What's at Stake?
State-Level Concerns
New Hampshire faces state-level policy proposals, including legislation and state budget proposals, that could significantly impact our Medicaid programs. These proposed changes include work requirements and cost-sharing measures such as premiums and copays, which can both create significant barriers to health care access for many low-wage families. As the state considers these changes, it’s crucial to understand the potential consequences for our residents who rely on Medicaid to access necessary health care services.
Senate Bill 134: Work Requirements for Medicaid Expansion
The Granite Advantage Health Care Program, more commonly known as Medicaid Expansion, is a unique New Hampshire solution that ensures all Granite Staters have access to health insurance. Medicaid Expansion is available to adults aged 19 to 64 who earn $20,815 or less per year (or $42,760 or less for a family of four). Over the past year, an average of 58,846 individuals were enrolled in Medicaid Expansion each month, using their insurance coverage to access necessary health care services including mental health care, substance use disorder treatment, and preventive and emergency room care.
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Senate Bill 134 (SB 134) aims to set burdensome work requirements for Medicaid expansion recipients in New Hampshire, requiring individuals to complete 100 hours of qualifying activities each month to remain eligible for health coverage. Research consistently shows that work requirements can cause significant numbers of people to lose their coverage, complicate access to care, and disproportionately harm those who need Medicaid the most.
Work Requirements Don't Work
National data shows that the majority of adult Medicaid enrollees are already working.
In 2023, 92% of adults on Medicaid were either working full- or part-time, or were not working due to caregiving responsibilities, illness or disability, or school attendance. The remaining 8% reported they were retired, unable to find work, or not working due to other reasons.
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Research shows that work requirements for Medicaid and SNAP don't increase employment but rather strip people of their health care coverage. These policies are less likely to lead to employment and more likely to reduce income and benefits.
The Negative Consequences of Work Requirements
Research consistently highlights the negative consequences of work requirements:
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​​Loss of Coverage and Gaps in Care: The implementation of work requirements could lead to significant disenrollment, as evidenced by New Hampshire’s previous attempt in 2019, which put 17,000 residents at risk of losing their coverage. When Arkansas initiated work requirements in 2018, about one in four enrollees, which was more than 18,000 individuals, lost their coverage within the first 7 months. This can result in gaps in care, making it harder for individuals to manage chronic conditions and remain employed.
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Increased Administrative Burden and Costly Implementation: Work requirements add an administrative burden that is costly and difficult to implement. Many eligible individuals face barriers to compliance, such as difficulty proving work status and reporting qualifying activities. This complex process puts additional strain on state resources and can result in eligible individuals losing coverage.
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Barriers to employment: Medicaid Expansion supports employment and our state's workforce by helping people get back to work. Access to necessary health care keeps people healthy and working, while losing health coverage makes it more difficult to manage health conditions necessary for maintaining employment.
State Budget Considerations
This year, the New Hampshire Legislature will determine our state budget for 2025-2026. Governor Kelly Ayotte's budget proposal, along with the House proposal, includes the introduction of monthly premiums and increased pharmacy co-pays for some families and individuals covered by Medicaid expansion and CHIP. The proposed cost-sharing measures would shift more costs to families and enrollees, imposing additional financial burdens and barriers to care.
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​If these premiums and co-pays are imposed, about 10% of families with children in Medicaid and 20% of adults in Medicaid expansion would have to pay. For a family of three making $68,000 per year, the monthly premium could be over $280 each month, with $4 co-pays per prescription. A single individual on Medicaid expansion making around $15,000 per year could also be subjected to increased costs.​
Key Concerns of Cost-Sharing
The proposed cost-sharing measures pose a number of concerns:
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Barriers to Coverage and Care: Research repeatedly shows that requiring people to pay premiums or other costs to stay on Medicaid can make it harder for them to get and keep their coverage. Even small fees can stop them from accessing necessary health services. When Oregon introduced Medicaid premiums in 2003, nearly half of the people subjected to the new costs were disenrolled within a year, and were almost five times more likely to report using the emergency room as their main source of care compared to people who remained enrolled.​
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No Real Savings: Although cost-sharing measures are intended to save the state money, they have historically failed to produce cost-savings. Studies have found that when premiums increase, the people who drop out of Medicaid programs are usually the ones who cost less to care for, which raises the average cost of care for the people who stay in the programs. Studies also show that potential state savings from cost-sharing is often canceled out by more people dropping out of Medicaid, using more expensive services like emergency rooms, and additional administrative costs.
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Unintended Costs for Health Care Providers: Cost-sharing can also increase pressure on safety-net providers, such as community health centers and hospitals. When people lose their Medicaid coverage due to premiums or copays, more uninsured individuals seek care, especially in emergency rooms. This puts additional strain on already stretched providers and can lead to more costly care for both patients and the state.
Cuts to Medicaid Reimbursement Rates
The New Hampshire House of Representatives' budget proposal includes a 3% cut to Medicaid reimbursement rates. These rates are the payment amounts that health care providers receive for providing services to people covered by Medicaid. Decreasing these rates would further strain our health care system, reduce access to care for all New Hampshire residents, and potentially force some providers to limit Medicaid services or close their doors entirely.
By reducing coverage, increasing gaps in care, and adding financial burdens, these proposals could lead to worsened health outcomes, higher state costs, and greater financial strain on individuals and families who are already struggling.