‘Significantly at risk’ — Upper Valley health care providers warn that changes to Medicaid could reduce access to services

WEST LEBANON — Upper Valley health care providers are warning that changes to Medicaid at the state and federal levels will likely increase the uninsured population in New Hampshire and shift the cost of care to more expensive venues.

The biennial state budget signed into law late last month by Gov. Kelly Ayotte introduces monthly premium payments for some Medicaid recipients, raises the cost of prescription co-payments and may introduce a work requirement for Medicaid eligibility if approved by the federal government.

Starting in July 2026, households with children on Medicaid that earn incomes at or above 255% of the federal poverty level will have to pay between $190 and $270 per month depending on the household size. Currently, Medicaid recipients in New Hampshire don’t pay any premiums.

For people enrolled in the Granite Advantage program, New Hampshire’s version of Medicaid expansion that extends coverage to low-income households, individuals earning between 100% and 138% of the federal poverty level, or between $1,300 and $1,800 monthly for a household of one, will have to pay monthly premiums between $60 and $100 depending on the household size.

Based on current statewide enrollment, around 8,600 children and 10,200 individuals will be subject to premiums, according to data from the state Department of Health and Human Services. That’s about 10% of the Medicaid participants in New Hampshire.

Upper Valley health care providers are concerned that the changes will increase hardships for themselves and patients by threatening their access to care. They are also concerned about how the state changes could be compounded by the federal legislation Congress passed last week.

Between 30% and 40% of all patients at HealthFirst, a federally qualified health center with locations in Canaan, Franklin, N.H., and Laconia, N.H., are on Medicaid, CEO Ted Bolognani said last week.

“We get reimbursement from Medicaid if they’re on insurance,” Bolognani said. “We get nothing if they’re uninsured.”

With the institution of premiums and a work requirement, Bolognani expects that the additional complications added to state Medicaid will dissuade people from participating in the program.

“Some people are just going to say, ‘No, I’m not doing that,’ can’t afford it, won’t do it and then they become uninsured, but we still will see them,” Bolognani said.

Federally qualified health centers like HealthFirst are designed to increase access to health care in rural and underserved areas and are required to see patients regardless of their ability to pay.

The changes to the nonprofit’s income could be a big problem for HealthFirst’s Canaan location, which has “low volume and razor-thin margins.”

“It’s a struggle to keep those doors open as it is, so Canaan particularly is at risk, significantly at risk,” Bolognani said.

The way he sees it, the more rural a health center is the harder they will be hit by these changes because they most likely see a lower volume and less diverse patients. At HealthFirst’s other locations in the cities of Franklin and Laconia, Bolognani said there is less concern because “we have a good mix of patients and higher volumes.”

As for the patients themselves, Bolognani said he expects the changes will increase the cost of care. He noted that not having insurance does not stop people from needing medical attention. In fact, he said, patients on Medicaid are “some of the sickest patients we see.”

“You’re just shifting the sickness to a more costly system when you take away from community health in primary care,” Bolognani said. “You shift it to the much higher cost systems, the emergency room, needlessly and it’s short-sighted.”

Ayotte introduced the idea of Medicaid premiums in her February budget address. After signing the budget into law, she identified the changes as a way of “protect(ing) eligibility for Granite Medicaid Advantage.”

Ayotte has said the premiums will save the state money on the cost of implementing Medicaid and allow the government to keep income eligibility at current levels, which are higher than many states, New Hampshire Public Radio reported.

‘Faulty philosophy’

In Woodsville, Ammonoosuc Community Health Services, another FQHC, is bracing for the impact of Medicaid changes at the state and federal levels. The network announced in a news release last month that it would be closing its location in Franconia, N.H., later this year because of “inadequate financial support from both state and federal sources,” including cuts to Medicaid.

CEO Ed Shanshala said going forward he is more concerned about potential changes to Medicaid at the federal level than at the state level, but shares concerns that making Medicaid more complicated, expensive or exclusive will direct patients away from primary care to the emergency room.

About 44% of Ammonoosuc patients are on Medicaid, Shanshala said Tuesday and, like other FQHCs, no one will be turned away even if they cannot pay for treatment.

In addition to the access changes, providers are concerned about the introduction of a work requirement for which the state is pursuing a federal waiver. A work requirement was also approved by legislators at the federal level last week, but states do not have to comply until the end of December 2026, while the state budget requires the waiver to be submitted by January.

Jim Culhane, president and CEO of Lake Sunapee VNA and Hospice, said work requirements are “frankly a faulty philosophy” and pass cost burdens on to providers who will still see patients without the ability to pay.

“Whether there’s a work requirement or not, it doesn’t prevent people from needing to access health care when they have a medical emergency,” Culhane said.

In general, Culhane said the Medicaid changes create “additional hardships on individuals who already have financial constraints.”

“One hundred dollars for an individual who’s approaching poverty level per month is sizeable,” Culhane said in an interview last Tuesday. “We’re concerned that it has the potential to dissuade people from taking advantage of the Granite State Advantage product.”

While he is concerned about the changes, Culhane said the impact on the VNA itself will likely be minimal because only a “low single-digit percentage” of the patient population will be impacted. Most of the VNA’s patients are older adults on Medicare, Culhane said.

In Lebanon, Laura Byrne, executive director at the HIV/HCV Resource Center, said she is concerned about “any cuts to Medicaid,” but at the state level she highlighted the impact of increased co-pays and work requirements.

“Many clients of our harm reduction programs rely on expanded Medicaid to help pay for their recovery programs,” Byrne said via email. “Without this they will certainly fall through the cracks.”

As for a work requirement, Byrne said this will impose a hardship on people “who are already struggling.”

“We work with a vulnerable population who will become even more vulnerable without access to Medicaid,” Byrne said.

Clare Shanahan can be reached at cshanahan@vnews.com or 603-727-3216.