Beginning in 2027, people on Granite Advantage – the state’s expanded Medicaid program must document that they spend 80 hours per month working, volunteering, or in school, with exceptions for certain populations.
Roughly 46,900 people are enrolled in the state’s Granite Advantage program. Residents who qualify for this program include those with low incomes, disabilities, pregnant mothers and people who make an income of 138% of the federal poverty level.
Lunch break support groups
Dr. Melinda Asbury, interim director of Monadnock Family Services in Keene, which provides mental health care, said that work requirements do not fit the reality of people facing serious mental illness or substance use disorder.
She said people facing mental health challenges and substance use disorder can go through cycles of recovery and relapse that are not always in their control and that stress can cause relapses.
“The threat of losing one's own health insurance is extremely stressful,” Asbury said. “We have already seen at Monadnock Family Services and the community mental health system as a whole, an increase in our patients' stress and distress from the upcoming work requirements.”
She said their clients are also confused about the process of proving they’ve met the requirements, like how the state is going to process forms, and what documentation looks like.
“A lot of times people, especially for folks who have anxiety or obsessive compulsive disorder, their brain automatically thinks of the worst case scenario, and it just plays that on loop over and over,” Asbury said. “So when we don't provide our individuals who are receiving treatment, the knowledge and the information they need, they're just stuck in this loop of anxiety and it's worsening their mental health right now.”
In addition, her office is also trying to figure out the new requirements, including determining medical frailty, one of the conditions that excuses someone from work requirements.
“We are all, as a system, trying to be ahead of the game and prepare for this as much as we can, but just not quite having that clarity yet, I think has been a challenge,” Asbury said.
Therapists at Monadnock Family Services have started using their lunch breaks to offer support groups to people worried about upcoming changes, offering help with paper work but also holding community peer group listening sessions.
Asbury said the state health department has been notifying patients about the changes.
“They have tried to partner with us to make this be as low impact as they can, but they themselves can only do so much,” Asbury said.
Sam Burgess, director of healthcare access and affordability at New Futures, said work requirements don’t necessarily measure if someone is working, they measure a person’s ability to navigate administrative hurdles.
“I think it's important to think about who gets hurt, right?” Burgess said. “This is people working at your favorite diner on a construction crew at a seasonal job in the North Country. Small employers often can't offer insurance, and Medicaid really fills that gap.”
Burgess said daily impracticalities add to the burden of proving eligibility under work requirements.
In the North Country, for example, Burgess said people may have to drive further to get to their doctor’s offices, or they may have to work or volunteer at job sites that are far from them.
Burgess said Granite Advantage beneficiaries and losing health coverage could also impact the medical system.
“When people lose coverage, they don't stop getting sick, they just avoid routine care,” Burgess said. “They show up to emergency rooms later and they're sicker and they don't have insurance, and that ultimately falls upon the rest of the state as well. Those costs don't disappear.”
New Hampshire has elected to require people on Granite Advantage to re-determine for their benefits every 6 months as opposed to annually, as done in prior years.
Asbury said Granite Advantage, as it stands prior to the new work requirements, helps people that are between jobs or are seeking either mental health or substance use treatment plans.
“Forcing people to start to work really delays the amount of time that they have to make themselves well,” Asbury said. “That's part of the beauty of this program was it was meant to help people bridge that gap, to sustain them for a little while until they could go back to work.”
Financial and emotional impacts on service providers
Across New Hampshire’s ten-center community mental health system, there are about 4,000 people that use Granite Advantage, which is about 7% of the people they serve in total. Asbury said that if fewer people in that group have health insurance, their community mental health system could be financially under-resourced. The health system may also see an increase in uncompensated care as they continue to treat patients when medically necessary.
The work requirements can take a toll on workers in another way: the hassle factor, or how therapists, doctors and specialists may spend time filling out paperwork to keep patients connected to Medicaid. She said therapists at their practice are already anticipating and documenting conditions that patients may have that make it difficult for them to work, but that’s not necessarily the work they envisioned doing in their practices.
“That leads to moral injury,” Asbury said. “That leads to somebody who saw their life being a certain way and being able to help people, finding out, ‘You know what, because of this system, I actually can't help them in the way that I want.’ So then that leads to work disengagement, and then that leads to turnover and that leads to poor care for our patients.”
To prepare for work requirements, Asbury said Monadnock Family Services has hired a benefits specialist to help patients keep and maintain their Medicaid coverage.
Asbury said every dollar they spend on benefit specialists is a dollar less on patients.
“We've doubled the amount of people on staff that we have for that job in anticipation of the work requirements starting,” Asbury said. “So if the work requirements and the changes in Medicaid hadn't come forth, we would not have doubled that amount of time that we're paying for that because it's an administrative staff piece.”
Asbury suggested people look to the state health department’s website for all of the upcoming changes.
“If people are facing this, the more prepared that they are before they head into this, I think the better,” she said.
