The Medicaid changes enacted through the One Big Beautiful Bill Act are often described in terms of eligibility rules, work requirements and federal spending. In West Central Behavioral Health’s service area in lower Grafton and Sullivan counties, however, their consequences will be measured much closer to home: In parents delaying treatment, children living with greater instability, and community organizations being asked to meet growing needs with fewer resources.
Beginning in 2027, many adults enrolled through Medicaid expansion plans will be required to document at least 80 hours each month of employment, education, job training, community service, or other qualifying activity. New Hampshire law also requires documentary evidence, quarterly verification, and a one-month look-back period for many applicants. Self-attestation will not be accepted.
Some individuals — including certain parents and caregivers, people with disabilities, individuals who are medically frail, and people participating in substance use disorder treatment — may be exempt. But an exemption is meaningful only if people know about it, can obtain the necessary forms, and can successfully navigate the documentation process before their coverage is interrupted.
That is an especially important concern in our rural region, where communities we serve at West Central sites in Claremont, Newport, and Lebanon often face long travel distances, limited public transportation, housing instability, workforce shortages, and uneven access to reliable internet. Many Upper Valley residents work seasonal jobs, hold multiple part-time positions, or have schedules that change from week to week. Their hours may satisfy the law, but their employment may be difficult for an automated eligibility system to verify. For these families, losing Medicaid may have little to do with a lack of employment and everything to do with a missed notice, an incomplete form, or a documentation delay.
Children generally will not be subject to the new work requirements. That does not mean they will be protected from the effects.
A parent who loses coverage may stop taking medication, postpone counseling, or delay treatment for a substance use disorder or chronic health condition. When a parent’s health deteriorates, the entire household feels the consequences. Children may experience increased stress, disrupted routines, missed school, housing insecurity, or greater involvement with emergency and child-protection systems.
Health coverage for parents also helps families remain connected to pediatricians, schools, counselors, and community-based programs. When a parent falls out of the healthcare system, it becomes more difficult to coordinate the child’s care, address concerns early and keep a manageable problem from becoming a crisis.
This matters because children and families already face significant behavioral health needs. West Central Behavioral Health provides child and family therapy, medication evaluation, care coordination, and community-based services in Lebanon, Claremont and Newport, as well as connections to 24-hour crisis response. These services help children who are experiencing anxiety, depression, trauma, and behavioral challenges while supporting families dealing with addiction, violence, divorce, and financial hardship.
Medicaid is a critical part of the financial foundation that makes this system possible.
When adults lose coverage, community mental health centers do not stop receiving calls for help. Instead, they see more people who are uninsured, have discontinued treatment, or have waited until their condition became urgent. Providers must spend additional time helping patients restore coverage, document exemptions, and resolve eligibility problems. Those administrative demands take clinicians and care coordinators away from treatment and further strain a workforce that is already stretched thin.
The effects will extend beyond the mental health system. Schools may see more students struggling with attendance, concentration, or behavior. Hospitals and emergency departments may experience additional preventable visits. Municipal welfare offices, food programs, shelters, recovery organizations and other area nonprofits may be asked to fill gaps that health coverage previously helped address.
For a region with limited service capacity, even a relatively small increase in uninsured residents can create a significant ripple effect.
There are steps New Hampshire can take to reduce the harm while complying with federal law.
First, the state must use available data to verify employment and exemptions whenever possible instead of placing the entire burden on families, and send clear, timely notices with multiple ways to respond.
Second, healthcare providers, schools, employers, and community organizations need practical guidance before implementation begins. They must understand who is subject to the requirements, who may be exempt, what documentation will be accepted, and where residents can obtain assistance.
Third, mental health and substance use disorder protections must be applied consistently. No one should lose coverage simply because the symptoms of an illness make it difficult to complete the paperwork required to prove that the illness exists.
Finally, the state must recognize the administrative and financial impact on community mental health centers. West Central Behavioral Health and the other nine New Hampshire Community Mental Health Centers should be directly involved in implementation planning. These organizations understand the people most likely to be affected and can help design outreach, referral, and verification processes that prevent unnecessary coverage losses.
This is not an argument against employment. Work can provide purpose, stability, and an important path toward economic security. But healthcare coverage is often what enables a person to manage depression, recover from addiction, stabilize a chronic condition, and remain employed.
If Medicaid policy is implemented without accounting for that relationship, New Hampshire risks creating the opposite result: People losing treatment, becoming less stable and moving further away from sustained employment.
For the Upper Valley, thoughtful implementation is not simply an administrative responsibility. It is an investment in the health of families, the strength of communities, and the future of the region.
Lori Shibinette is the president & CEO of West Central Behavioral Health. She was previously commissioner of the New Hampshire Department of Health and Human Services.