Rural New Hampshire hospitals brace for potential Medicaid cuts

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01-05-2025

U.S. Sen. Jeanne Shaheen speaks with Matt Foster, Valley Regional Hospital CEO, in front of an MRI machine at the hospital last week. Rural hospital leaders have been telling Shaheen and the rest of New Hampshire's congressional delegation about the impact cuts to Medicaid would have on their operations. (Photo by William Skipworth/New Hampshire Bulletin)
At 16 beds, Colebrook's Upper Connecticut Valley Hospital is the smallest licensed hospital in New Hampshire.
'We call it 'frontier medicine,'' Tom Mee, CEO of the hospital's parent company, North Country Health, said. 'It's the lifeblood of health care for that community.'
Situated in rural northern Coös County near the U.S.-Canada border, Upper Connecticut Valley Hospital is the only hospital nearby, which makes it vital to the health and well-being of area residents.
'When an urban hospital closes or cuts back programs, you just go to the other hospital that's five miles away,' Mee said. 'In our community, you're driving hours.'
That's why Mee and other rural health providers are so afraid of Republican proposals in Washington, D.C., to gut Medicaid, the country's public health care program for those with low incomes and unique needs. They argue this move would further destabilize an already challenging rural health system.
In early April, Republicans in the U.S. House of Representatives voted to approve a resolution outlining the federal budget, an early step in the lengthy federal budgeting process. That outline called for $1.5 trillion in spending cuts to renew President Donald Trump's 2017 Tax Cuts and Jobs Act — which his opponents and many economists decry as a tax break for the richest Americans.
The resolution tasks several legislative committees with cutting different areas of the budget. The House Energy and Commerce Committee has been instructed to cut its portion by about $880 billion over 10 years. While it doesn't explicitly specify these cuts come from Medicaid, the program comprises about $8.2 trillion of the almost $9 trillion the committee can cut from. This means, experts say, it would be impossible to do so without reducing Medicaid or Medicare. Some Republicans have proposed shrinking Medicaid by about a third over 10 years.
If that cut went into effect, an estimated 24 million people receiving Medicaid would lose their health care coverage; 10 million of those would be children. In New Hampshire, that's 60,000 people and 30,000 children. One in 7 New Hampshire residents in total receive Medicaid, and 17.1% of all New Hampshire Medicaid recipients live in Coös County, despite the county comprising roughly 2% of the state's population.
Mee said the country must 'get past this notion that getting people off Medicaid saves money.'
'There is no model where, from a taxpayer perspective, taking somebody off the Medicaid rolls is a net positive for the taxpayer,' Mee said. 'In the short term, yeah, it sounds good that we've got somebody off the Medicaid roll or that they're working, but the flip side of that is that these patients then become uninsured, they don't get preventative health visits in general, and they show up in our ERs months later, sicker than they ever were before.'
Hospitals cannot turn away patients who are unable to pay like most businesses can. They are legally required — through a 1986 law called the Emergency Medical Treatment and Labor Act — to provide emergency treatment to all patients who need it regardless of ability to pay. Without Medicaid, more people will be unable to pay. Hospitals are forced to absorb that cost.
Mee called it 'a long-term drain on the system.'
Coös County is the state's largest county by area (about 1,800 square miles) and its smallest by population (about 32,000 residents). The county has three hospitals — Upper Connecticut Valley Hospital, Androscoggin Valley Hospital, and Weeks Medical Center — all operated by North Country Health. All three are designated as critical access hospitals by the federal government, meaning they're far enough from any other hospital that the government believes they're essential to ensure that an area has access to care.
'On a perfect day, we can drive about 90 minutes between sites,' he said. 'But on a snowy day, you're talking about real life and death at that point if we have to start cutting back on services.'
Mee said that if these Medicaid cuts go into effect, North Country Health would have to consider doing so. About 15% of North Country Health's patients are on Medicaid, he explained.
'I don't lie awake at night worrying about our hospitals closing,' he said. 'But I do worry about whether or not we're going to continue to offer the full scope of services that we do today.'
He said the first services they'd have to consider eliminating are in women's health, including OB-GYNs and baby deliveries, and behavioral health, including psychiatry and substance use disorder. He said the results would be disastrous.
'If we're not able to deliver babies in Coös County, pregnant women and neonates will die,' he said. 'It's a fact.'
Mee said the health system has already eliminated every non-essential cost.
'We've already picked all the low-hanging fruit,' he said. 'So if Medicaid reductions, or however it looks, force us to look at it again, then we're going to have to look at something a bit more draconian than what we've done in the past.'
U.S. Rep. Maggie Goodlander, who represents the North Country — as well as Nashua, Concord, and the western half of New Hampshire — said she's worried about the viability of rural hospitals like those in the North Country and other rural parts of New Hampshire should these cuts be enacted.
'What I'm hearing from so many rural hospitals in our state is just how fragile they are,' Goodlander said. 'I mean, they're operating on the slimmest of margins.'
The congresswoman visited Monadnock Community Hospital in Peterborough, another rural critical access hospital, last week to hear from some of those health care leaders.
'We are really concerned about what's going to happen with Medicaid,' Richard Scheinblum, executive vice president and CFO at Monadnock Community Hospital, said.
In New Hampshire, the fear of federal Medicaid cuts is twofold. Medicaid is funded jointly by the federal government and states. New Hampshire has a trigger law on the books mandating that if federal funding for the expanded Medicaid program falls below 90%, the state government will revoke its portion of the funding for about 60,000 of New Hampshire's recipients who receive coverage through the 2014 expansion.
'If expanded Medicaid blows up, that's between a $1 to $2 million loss to us,' Scheinblum said. This figure is per year, he said, and he calculated it by examining figures from before expansion was enacted, factoring in recent market developments and updated variables.
Goodlander said she's spoken with state lawmakers who don't seem to understand what the impact of this trigger law being activated would be.
Cynthia McGuire, president and CEO at Monadnock Community Hospital, said the hospital isn't sure they'd be able to continue employing the entirety of their current staff with Medicaid cuts. The hospital is one of the largest employers in Peterborough. Additionally, Upper Connecticut Valley Hospital, Androscoggin Valley Hospital, and Weeks Medical Center are the largest employers in their respective towns.
Scheinblum and McGuire said if these cuts went into effect, like North Country Health, they'd also have to look carefully at downsizing their operations.
'What I'd hope we could do is look at some alternative revenue sources or some other areas to scale back,' Scheinblum said, listing philanthropic grants and donations and partnerships with other hospitals as examples. 'Everything would be on the table.'
They noted that due to their community's financial support they're really well positioned compared to other hospitals.
'There are a lot of hospitals in our state that will not survive,' Goodlander noted.
The hospital leaders emphasized the importance of critical access hospitals.
'We're the last stop,' McGuire added. 'We can't shut our door and say we're not going to take care of any more people today. That's what we are here for.'
Matt Foster, president and CEO of Valley Regional Hospital, a critical access hospital in Claremont, said this moment feels like 'December to January 2020 pre-COVID when something's coming but you're really not sure how to plan.'
He said the hospital has 'started to think about' a contingency plan should these cuts be enacted.
'This has come on so quickly we're kind of in the reactive phase,' he said. 'It's like Mike Tyson said, which is, 'Everybody has a plan until they get punched in the face.''
Foster noted the challenges their community faces: Roughly 15% of the population lives below the poverty line, according to the U.S. Census Bureau. About one-third of Claremont's population is on Medicaid.
'Finances are like oxygen,' he said. 'They're not why we're here but they're necessary for life.'
Foster, too, explained that Medicaid would force their hospital to make tough decisions about services, specifically on their payroll.
'We're about as efficient as we can be,' he said. 'There's only so many things you can do that don't rely on (employees).'
Officials at Valley Regional Hospital, which is operated by Dartmouth Health, explained that cutting Medicaid keeps people from obtaining preventative care and forces them to go to the emergency department for things that should be handled by a primary care physician. Jocelyn Caple, interim CEO of Valley Regional Hospital, likened it to 'taking a water balloon, going and squeezing it.'
'It ends up somewhere else, which is not the most efficient or effective place to pay for it,' she said.
U.S. Sen. Jeanne Shaheen spoke with Foster, Caple, and other Valley Regional Hospital officials during a visit to Claremont last week.
'You talk about uncertainty, and one of the challenges that we've had in Washington is also uncertainty,' Shaheen said.
Shaheen said she's also concerned about rural New Hampshire hospitals' ability to remain solvent amid these cuts. Asked what recourse New Hampshire Medicaid proponents have in the event that the trigger law is enacted, Shaheen, who is a former New Hampshire governor, deflected, noting it is a state-level decision, not within her jurisdiction as a federal lawmaker.
Still, she encouraged constituents to 'call your legislator, call the governor, call everybody you can think of, and let them know that that's not acceptable.'
At the same time as federal lawmakers weigh trimming Medicaid, state lawmakers are also proposing changes to the program in New Hampshire. The state Senate passed a bill — Senate Bill 134 — in March requiring people to work in order to receive Medicaid in New Hampshire, and the House approved a plan to charge certain Medicaid recipients premiums and increase the share of prescription costs recipients are responsible for in the budget they passed in April.
Gov. Kelly Ayotte's office, which originally proposed the premium and prescription cost plan, and would have to sign off on work requirements for them to be enacted, did not respond to the Bulletin's requests for comment about state or federal proposals.