.

But soon after she arrived in Lebanon, the pediatrician called. Tests results indicated her baby was at a higher risk of developing jaundice. She needed light therapy right away – back in Plymouth.

“Two days after giving birth, you’re barely able to walk,” Lareau said. “The idea of having to travel again – I just broke down hysterically at Dartmouth.”

Instead, Lareau drove more than 30 miles home and headed to Plymouth with her daughter the next morning.

Lareau’s trip around New Hampshire two days post-partum is an example of just how challenging it can be to access health care in northern New England.

Proximity to health care is a common concern in rural areas. But the miles and minutes between patients and care in northern New England have been increasing for years, and the implications are troubling.

Greater distances from hospitals is linked to higher rates of fatal accidents, fatal heart attacks, and infant mortality, according to Federal Reserve Bank of Boston senior policy analyst Riley Sullivan, who has studied diminishing health care access in northern New England.

Meanwhile, health care facilities are finding it harder to attract the workers they need for a variety of reasons, including a lack of housing and high costs of living. And providers everywhere say inadequate reimbursement rates for certain patients are leading to major losses.

Overall, hospitals are finding that they have no choice but to cut back on services due to acute financial challenges. Lareau had her baby in Lebanon because the next-closest hospital had closed its labor and delivery unit years ago.

Lareau said she often wondered what she’d do if her water broke while her husband was at work 40 minutes away. How fast would an ambulance arrive? Would she have to drive herself to the hospital?

“I've heard some wild stories about people having to drive two-plus hours to get to the hospital,” she said. “It just emphasizes how important care is.”

“We need more people to move in”

Lareau is part of what she described as a “mini-baby boom” in Piermont, a town of less than 800 people. But this is not the trend across northern New England. Its states are the nation’s three oldest by median age, with Maine at 45.1, New Hampshire at 43.3, and Vermont at 43.2.

They also have some of the nation’s lowest fertility rates. Vermont is lowest, at 44.3 live births per 1,000 women of childbearing age. New Hampshire is 5th-lowest (47.9), and Maine is 7th-lowest (49.7).

Both trends have huge implications for health care. One obvious issue: Older populations need more medical care. And Sullivan notes older populations are also more often aging into retirement.

“We're losing some of the working-age population who would be working in these hospitals,” he said.

Meanwhile, the number of births is too low in several areas to support maternity wards.

Sullivan’s report said 22 of northern New England’s 75 hospitals didn’t have maternity wards in January 2019. Maine has since seen seven more shut down in a spate of closings, while one more each has closed in both New Hampshire and Vermont.

Sullivan said the closures build on themselves, because the area becomes less appealing to young families planning to have children.

“It would just exacerbate the drainage of prime-age people away from those areas that are already having birth-rate problems,” Sullivan said.

Medical workers who do want to come to these areas face escalating costs of living. Between April 2020 and April 2025, the value of a single-family house rose 65.3% in New Hampshire, 63.7% in Maine, and 41.8% in Vermont, according to Zillow.

Boston Fed principal economist and policy advisor Mary Burke, who studies regional labor force participation rates, said higher costs of living make rural areas a harder sell, even when people want to be there.

“The equation has to work in terms of what they can afford and just the availability of housing,” she said.

All these issues – including a contracting patient base, workforce shortages, higher costs, and what providers say are low reimbursement rates – add up to big strains on health care systems:

• Northern Light Health, Maine’s second-largest health care system, lost a staggering $156 million in 2024, according to its annual report. Northern Light Inland Hospital in Waterville closed last month.
• A state-mandated (and disputed) analysis found that – under various assumptions about 5-year revenue and expense growth – Vermont hospitals will need to find between $700 million and $2.4 billion to break even by 2028.
• Catholic Medical Center in Manchester, New Hampshire, last year reported “monthly losses ranging from $2 - $3 million,” before being sold in February.

Dr. Sunil “Sunny” Eappen, CEO of The University of Vermont Health Network, said economic development is the key to reversing these trends and expanding health care access.

“I think that when you look around the country in rural areas and you find thriving health care systems or hospitals, what you see are thriving communities, where economic development is strong,” he said.

Eappen cites various potential catalysts – including improved infrastructure and more housing. Ultimately, it all comes down to one thing, said Eappen, a member of the Boston Fed’s Board of Directors.

“We need another 100-150,000 young people to move in who are working and paying into a commercial insurance population,” he said. “We need more people to move in.”

“Treat it best you can, Doc. Or I’ll get by on my own”

Dr. Ronald Blum did not expect to move to the northern Maine town of Patten.

The southeast Pennsylvania native and his wife were exploring the continent on a post-med school road trip in their Volkswagen van in 1973. His folks were forwarding his mail to stops along the way, and Patten – a former logging town of about 900 people in the foothills of Mount Katahdin – was just outside Baxter State Park, the Blums’ next destination.

Who knew a truckers strike would delay the mail and force them to extend their visit? Who knew they’d meet friends who’d insist they stay through New Year’s? A month passed before they left. And the connections they made were so deep that when Patten needed a doctor for the local clinic, residents reached out to Blum.

“You're in for a one-year contract,” said Blum, now 80 and retired. “You're still there 50 years later.”

Blum learned quickly that rural medical practices were different. One of his early patients sheared off the top of his hand with a chainsaw cutting firewood. Blum prepped the wound, exposed tendons and all, for a trip to the closest surgeon 35 miles away. But that wasn’t happening.

“You can treat it best you can, Doc,” the man told Blum. “Or I'll get by on my own.”

Patients showed up at his house so often that Blum remembers his 5-year-old daughter at the screen door during one drop-in, wondering if he needed her to “assist” by handing him gauze and other supplies: “Is that anything good, Dad?” she asked. “Or should I go play?”

Blum had to be versatile in his practice. But sometimes patients needed a specialist, and those have become harder to find, he said. Blum recalls diagnosing a patient with kidney failure and arranging a visit to a specialist 100 miles away in Bangor for the next day. That doesn’t happen as easily now, he said.

“There's nobody at the other end that'll say, ‘I'll see you tomorrow’ anymore,” he said.

Blum thinks attracting doctors and health care workers starts with finding people who already feel a pull to rural places and outdoor life, like he did.

“You have to want to live here,” Blum said. “Then you can work out the economics.”

Young docs choosing rural medicine must weigh worries and rewards

Dr. Anne Morris, 41, is exactly the kind of person Blum is talking about. She loves rural life and wants to serve communities similar to where her parents grew up in Vermont. Since 2014, she’s been practicing family medicine in Milton, Vermont, a tightknit community about 35 miles from the Canadian border.

“I have a couple of families that are three or four generations deep. I take care of grandkids, children, parents, and siblings. It’s really special,” said Morris, who emphasized during an interview that she was sharing her own personal views.

Morris and Blum are both primary care physicians, and they are in huge demand nationally and regionally. The Vermont Medical Society says the state’s current supply of primary care physicians is about 370 full-time equivalents short of what it will need in 2030.

Morris directs the University of Vermont’s residency program for family medicine, so she teaches young doctors in a clinical setting along with treating her own patients. She knows what worries new physicians:

Will I be able to pay off five- and six-figure student loans? Will I have to spend dozens of unpaid hours weekly on administrative tasks? If I move for work, can my spouse find a job? Will my children be able to attend good schools?

The answers can be more uncertain in rural areas and for primary care physicians, who sometimes get paid less than doctors in other specialties. Morris adds there’s no doubt that Vermont’s housing shortage is hurting recruitment, but that’s just one worry.

“The combination of mortgage, daycare, and student loan payments would have been a lot to handle myself as a young physician,” she said.

Morris said Vermont has stepped up to draw more primary care providers. One effort offers student loan repayment programs for physicians and other health care providers who work for a time in Vermont’s underserved areas.

Morris said she’s proud that about half of graduates from her residency program stay in Vermont. They aren’t choosing family medicine for money, she said, but because they believe they can help the community.

“I hope that I’ve done that even just a little bit over the last decade,” she said, “And I hope that I'm instilling that ethic into my residents.”

“Deserts” are everywhere in northern New England

Health care workers who do decide to come to northern New England accept that they’ll live in a challenging medical environment – and one that’s developed a few too many “deserts.” Among them: “medical deserts,” “ambulance deserts,” and “maternity deserts.” Each desert is defined differently, but access to important health care services or personnel is relatively scarce and distant in all of them.

In a primary care medical desert, for instance, there’s no more than one primary care doctor for every 3,500 people. It’s also at least a 30-minute drive to primary care medical services, among other measures in the Code of Federal Regulations. Maine leads the region with nine medical deserts called “geographic primary care Health Professional Shortage Areas.”

Driving distance also defines “ambulance deserts” which are “more than a 25-minute drive from where an ambulance is stationed,” according to a 2023 paper from the University of Southern Maine.

Rural counties host more than half of the 4.5 million people in the U.S. who live in ambulance deserts, and rural northern New England fits this trend. The “rural mountainous” areas of Maine and Vermont were cited in the report among the places with the “highest share and number of people living in ambulance deserts” in the country.

The study’s lead investigator, Yvonne Jonk, said ambulance services now provide much more than just transportation to hospitals. Their added capabilities have increased the costs of equipment, training, and certification and made the services tougher to afford in sparsely populated places.

In some areas, those well-trained ambulance workers are the community’s chief care providers, Jonk said. So reduced access to them really matters.

“They're like the front line in many communities for health care,” she said. “They're doing a lot of primary care out in these communities that otherwise these people would never receive.”

“If you kill obstetrics, you kill a community”

“Maternity care deserts” aren’t as precisely defined. But in New Hampshire, many residents of the beautiful and remote North Country – which spans about one-third of the state – say they’re living in one after being forced to travel longer distances to find maternal care.

Of the 11 hospitals in New Hampshire that have closed their labor and delivery units since 2000, three were in the North Country.

Neonatal nurse Lisa Lamadriz, 64, and her husband moved to the North Country in 1993 to work at Cottage Hospital in Woodsville. She was often alone in the delivery unit when patients in labor arrived on snowy nights.

“In a rural hospital, the physician can’t always make it in time,” Lamadriz said. “I had my kit ready and got used to catching babies on my own.”

Lamadriz now works at Dartmouth Hitchcock Medical Center in Lebanon, but she still lives in the North Country. She was devastated when Cottage closed its labor and delivery unit in 2014.

“I knew it was going to cause a tremendous hardship on a community that was already impoverished,” she said.

One of the last labor and delivery units in northern New Hampshire belongs to Littleton Regional Healthcare, a hospital founded in 1907. Dr. Edward Duffy, Littleton’s chief medical officer, said the hospital is committed to keeping their unit open, declining local birth rates or not.

“Caring for the health of women in general – which, after all, is about half the population – has been very important economically,” he said. “If you kill obstetrics, you kill a community, because young people don't want to stay.”

Duffy said Littleton Hospital works closely with Dartmouth Hitchcock Medical Center on maternity care and an effort to help address care deserts called the North Country Maternity Network. Dartmouth coordinates with local hospitals and also brings North Country nurses to Lebanon for periodic training in obstetric emergencies, said Daisy J. Goodman, a nurse and associate professor at Dartmouth’s Geisel School of Medicine.

“Our goal … is to provide a safety net for anybody who's pregnant in the North Country and their families,” she said.

What stops the bleeding?

Steve Michaud has been president of the Maine Hospital Association since 1999. He knows hospitals lose money. But what he’s seeing today is different.

“What we’re not used to is how much they’re losing,” Michaud said. “It’s far more money than we ever saw before.”

The $156 million loss at Northern Light Health more than quadrupled its $36 million loss from the prior year. And MaineGeneral Health in Augusta, the state’s fourth-largest health care system, announced in March that's it's losing about $600,000 a week.

Michaud blames a “pandemic hangover” for the precarious condition of the state’s health care system. First, the stresses and demand for care during COVID caused an acute labor shortage. People burned out and left the field, while others retired, if they could.

He said hospitals were forced to turn to enormously expensive traveling staff, like nurses, who moved around the country to fill labor demands. Plus, they had to boost salaries to retain their current workforce.

At the same time, high post-pandemic inflation worsened intense pressure from rising costs.

“We just couldn't keep up,” Michaud said.

Maine’s hospitals were struggling pre-pandemic with the demands of an aging population and what Michaud calls the “flight of youth.” Today, the demographic picture is not improving, and hospitals are faced with trying to sustain themselves in places with dropping populations.

Michaud says more federal money is badly needed – for training and other essential services and expenditures. That won’t solve Maine’s fundamental demographic issues, but it will help sustain current systems, he said.

“I’m kind of going at it from the angle of, ‘Look, what stops the bleeding here?’” Michaud said. “What I'm seeing is a very rapid decline in the provision of care. And that's what's so concerning. I don't know where this is heading very quickly.”