Opinion: A roadmap for New Hampshire to fund long-term care


Published: 06-18-2023 8:30 AM

Brendan Williams is the president and CEO of the New Hampshire Health Care Association.

We live in times of incredible partisan division, as exemplified in culture wars playing out in legislatures across the nation, and a Congress nearly inert due to conflict, with the recent fortunate exception of a debt ceiling deal that averted fiscal doomsday.

Thus, while what happened in Concord this legislative session may prove more of an outlier than replicable, it was still heartening to see the two parties rally together around a state budget. Particularly welcome was the emphasis on Medicaid funding for our most vulnerable Granite Staters.

The COVID-19 pandemic was decimating to long-term care. Between February 2020 and June 2022 both the home health and facility-based care sectors lost over 10% of their workforces. Nationally, as of last month, data showed nursing and residential care facilities still needed 242,800 workers to recover to a pre-pandemic level.

New Hampshire has ranked low compared to other states in the proportion of its long-term care budget that goes to home and community-based services (HCBS) as opposed to nursing home care. But this is not because what has been appropriated to nursing home care here has been so generous. It is because what has been appropriated to HCBS has been so poor.

As of the last federal government calculation, Oregon ranked first in the proportion of long-term care Medicaid expenditures going to HCBS: 83% in 2019. So that must mean Oregon nursing home care receives nothing, right? Wrong. Oregon’s current basic rate for nursing home care is $458.45 per day, while the Medicaid rates here, even combined with federal funds generated by a fee that facilities pay, are well under $300 on average. Oregon home care workers currently make a base rate of $17.77 an hour, paid by the state, certainly more than my wife, who makes $14 an hour in high-cost New Hampshire working with her clients in a homemaker position.

Oregon, and other states, prove it possible to honor the full continuum of long-term care without robbing Peter to pay Paul. And here in New Hampshire House Bill 2, the budget policy bill, incorporated elements from a Senate bill meant to better fund HCBS options in the future, while it also provided Medicaid increases that played no favorites between vulnerable populations, whether they are being cared for at home or in a facility.

In the future, it may be that what happens here is what has happened in Washington, another top state for HCBS funding. There, if we look at data from a three-year period ending February 2020, before the pandemic skewed everything, the nursing home Medicaid population dropped 3%. Does this mean the population receiving state-paid in-home care grew by that same amount over that period? No, it grew 11%.

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If you make in-home care a well-supported option you are not so much diverting nursing home residents, who reside in facilities out of medical necessity and the need for 24/7 support, as you are creating an accessible benefit for aging adults.

In their legislative session that ended last month, Washington legislators appropriated funding to start state-paid home care workers at $21 an hour. But they also provided a 15% increase in nursing home funding.

These examples of other states provide a roadmap for New Hampshire legislators to build upon what they did with their socially-just budget work this year: Fund long-term care in a way that leaves no one behind.