New Hampshire's Medicaid program faces threats on both the federal and state level

Yahoo

05-03-2025

Gov. Kelly Ayotte, a Republican, speaks with reporters in her office Wednesday, Feb. 26, 2025. Ayotte has proposed several changes to Medicaid aimed at cutting down the cost of the program that would increase the financial burden on recipients. (Photo by William Skipworth/New Hampshire Bulletin)
After being found floating in a pool in Florida following a drug overdose, Shawn Cannizzaro — a Boston native — moved to Littleton to get help with his substance use disorder at a recovery house.
'I'm saying to myself, 'What am I doing going to Littleton, New Hampshire?' he said. 'It's a blizzard out. It's the end of January. I'm coming off every drug you can imagine — alcohol, crack, cocaine, heroin, everything. I am a mess, and I do not want to live anymore.'
Three years after arriving in Littleton, Cannizzaro was sober and beginning to thrive. So he decided to try to help others facing the same struggles. He's now the owner of Hope 2 Freedom Recovery Homes, an organization that operates several sober living homes in Claremont.
'I've been in and out of sober living houses my entire life, and now I own four of my own,' he said. 'I just celebrated six years clean a couple weeks ago.'
Cannizzaro said it's Medicaid — the U.S.' public health insurance program for people with low income or high needs — that makes this work possible. The program funds treatment for 90% of people at his sober living homes. But Medicaid didn't just help his clients.
'This is important on a lot of different levels for me,' Cannizzaro said.
Cannizzaro explained that his organization provided him some income, but not enough to buy private insurance, so he got on Medicaid himself. He said after dealing with some health issues, he was able to earn enough money to no longer need Medicaid.
Cannizzaro, who is one of several who spoke at an event in Manchester last week about how Medicaid helped them, isn't alone in using Medicaid to address substance use disorder. Medicaid paid for 21% of all substance use disorder treatment in the U.S., and 7.2% of Medicaid recipients ages 12 to 64 have a diagnosed substance use disorder, according to analysis of recent years' Medicaid claims data by the Kaiser Family Foundation.
More broadly, around 80 million people across the U.S. receive health care coverage through Medicaid or the Children's Health Insurance Programs, the Center for Medicare and Medicaid Services reported. In New Hampshire, that number is around 183,000.
Medicaid, which is operated jointly by states and the federal government, also finances around 2 of every 5 births in the U.S. — a little over 1 of 5 in New Hampshire — and Medicaid is the primary payer for about 2 of every 3 nursing home patients both across the U.S. and in New Hampshire specifically, per CMS and KFF.
In New Hampshire, the program could be scaled back if proposals from Republican leaders on both the national and federal level come to fruition.
Republicans in the U.S. House of Representatives passed a resolution last week outlining a framework for the federal budget — an early step in the lengthy federal budgeting process. That framework seeks to impose a series of spending cuts in order to reduce the federal deficit and introduce tax cuts. Experts believe for the government to make these cuts happen, it would need to remove an estimated $800 billion from Medicaid nationwide, which has drawn concern from Medicaid recipients and advocates.
'What is so frustrating about that is that this is not being done because we have a national emergency,' U.S. Sen. Jeanne Shaheen, New Hampshire's Democratic senior senator, said. 'This is being done so that the Republicans in Congress and President Trump and Elon Musk can come up with $2 trillion in cuts so they can pay for their tax breaks for the wealthiest in this country.'
In New Hampshire, the concern is particularly acute due to a so-called trigger law the state passed in 2018 that would cut state funding for New Hampshire's Medicaid program if federal funding falls below a certain level.
In 2014, New Hampshire lawmakers expanded Medicaid using federal funding from the Affordable Care Act, creating what is now known as the Granite Advantage Program. This program has since brought Medicaid to an additional 60,000 New Hampshire residents, according to state figures reported in January. In total, Medicaid in New Hampshire costs $2.5 billion to operate each year, $1.4 billion of which comes from the federal government.
Then, in 2018, state lawmakers passed the trigger law, which dictates that if federal funding for Medicaid expansion falls below 90% of the cost of the program (though previous laws had also set triggers at different rates), the state will revoke the funding it devotes to the expansion program and eliminate it.
U.S. Sen. Maggie Hassan, New Hampshire's Democratic junior senator, described Medicaid as 'a pillar of American life,' arguing 'it helps strengthen our economy, our workforce, and the health of our people. It's indispensable to families who are trying to make ends meet.'
Before becoming senator, Hassan was New Hampshire's governor and oversaw the 2014 Medicaid expansion.
'We did it on a bipartisan basis,' she said. 'And we did it because we recognized that there were people who wanted to go to work but couldn't go to work because they had health conditions and they couldn't get health coverage, so they couldn't get better.'
She said she consistently heard from people who went on Medicaid, got healthier, and then no longer needed Medicaid because they were able to earn more when they were healthier.
U.S. Rep. Maggie Goodlander, a Democrat who represents New Hampshire's 2nd Congressional District, called Medicaid, in addition to Medicare and Social Security, 'the lifeblood of our communities.'
Still, a lot more must happen for these cuts to materialize. There appear to be major differences between the U.S. House and U.S. Senate.
U.S. Sen. Josh Hawley, a Missouri Republican, told reporters in the Capitol last week he won't vote to approve Medicaid cuts. He's also alluded to other differences the two chambers have.
'There's a lot of distance between where the House and the Senate are on this,' Hawley said.
President Donald Trump also said he wants to see Medicaid maintained. However, he has been perhaps even more forceful in calling for the tax cuts he and his congressional allies instituted through the 2017 Tax Cuts and Jobs Act during his first term to be extended. Many have argued doing both without raising the deficit — a nonstarter for many Republicans — would be infeasible.
'We know we're going to be in a fight to protect these mission critical programs,' Goodlander said.
Asked about whether she is concerned about Congress cutting Medicaid enough to activate New Hampshire's trigger law, Gov. Kelly Ayotte, a Republican, said 'I can't deal in hypotheticals.'
As this fight over Medicaid unfolds in Washington, Ayotte is working to scale back the cost of Medicaid in her own state. The governor is proposing state level changes to the program that would shift more financial cost to Medicaid recipients and tighten eligibility for the program in New Hampshire.
If adopted, Ayotte's new state budget, and the accompanying policy-related 'trailer bill,' would add premiums for some recipients, increase pharmacy cost-sharing, and end the already winding down continuous eligibility system.
The proposed premiums would require Medicaid recipients, with children, who earn 255% of the federal poverty level and those without children who earn between 100% and 138% of the poverty level to make a payment of up to 5% of their household income in order to receive coverage. As for the co-pays, the proposal would change the amount Medicaid recipients pay for their prescriptions from $1 or $2 to $4 per prescription (unless that exceeds 5% of household income). Finally, it would end continuous enrollment, which began during the COVID-19 pandemic and allowed people to stay on Medicaid even after they no longer met the requirements; that system has already ended, but the state needed time to disenroll recipients.
Ayotte also proposed a change meant to make the program more cost efficient. Her proposal would allow Medicaid to purchase name-brand drugs instead of generics if they were cheaper — it had previously been required to purchase generics as a cost-saving measure, but recent market developments have meant name brands are sometimes cheaper.
Ayotte predicted these changes would save the state about $27 million.
'We obviously tried to be thoughtful in how we did this,' she said, adding that they'll include a provision to allow people experiencing hardship relief from the premiums and stressing that eligibility would not change.
Ayotte defended the move by pointing out how permissive New Hampshire's eligibility requirements are comparatively.
'New Hampshire has among the highest eligibility in terms of who's covered for Medicaid in the nation,' she said. 'People aren't even eligible to get Medicaid above 255% of poverty in 26 states.'
Indeed, New Hampshire ranks sixth among U.S. states and territories for most expansive income eligibility requirements for children, as of May 2024, according to KFF. If you include only children ages 1 to 5, New Hampshire has the most expansive eligibility requirements for Medicaid of any state or territory except Washington, D.C.
'My proposal is one that, regardless of what happens in Washington, is meeting our financial needs in New Hampshire to maintain eligibility and to sustain the budget for essential services,' Ayotte said.
State House Deputy Democratic Leader Laura Telerski, a Nashua Democrat, said Ayotte's proposals 'sound like an income tax to low-income and working families just to access health care.'
Telerski noted that this 5% premium could cost a single parent with two kids making $67,000 annually about $280 a month to keep their children's health care. As for adults who make between 100% and 138% of the poverty level, Tellerski pointed out that these people make between roughly $15,500 and $22,000.
'These are extremely low-income people,' she said, 'These individuals barely have enough money to put a roof over their head or find sufficient food. And they're also going to be subjected to a 5% fee based on their income.'
Telerski argued these premiums would push eligible people off Medicaid because they can't afford premiums.
'I think it's great that we have been able to provide coverage for these families,' she said, discussing New Hampshire's expansive eligibility. 'But to take away that benefit that they have for their kids to get health care and putting a price tag on it is only gonna put kids at risk. It's only going to make working families have to make very hard choices on how they're gonna put together their monthly budgets.'
Telerski did, however, say she likes the rule change on purchasing name-brand drugs. She also acknowledged the current budget cycle 'is gonna be tough' fiscally. However, she'd rather look at limiting other programs like the education freedom accounts to find savings.
'(Ayotte) said in her budget address that her budget will protect the most vulnerable,' she said. 'Well, I see no one more vulnerable than children and extremely low-income people and people with disabilities.'
Conservatives have long criticized Medicaid expansion for being too expensive and covering too many people.
Even before Trump took office in January, the Cato Institute, an influential conservative think tank, called for the now-president to place a cap on Medicaid funding sent to each state, saying he could save the federal government $300 billion annually.
'This health program has grown explosively because the federal government subsidizes state program expansion in an uncontrolled manner,' the organization wrote.
Locally, the Josiah Bartlett Center for Public Policy, a New Hampshire-based conservative think tank, has also decried how much Medicaid has expanded and advocated for those expansions to be halted.
'These expansions are unsustainable for both the state and federal governments,' the think tank's president Andrew Cline wrote in a 2023 blog post. 'Eventually, some level of financial discipline, however small or limited, will have to be imposed. … Any discussion of expanding Medicaid coverage or eligibility should start with the understanding that current spending levels are unsustainable.'
Among the groups that rely on Medicaid the most are people with disabilities.
Stephanie Patrick, executive director at the Disability Rights Center-NH, said cuts to Medicaid 'could be devastating' for people with disabilities in New Hampshire.
'People with disabilities rely on Medicaid for not just health care,' she said, 'but for the services they need that aren't covered by private health insurance.'
People with disabilities can use Medicaid to receive the nonmedical supports they need to live in the community, such as a direct support professional or case management.
Katie Philips, of Dover, is one of those people.
'If we lose Medicaid, it would just hurt so much,' Philips said at last week's Manchester event tearfully. 'It's just been so helpful to me to have it.'
She said Medicaid has allowed her to see her doctor even though she isn't critically ill. It's also allowed her to get medications she needs.
'And I'm able to live on my own, which I'm doing a really good job at,' she added.