The Caledonian Record – April 14, 2025
By PAUL HAYES, Staff Writer
Health care leaders are warning that proposed reductions in state and federal Medicaid funding could deal a severe blow to rural New Hampshire, where hospitals and health centers are already struggling to stay open. At a virtual roundtable hosted by Protect Our Care New Hampshire during Medicaid Awareness Month, providers and policy experts said the reductions — both at the state and federal level — could severely disrupt access to care for low-income families, seniors, veterans and people with disabilities.
“Medicaid is the backbone of our health care system,” said Tess Kuenning, president and CEO of Bi-State Primary Care Association. “It supports strong and healthy families, it supports rural America, and it keeps us working.” About 13 percent of the state’s population is enrolled in Medicaid. In the rural North Country, those dollars support services like primary care, mental health treatment, maternity care, and home visits for older adults. Cuts could destabilize entire systems.
Ed Shanshala, CEO of Amonoosuc Community Health Services (ACHS), said his center, which serves over 10,000 patients across 26 towns, could face a $2 million shortfall over three years. That would directly impact care for nearly 500 patients, he said. “Medicaid is an economic lifeline for rural communities… These dollars move around within the local economy. People pay their mortgage. They buy groceries. They buy a car. Without that investment in the state loan repayment program, it’s difficult. They want to come back. They want to care for their friends, family, and neighbors who nurtured them,” Shanshala said.
Shanshala also warned of cascading effects: community health centers rely on Medicaid to fund preventive care, including maternity services. Currently, just three hospitals in the region — Plymouth, Littleton and Berlin — still deliver babies. Others, like those in Woodsville, Lancaster and Colebrook, have stopped. Also, in areas like the North Country, where small businesses and seasonal work are common, many workers rely on Medicaid for health coverage. Jobs such as ski instructors, landscapers, and restaurant staff often do not offer employer-sponsored insurance. “If you’re working three jobs to get by, you need to be healthy to show up,” said Shanshala. “Local businesses depend on a healthy workforce, and Medicaid helps make that possible.”
New Hampshire’s Medicaid expansion, enacted in 2014, currently provides coverage to about 60,000 residents. Under federal law, 90 percent of expansion funding comes from the federal government and 10 percent from the state. But if the federal share — called the Federal Medical Assistance Percentage (FMAP) — is reduced, the expansion could be automatically repealed, leaving tens of thousands without coverage. Meanwhile, the state budget proposal approved by the House last week includes a 3 percent cut to Medicaid reimbursement rates and elimination of a student loan repayment program that incentivizes health care workers to serve in rural areas. Shanshala said ACHS has been able to recruit young professionals — including several “local kids gone good” — through the program.
“The program helps them stick, like burrs to a wool sweater,” he said, adding loan repayment funds are “essential for us to recruit talent into the North Country. Without it, it’s hard for us to compete economically.” Speakers also pointed to Medicaid’s role in treating substance use. In 2022, New Hampshire had the second-highest rate of Medicaid enrollees with opioid use disorder receiving medication-assisted treatment. That care, they said, helps people recover and return to work — boosting the state’s labor force.
Shanshala said ACHS used Medicaid funds to place behavioral health counselors in elementary schools to reduce future substance use and mental health crises. He likened it to investing early in a child’s future. According to him, cutting Medicaid means ending critical programs that lower emergency room visits, NICU admissions, and long-term health expenses. He pointed out that an ICU day costs $10,000, whereas preventive care is more affordable.
Work requirements and cost-sharing proposals are also raising red flags. A 2018 work requirement in New Hampshire led to 17,000 people losing coverage in just two months, largely due to administrative barriers. Speakers said most Medicaid recipients already work — often in part-time or seasonal jobs that don’t offer insurance. “You’re trying to play ‘gotcha’ when there isn’t anything to find,” Shanshala said, referencing an $87 million work requirement program in Georgia that enrolled only 6,500 people out of 250,000 eligible. “That money could have paid for over 200,000 primary care visits.”
Kuenning noted that most people on Medicaid are already working — just not in jobs that provide insurance. Many earn less than $21,000 a year, and with housing, heating, and food costs rising, even small co-pays can be unaffordable. “We shouldn’t be having people feel that they’re a burden on the system. Just the opposite, they’re actually working,” she said. “They’re working in really important service industries, and we are a service industry state.”
New Hampshire has the second fastest-aging population in the country, behind only Maine. With rural hospitals operating on thin margins and patients often traveling long distances for care, reductions in Medicaid support could worsen health outcomes and increase emergency room use, driving up system-wide costs.
Shanshala said every dollar that comes into health centers through Medicaid moves through the community — buying groceries, paying rent, and keeping people employed. “We need to think about these dollars as an investment,” he said. Health care advocates say the state must protect and strengthen Medicaid funding, or risk long-term damage to rural health care access, economic stability, and public health. “If we don’t act now,” said Kuenning, “we’re going to pay a much higher price later.”