In 2018, New Hampshire care providers put up a united front in opposition to managed care insurance companies running the Medicaid program for long-term care payments, and legislators, in bipartisan votes, rescinded a law that would have resulted in this privatization.

Going into 2019, providers again united and pushed for a uniform Medicaid funding increase. This approach played no favorites and provided the same proportional boost for all Medicaid care settings. This was adopted in the bipartisan budget that finally passed into law in September. New Hampshire still has New England’s worst Medicaid underfunding, but this investment was an essential lifeline.

With the budget adopted, the current legislative session focuses on policy. One bipartisan policy bill from Sen. Cindy Rosenwald, Senate Bill 715, would eliminate an arbitrary restriction that caps the average annual cost for “home-based care” at “50 percent of the average annual cost for the provision of services to persons in a nursing facility.”

Representing facility-based care, we have no objection to this reform. Nursing homes, for example, play a vital role in rehabilitating those who are discharged from hospitals – the only circumstance in which Medicare pays for nursing home care – and, upon rehabilitation, those who are medically indigent will often need in-home care. We also represent assisted living facilities in a state where the Medicaid rate is less than what a bargain motel would charge, which has driven facilities into closure. While cost is a legitimate state concern, we need a robust system of home-and-community-based services. It didn’t help, for example, when Swanzey had to close its 16-bed Carpenter Home.

Oregon has led the nation in providing the highest proportion of Medicaid funding to HCBS. It guarantees home care workers a wage of no less than $15 an hour while also providing a nursing home rate that is more than $100 a day higher than what New Hampshire pays. Oregon, and other states, show it is possible to honor the entire continuum of long-term care without robbing Peter to pay Paul.

New Hampshire has the nation’s second-oldest population, and each care sector plays its role. There is a moratorium on new nursing home beds. Medical necessity means that demand will not go away. A 2017 RAND Corporation study determined that among those between 57 to 61, over half would spend at least one night in a nursing home during their lifetimes. Yet it’s challenging to staff existing beds given Medicaid underfunding so severe that it can place licensed nursing assistants – 92% of whom are women – into poverty.

Where the elderly can make Medicaid care choices, they should be able to. A Granite State poll question posed last year found almost two-thirds of New Hampshire residents (64%) would prefer to be cared for in their own homes, on an hourly basis, if they needed assistance with the activities of daily living. Twenty-three percent would flatly choose a long-term care facility in those circumstances, while the rest were undecided. The percentage of those who would choose a facility, interestingly, was as high as 28% for the youngest respondents – those between 18 to 34.

The continuum of long-term care is fragile and interdependent. In shoring up HCBS, Senate Bill 715 is a step in the right direction.

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

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