New Futures Comment Letter to NH DHHS on Granite Advantage Premiums
New Hampshire Department of Health and Human Services
Office of the Commissioner
129 Pleasant Street, Concord, NH 03301
Public Comment on New Hampshire’s Proposed Section 1115(a) Demonstration Waiver Application – Granite Advantage Health Care Program Premiums
Dear Commissioner,
On behalf of New Futures, I am writing to offer public comments on the New Hampshire Department of Health and Human Services’ (NH DHHS) Section 1115(a) Demonstration Waiver application.1 While we understand the Department is carrying out statutory directives, we urge NH DHHS and the Centers for Medicare & Medicaid Services (CMS) to reject mandatory monthly premiums for Granite Advantage enrollees. Imposing monthly financial obligations on low income adults enrolled in Granite Advantage will make coverage unaffordable, result in coverage loss, and increase financial strain on community healthcare providers across New Hampshire.
For Granite Advantage enrollees, healthcare affordability is directly linked to monthly living expenses. Adding mandatory monthly premiums creates an immediate barrier for working adults already balancing tight budgets against the rising costs of housing, utilities, and food. Extensive research demonstrates that charging premiums to low-income populations leads directly to enrollment declines. When Oregon introduced sliding-scale premiums for low-income Medicaid beneficiaries, overall enrollment dropped by 46% in the first year for the affected population, leaving thousands uninsured and three times more likely to rely on emergency rooms for routine medical care.2 Similarly, an evaluation of Wisconsin’s BadgerCare program found that a $10 monthly premium shortened average enrollment by 1.4 months and reduced full-year continuous coverage by 12 percentage points.3 For low-income individuals with variable hourly earnings, even small recurring monthly fees lead to coverage disruption and disenrollment.
Imposing premiums on Medicaid expansion enrollees is also counterproductive from a fiscal and administrative perspective. A study published in the American Economic Review demonstrated that charging premiums in public health programs drives healthier, lower-cost individuals out of coverage.4 Sicker beneficiaries with ongoing medical needs remain enrolled because they cannot forgo care. As healthier enrollees drop off, the remaining risk pool deteriorates, increasing average medical claims for remaining enrollees. Furthermore, the administrative cost of establishing billing systems, issuing invoices, tracking grace periods, and executing disenrollment notices often consumes the vast majority of revenue collected. Demonstrating the operational challenges of Medicaid cost-sharing, state data from Michigan’s Medicaid expansion program shows that over its first five years, the state billed more than $83 million in enrollee co pays and income-based contributions, but collected just over $27 million.5 This is a cumulative collection rate around 32%, with quarterly collection rates dropping under 26% for certain periods.
When low-income adults lose insurance due to unpaid premiums, their medical needs do not vanish. Instead, unmanaged chronic conditions escalate into emergencies, shifting care to hospital emergency departments where treatment cannot be turned away. Prior to Medicaid expansion in 2014, New Hampshire hospitals absorbed $174 million annually in uncompensated care. Following expansion, that figure fell to $69 million by 2021. Reintroducing mandatory premiums threatens to reverse these gains, shifting unpaid medical costs back onto community hospitals that already provided over $674.9 million in total community benefit investments, including $412.5 million in unreimbursed Medicaid care and $40.3 million in direct financial assistance to patients.6 Section 1115 waivers are intended to test innovative methods to expand access to high-quality care, not erect financial barriers that disenroll eligible Granite Staters. We urge NH DHHS and CMS to protect healthcare coverage in New Hampshire by rejecting the requested premium requirements.
Respectfully submitted,
Samuel Burgess
Healthcare Policy Director
New Futures
