The Boston Globe – February 19, 2025
By STEVEN PORTER, Globe Staff
Medicaid is funded jointly by federal and state taxes. Unlike the rest of New England, New Hampshire would automatically sunset its Medicaid expansion program if the federal government’s match ever falls below 90 percent.
MANCHESTER, N.H. — As congressional Republicans consider cutting federal funding for Medicaid by billions of dollars, community health care leaders at the local level are warning such drastic reductions would harm vulnerable people and inflict pain across broader systems of care.
Dr. Gavin Muir, chief medical officer of Amoskeag Health, a nonprofit community health center that delivers primary care services to more than 16,000 people in the Greater Manchester area, said many patients had delayed care during the pandemic.
“We’re just now kind of digging out from that deficit,” he said, “and to be hit again with continued barriers for people to access the necessary health maintenance screenings that we should all have as a healthy population would be truly concerning.” Since most of their patients are either on Medicaid or uninsured, Muir said his team is accustomed to navigating discount programs to help people actually obtain the medications they are prescribed. He worries federal cuts would make that already-difficult task harder, even for standard drugs to treat common conditions like diabetes and heart disease.
Muir joined several other community health leaders Tuesday for a roundtable at Amoskeag Health with Democratic US Representative Chris Pappas, who noted that his GOP colleagues are considering these cuts primarily because they aim to extend their 2017 tax cuts for the wealthiest Americans and curtail taxes even further. “As they propose cuts that are going to impact and harm constituents, members of Congress should be raising their voice,” Pappas said, “and I’m hopeful that colleagues will be having the same sorts of conversations in their district that we had here.”
Medicaid is funded jointly by federal and state taxes. It provides health insurance for roughly one in five Americans, including impoverished children and adults.
Most states, including all six in New England, expanded Medicaid eligibility under the Affordable Care Act in what Democrats have heralded as a success. But, unlike the rest of the region, New Hampshire included a trigger clause to automatically sunset its Medicaid expansion program if the federal government’s match ever falls below 90 percent. That means, if congressional Republicans follow through on one of the changes they are considering and enact even a modest reduction in the federal match for Medicaid expansion benefits, then about one-third of Medicaid beneficiaries in New Hampshire — roughly 60,000 Granite Staters — would lose coverage.
In that scenario, the Republican-controlled New Hampshire state legislature could step in to maintain eligibility for those who currently have it under Medicaid expansion. But that would require amending state law and would probably also require re-structuring how the state funds its share of the program, according to Phil Sletten, research director at the New Hampshire Fiscal Policy Institute, an independent nonprofit. Although the other five New England states don’t have trigger laws in place, eliminating the federal match for Medicaid expansion could cause total Medicaid enrollment to drop by 19 percent in Massachusetts, 25 percent in Rhode Island, 27 percent in Maine, 29 percent in Connecticut, and 37 percent in Vermont, according to an analysis by KFF, a health policy research firm.
Jake Berry, vice president of policy for New Futures, a nonpartisan health policy nonprofit in New Hampshire, said allowing Medicaid expansion to expire would cost more in the long run than finding sufficient state funding to maintain the program, which has become “the backbone” of New Hampshire’s substance use and mental health treatment systems. “This program is the literal safety net for our state,” he said. Patricia Carty, CEO of The Mental Health Center of Greater Manchester, said the state has just recently found success in its so-called “Mission Zero” efforts to ensure patients who need inpatient psychiatric care don’t get stuck in hospital emergency departments. “We are finally seeing the light of having a day here and there where no one is in the emergency room boarding,” she said.
If people lose health insurance, Carty said they will delay routine care until they land in an emergency department as a last resort, ultimately undermining the progress New Hampshire has made on this issue. What’s more, Carty said health centers like hers are legally required to provide care in certain situations, so a reduction in Medicaid funding would force providers to shoulder a higher share of the cost burden for care that patients need but cannot afford. “We’ve always been able to tolerate a certain amount of uncompensated care. We’ve always had this,” she said. “But with cuts this critical, it would mean closing certain services, and we would have to make really tough decisions about that.”
Carty said her team would likely have to prioritize core critical services, leading to cuts in the recovery-oriented programming that they have been using to connect people to treatment and services after a hospitalization. The impact on New Hampshire’s state budget could be severe as well. The policies being considered in Washington could cost the state as much as $493 million per year, according to analysis by the New Hampshire Fiscal Policy Institute. Medicaid is the most expensive program that New Hampshire operates, so even minor adjustments to the federal contribution could impact the state’s bottom line by tens or hundreds of millions of dollars, Sletten said.
Republican Governor Kelly A. Ayotte unveiled her two-year budget proposal last week, with funding for Medicaid expansion at pre-pandemic levels. In an interview after her budget address, Ayotte acknowledged widespread uncertainty about what the future holds on this topic. “I don’t know what Washington is going to do on Medicaid,” she said. “I don’t think anyone does.”