By By William Skipworth N.H. Bulletin,William Skipworth N.h. Bulletin

Copyright keenesentinel

Lawmakers on both the federal and state levels have spent much of 2025 work-shopping and debating changes and cuts to Medicaid, the nation’s public health care program for people with low incomes or unique needs.

The Republicans behind the changes have looked to the program for cost-savings and claimed they’re just trying to root out waste, fraud, and abuse. Democrats, on the other hand, have decried the cuts as cruel and argued their sole purpose is to fund tax cuts for the ultra wealthy. In the end, Republicans, who control both Congress in Washington and the state Legislature in Concord, succeeded on most counts in enacting their desired changes to the program.

From work requirements to premiums, here’s a look at where lawmakers landed and what it all means for New Hampshire’s health care landscape.

Work requirements

Both Congress and the N.H. Legislature enacted plans to implement work requirements for Medicaid enrollees this year.

When the Republican-controlled state Legislature passed a new budget in late June, it also kickstarted the state’s work requirement system. In addition to funding the state government, the budget legislation instructs the state Department of Health and Human Services to devise a work requirement system for Medicaid and submit it to the federal government. Because Medicaid is a program run jointly by the state and federal governments, the federal Centers for Medicare and Medicaid Services must approve changes through what is known as a demonstration waiver. The details of that work requirement plan need to be approved by New Hampshire’s Joint Legislative Fiscal Committee before being sent to the federal government.

In arguing for work requirements on the Senate floor in March, state Sen. Howard Pearl, a Loudon Republican, argued “Medicaid and other welfare programs should be a bridge for non-aged, non-disabled adults, not a destination.” He and his Republican colleagues framed the work requirements as a way to encourage employment and help people get jobs.

However, research compiled by the Brookings Institution and other research organizations suggests work requirements for Medicaid and other social programs don’t increase employment and often strip benefits from eligible people due to the burdensome bureaucracy necessary to administer the requirements.

Before the work requirement plan was added to the budget bill, it was part of a standalone piece of legislation. That legislation failed, but its provisions were incorporated into the budget as a nongermane amendment.

And then the One Big Beautiful Bill Act passed Congress. The behemoth omnibus bill, which had been in the works for months and was signed into law in July, has been the signature legislation of President Donald Trump’s second term in office so far. Among the hundreds of provisions in the law is a work requirement system for Medicaid. The law mandates able-bodied Medicaid enrollees work 80 hours a month or lose coverage.

It is unclear how the federal work requirements will interact with the state-level requirements. Kathy Remillard, deputy director of communications for the N.H. Department of Health and Human Services said in an email to the Bulletin: “The Department is reviewing the new federal and state work requirements language to ensure program changes comply with state and federal law. We are working with the Governor’s office and the Legislature to identify differences and determine next steps.”

Federal cuts

The One Big Beautiful Bill Act affects Medicaid in New Hampshire in several ways.

It eliminates some financing that the federal government has been providing to states since 2010 for the expansion of Medicaid. It restricts states from using special funding — known as state-directed payments — to pay Medicaid providers higher rates than Medicare. It also limits retroactive payments, requires enrollees to prove their eligibility every six months instead of yearly, and freezes states’ ability to charge Medicaid providers taxes, among other changes. In all, it’s expected to revoke roughly 15 percent of New Hampshire’s federal baseline Medicaid spending through these and other provisions, according to analysis from the Kaiser Family Foundation.

KFF’s analysis also estimates the bill will result in between 17,000 and 29,000 people in New Hampshire losing health care coverage by 2034. Nationwide, the foundation estimates roughly 10 million will lose coverage.

Premiums and increased copays

Back at the state level, New Hampshire Gov. Kelly Ayotte entered office in January with a series of fiscal priorities. One was to save money on Medicaid. To do that, she proposed a number of changes to the program in New Hampshire.

The most significant of those was to introduce premiums for some enrollees. Ayotte proposed that families that earn at least 255 percent of the federal poverty level (or 100 percent and up for those without children) be required to make a payment of up to 5 percent of their household income in order to receive coverage.

For reference, a family of three earning 255 percent of the federal poverty level would be bringing in an annual salary of $59,962.50, according to the U.S. Department of Health and Human Services.

Ayotte proposed these premiums as part of the budget. However, when the Legislature got its turn to work on the budget, lawmakers altered it to be a fixed price based on the size of a family rather than a share of the income.

In the final version that was signed into law, enrollees making 100 percent of the poverty line or more will pay between $60 to $100 per month, depending on the size of their families; enrollees making at least 255 percent of the poverty line will pay $190 to $270 monthly.

The family of three earning $59,962.50 is set to pay $233 a month, based on 2025’s poverty level guidelines. A family of three earning $26,650 is set to pay $90 a month.

In an interview at the time, Ayotte defended these premiums by pointing out how broad New Hampshire’s eligibility requirements are compared to other states.

“New Hampshire has among the highest eligibility in terms of who’s covered for Medicaid in the nation,” she said. “People aren’t even eligible to get Medicaid above 255 percent of poverty in 26 states.”

Indeed, as of January, the most recent data available, New Hampshire ranks fourth (tied with Connecticut) among U.S. states and territories for most expansive Medicaid income eligibility requirements for children, according to KFF.

Democrats lambasted the premiums, likening them to an “income tax on the poor.”

The legislation instructs DHHS to devise a plan to implement the premiums by July 2026

Ayotte also looked for cost savings in copays, the portion of prescriptions that enrollees are responsible for. The budget legislation changes the amount Medicaid recipients pay for their prescriptions from $1 or $2 to $4 per prescription (unless that exceeds 5 percent of household income).

The new copays go into effect in January 2026.

Name-brand drugs

Another of Ayotte’s cost-saving measures, unlike the premiums or copays, saw bipartisan support.

New Hampshire’s Medicaid program has long been prohibited from buying name-brand drugs when a generic version is available because historically the name brands are more expensive. However, in recent years, some name-brand drugs have become cheaper than their generic counterparts, so lawmakers altered that rule this year. With the enactment of the new budget, N.H. Medicaid is allowed to purchase name-brand drugs if they’re cheaper than the generic.

Jake Leon, DHHS director of communications, told the Bulletin the state won’t know how much money is being saved until the end of the second quarter or early third quarter of the fiscal year (the second quarter closes at the end of December). However, Leon said the department budgeted savings of just under $1 million in the fiscal year that started in July and just under $3 million in the year after that.

The trigger law

A big fear among Democrats and Medicaid proponents in New Hampshire has revolved around the state’s 2018 trigger law.

In 2014, New Hampshire expanded Medicaid using funding provided by the federal government through the Affordable Care Act. Today, roughly 60,000 New Hampshire residents are able to receive Medicaid through that expansion, which is funded 90 percent by the federal government. (Roughly 186,000 people are on Medicaid in New Hampshire in total.) In 2018, however, New Hampshire passed a law that would revoke Medicaid from these 60,000 people under the expanded eligibility if the federal funding falls below 90 percent of the cost of the program. (Previous laws had also set triggers but at different thresholds.)

As Republicans in Washington debated cuts to Medicaid, many in New Hampshire, particularly Democrats and those working in Medicaid, feared this so-called trigger law would be activated.

In order for the trigger law to be activated, the federal government would’ve had to reduce its share of the cost of that expansion below 90 percent, which it has been contributing to states that opt in since the Affordable Care Act was enacted. That hasn’t happened so far with this round of Medicaid cuts.