[Click here to watch the full conversation on The State We’re In]
By Rosemary Ford and Caitlin Agnew
This article has been edited for length and clarity.
What are the impacts of federal policy changes on health and welfare benefits and what changes we expect to see in New Hampshire? The N.H. Fiscal Policy Institute has issued briefs on health care cuts and other changes that affect New Hampshire residents, and here to discuss that is Phil Sletten, research director at the Fiscal Policy Institute.
Melanie Plenda:
On Oct. 24, the N.H. Fiscal Policy Institute hosted an all day event that focused on the high cost of living in New Hampshire, titled “Working Hard and Falling Behind.” What is it that makes New Hampshire so expensive?
Phil Sletten:
What we really wanted to examine both at the event and in research that was led by my colleague Nicole Heller, was what has happened to the cost of living in New Hampshire over a 20-year period. So we looked at data from 2005-2015 and 2024. We looked at some key living costs, particularly housing, child care, health care, food and gasoline. We also looked at what a median price single-family house would cost, including interest rates and property taxes, etc.
So those data allowed us to have insight into what these core living costs mean for Granite Staters, and how they have changed for Granite Staters over time. We see that, particularly in the last 10 years, it has become substantially less affordable to live in New Hampshire, especially for a household with median household income, than it was 10 years ago.
Melanie Plenda:
There were four areas of concern presented at the conference. What is the connection between health care, housing, caregiving and a new term, “rurality”?
Phil Sletten:
We examined these four areas, because these are all cost areas that affect people in ways that, I would say, are difficult to avoid. All of us get sick at some point, so health care is going to be an expense that many of us face. Having health insurance is something that, because of the high cost of basic care and specific expenses, health insurance is something that people — either in conjunction with their employer, through individual means, or through public support — try to maintain.
Caregiving is a cost that households with children often face or they take the tradeoff of, if you’re not active in child care of some form, then you’re maybe not in the labor force as much but we’re all going to need care at some point or provide care at some point, whether it’s to someone younger or someone older or whether we need care when we’re older ourselves, for example.
Housing is another one. Everyone needs a place to live, whether it’s owning a home or renting.
Then living in rural areas presents particular challenges as well. Some of those costs, particularly transportation costs and also the access to goods and services — not just moving them, but also what happens to them in the process of getting there, or do even often make it to where you live in a rural area. Those are all costs that are difficult to avoid, and all ones that we consider relatively core. There are some costs that you can sort of find inventive and creative ways around, and people do. But we wanted to focus on those areas, because we think there was a lot to unpack there in terms of both cost drivers and some of the potential solutions that our panelists brought forward in the conference.
Melanie Plenda:
Is there a connection between housing accessibility and health?
Phil Sletten:
Absolutely. If we think about the social determinants of health — which is a fancy way of saying all the things that are sort of upstream of getting sick that may happen to you before you might consider yourself sick, having an illness or some form of disability. All those things are what researchers would call the social determinants of health, and that includes your built environment. Does your housing have all of the things that it needs? Something as simple as having the plumbing fixtures or kitchen fixtures available. Is there mold in the home? Is it difficult to keep your home at temperature when it's very cold outside, because it may not be as well-insulated? Those are all built environment characteristics that could interact with health and social determinants of health, which can also include access to food and other services such as education.
Melanie Plenda:
The “One Big Beautiful Bill,” which became law in July, makes significant changes to the Supplemental Nutrition Assistance program known as SNAP. Who is most affected by these changes?
Phil Sletten:
The changes to the Supplemental Nutrition Assistance Program in the federal reconciliation law that passed back in July are ones that are direct, but some of them we're going to have to see how they shake out at the state level. That's because SNAP is a program in which all the benefits are federally funded, but there is a split in administrative costs and administrative responsibility between the federal government and the state governments, and that cost split is actually going to change. Both those administrative costs and states are more likely going to have to carry most of the cost of paying for those benefits.
Melanie Plenda:
What is the state of New Hampshire doing to fill the gap in funding?
Phil Sletten:
Right now, the SNAP program is facing a gap in funding that's associated with the federal government shutdown. So there's two components here. One is the long-term reduction in funding associated with the federal reconciliation law. The other is what's happening immediately and has been happening since Oct. 1, which is that the federal government isn't technically open, or at least not all of it is technically open and funded.
So the federal government pays for SNAP benefits in monthly installments, and the state will not be receiving its monthly installment for November. That means that the roughly 76,000 people in New Hampshire, including about 26,000 children, who are enrolled in the SNAP program in the state won't receive assistance to afford food from the federal government in November, at least until the federal government reopens. So what the state is doing is finding ways of additional resources and contracting with the New Hampshire Food Bank.
[Editor’s note: Since this interview took place, the Trump administration agreed to partially fund SNAP, providing 50% of the normal amount.]
Melanie Plenda:
Let’s turn now to Medicaid. More than 180,000 New Hampshire residents are on Medicaid. Who is at greatest risk of losing their benefits with changes to Medicaid enrollment eligibility?
Phil Sletten:
There are both federal and state changes here. The state passed its state budget on June 27, and the federal government passed the federal reconciliation law on July 4. The two pieces of legislation didn't really have a clear vision of what each other was doing as they were being changed. Indeed, the federal changes were happening relatively late in the process, and they weren't watching all the state budget changes.
So there's a couple of different layers of changes here. The largest one is work requirements. Medicaid, unlike SNAP — which has work requirements currently to maintain enrollment — doesn't have work requirements. Arkansas, New Hampshire and Georgia have all conducted experiments with work requirements in the past, over the last seven years or so, but those have been stopped because of federal law or have been maintained as just a small pilot component because of federal law.
Now that federal law has changed, there are work requirements that are part of the Medicaid program and they affect particularly Medicaid expansion enrollees, who are adults with poverty-level or near poverty-level incomes who are enrolled in what we call in New Hampshire, the Granite Advantage program. The state version of those requirements would have about 100 hours a month of work or community engagement requirements that fit the approved list. The federal government has a somewhat different approved list and identifies 80 hours per month as the threshold for maintaining coverage. It's not clear exactly which of these versions is going to be the dominant one in New Hampshire.
But that's not the only change for enrollees. There are also going to be co-payments for Medicaid enrollees, and the state passed a version of premiums — payments that people make to the state to remain enrolled in Medicaid, when previously they didn't have to make payments, or at least not payments of this scale. The state implemented premiums, and the federal government implements co-pays in its new law, and those will probably override at least some of the premiums for some populations.
There are also some certain lawfully present immigrants in the United States who are currently eligible for Medicaid as well as Medicare, SNAP and health care premium assistance tax credits that will no longer be eligible for those services. This includes refugees, asylees, victims of domestic and sexual violence and human trafficking who are lawfully present in the U.S., currently eligible, who will no longer be eligible starting next year.
There are also limits on what are called provider taxes, in this case taxes on hospitals. It's very complex, but the basic upshot of it is that the state raised about $280 million in the state fiscal year 2024 through these provider taxes and federal matching funds to fund the Medicaid program. When the federal limits that are new are fully put into place, that $280 million wouldn't have been able to be raised that way, so it would have to be raised through some other fashion. So that will likely change the Medicaid program in New Hampshire, but we don't know how.
Melanie Plenda:
Do we have a sense or there data that might show, with all of these changes, what might happen as a result in our state?
Phil Sletten:
There are two categories of what might happen. One is disenrollment, and the estimates that I’ve seen from KFF projected that with, all the changes in the federal reconciliation law — just what happened federally, not counting what we might see with the federal-state policy interactions that are a little harder to predict at this point — that was about 27,000 fewer people would have health coverage in New Hampshire in 2024 than would have otherwise if the federal reconciliation law had not passed. That number changes if you include the premium tax credits that are up for discussion at the federal level currently. That would boost it to about 32,000 people.
There’s also a set of unknowns related to fiscal pressures on the state that may prompt state policy decisions because of changes at the federal level.. We don’t know how those are going to shake out in the coming years because those will be a series of state policy decisions that will be implemented at the time those provisions are implemented.
Melanie Plenda:
Phil Sletten, research director at the N.H. Fiscal Policy Institute, thank you for joining us today.
“The State We’re In” is a weekly digital public affairs show produced by NH PBS and The Marlin Fitzwater Center for Communication at Franklin Pierce University. It is shared with partners in the Granite State News Collaborative, of which both organizations are members. For more information, visit collaborativenh.org.