Passage of the federal budget reconciliation bill has left health care advocates fearful, and some panicked states are already cutting Medicaid well in advance of federal impacts. The enormous federal deficit increase will also trigger automatic Medicare cuts unless Congress stops them.
Here in New Hampshire, all we can do is soldier on.
Long-term care advocates were very pleased that state legislators were responsive to a logjam in the Medicaid application process resulting in uncompensated care. I know of a single nursing home awaiting over $1 million for care it has provided.
This application logjam is due to a combination of factors, including how daunting it can be for someone seeking long-term care, or their family members, to round up all the documentation necessary to qualify for Medicaid. Legislators provided $3 million in state funds to contract out to assist this process, with nursing homes volunteering to pay higher fees toward this cost.
Given how very precarious long-term care provider finances can be — whether that provider is a home health agency or a nursing home — it is urgent to get a contractor onboard as soon as is practicable. In working with providers, the Department of Health and Human Services has shown appreciation of that urgency and will soon solicit bids from prospective contractors.
The one positive aspect of the federal reconciliation bill for health care is its appropriation of $50 billion toward a Rural Health Transformation Program. All states are under a tight timeline to apply, by Nov. 5, for grants under that program. Half of its money will be distributed evenly among states for five years, assuming the U.S. Centers for Medicare and Medicaid Services approves a state’s application, and the other half awarded to states based on CMS discretion.
Governor Kelly Ayotte and DHHS held an initial forum on this opportunity in Littleton, and, in a sign of the interest it’s generated, Joe Kenney and John Stephen of the Executive Council have held roundtables in Berlin and Laconia, with one yet to occur in Conway.
Shoring up the direct care workforce is a critical priority for providers, and at the Littleton forum Kenney expressed a desire to ensure grant spending doesn’t get too diffuse and fail to serve the needs of rural communities like those in the North Country. In remote Berlin, for example, one nursing home has been forced to use staffing agencies to fill three-quarters of its care needs.
These challenges are not new. In 2002, a Long-Term Care Rate Advisory Commission urged higher Medicaid rates, noted “the chronic shortage of nurses in New Hampshire,” and suggested tuition guaranteed by the state with a post-graduation service obligation “in a New Hampshire hospital, nursing home or home health agency.”
In 2016, I was a member of a similar commission legislators created to study the long-term care workforce shortage and chaired its recruitment and retention sub-committee. As was true in 2002, we noted that Medicaid rates hindered workforce efforts, and we called for “an incentive for caregivers to stay in New Hampshire post-graduation.”
Yet in 2025, Medicaid still limits recruitment and retention efforts, too many nurses licensed here leave to work in Massachusetts and there are not enough licensed nursing assistants critical to frontline care in any health care facility. The Rural Health Transformation Program gives us a once-in-a-generation chance to make direct care workforce investments that our state’s habitually revenue-strapped state budgets have not.
Brendan Williams is the president and CEO of the New Hampshire Health Care Association.