Among the several unknowns associated with the state’s new budget is the fate of Medicaid in New Hampshire, particularly since its future is now tied to a Republican supermajority in Washington, D.C., that is committed to slashing federal spending.
Republican Gov. Kelly Ayotte is in the process of fashioning her first budget, which takes hold on July 1 of this year and runs for two fiscal years until June 30, 2027.
Her budget address to a joint session of the New Hampshire House and Senate on Feb. 13 , while emphasizing the need for what she called “recalibration,” mentioned Medicaid once in her 30-minute speech.
She said the state “found areas to make responsible adjustments that bring us in line with the times and what other states are doing as well. We brought our adult Medicaid eligibility back in line with pre-pandemic levels and joined our neighbors in requiring nominal co-pays for those receiving these benefits.”
Since Medicaid is a state-federal partnership, what happens to New Hampshire Medicaid recipients — whether their coverage will require bigger co-pays, whether it might disappear altogether for some — depends on what happens in Washington in the coming months.
It has the attention of Jeanne Shaheen, Democrat and senior U.S. senator from the Granite State.
“Current Republican proposals in Congress would gut Medicaid and be catastrophic for the 180,000 Granite Staters who rely on this program,” she said. “These cuts aren’t just line items on a budget; they impact real people in New Hampshire who would lose access to health care and substance use disorder treatments. We should be focused on lowering health care costs for Americans, not slashing programs that make it more affordable.”
While nothing specific has emerged from the White House, Trump during his previous administration supported policies to repeal or weaken the Affordable Care Act (ACA), as well as cap and reduce Medicaid financing.
Media analysis of the possible effect on Medicaid here in New Hampshire puts the state general fund appropriation at $90 million less than in the current biennium, which means $90 million less will be coming to the state in federal funds for health care as well, since the program is a 50-50 split.
One issue is Granite Advantage, the program of expanded Medicaid availability that was passed by the New Hampshire Legislature in 2014 as part of the Obama-era American Care Act providing health coverage to more than 96,000 Granite Staters as of 2023.
The federal government pays 90% of the Granite Advantage costs. By state law, if that threshold falls below 90%, the program ends.
That has Shaheen and others concerned.
Shaheen is working to prevent proposed cuts to Medicaid that would cause federal funding to fall below 90% and activate New Hampshire’s trigger law. She would like to see the Legislature repeal the trigger law and write legislation that ensures Granite Advantage beneficiaries don’t lose their coverage.
Additionally, New Hampshire stands to lose significant Medicaid funding should proposed changes to Medicaid’s federal match be signed into law. That split right now is 50-50 with implications should a greater share of that cost downshift to the states.
How to cover those costs — higher possible co-pays, less coverage, work requirement for recipients — was the topic of a webinar discussion Feb. 14 with Phil Sletten, research director at the New Hampshire Fiscal Policy Institute (NHFPI), and Lisa Beaudoin, a health care advocate in New Hampshire.
All in all, cuts to Medicare in New Hampshire could account for a $493 million shortfall in the state budget, said Sletten.
“The governor didn’t include those assumptions, or didn’t appear to include those assumptions, in her budget proposal,” said Sletten. “Medicaid is the single largest program the state operates in dollar terms. Small changes to Medicaid funding can have a big impact on the rest of the budget. The governor actually has to balance her budget.”
“So if you were to see a swing in federal funds of tens or hundreds of millions of dollars, that would affect other parts of the state budget and other considerations around health services and other services to fund that Medicaid shortfall,” he added. “Or Medicaid services themselves may have to change to keep everything else in line in the budget.”
Traditional Medicaid in New Hampshire covers about 126,000 individuals. Adults with household incomes up to 133% of poverty are eligible and pregnant women with household incomes up to 196% of poverty are eligible. Children are eligible for CHIP (Children’s Health Insurance Program) with household incomes up to 323% of poverty.
To be eligible for Granite Advantage in New Hampshire, enrollees must be between the ages of 19 and 64, have a household income at or below 133% of the federal poverty level, not be pregnant at the time of application, and not be entitled to or enrolled in Medicare Part A or B benefits.
According to an NHFPI analysis, Granite Advantage has lowered the number of uninsured Granite Staters, improved health outcomes and lowered uncompensated medical care costs for hospitals.
Beaudoin said any cuts to Medicare could have far-reaching effects beyond the individual who receives the coverage. If services and support people are removed from a patient’s care, family members would be forced into a position of having to find a way to fill in the coverage gaps, according to the health advocate.
“So if their parents have to quit jobs, and their staff are being let go, this has an overall negative impact on New Hampshire’s economy,” said Beaudoin. “This is a bad direction for New Hampshire.”
There could also be far-reaching effects on hospitals, according to Beaudoin, particularly in rural areas.
“Uncompensated care costs for our rural hospitals will skyrocket and put them at risk for not being able to serve their communities at all,” she said.
There have been efforts in the past to make Medicaid in New Hampshire more restrictive.
A federal judge in July 2019 ruled against the state’s attempt to impose a work requirement — made with the blessing of the then-Trump Administration — on Granite Advantage enrollees. The judge said the state failed to consider how the requirements would affect coverage.
