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Almost everything Granite Staters are hearing about Medicaid in New Hampshire is wrong.

So say supporters of the Medicaid reforms proposed by Gov. Kelly Ayotte and passed by the GOP-controlled House. To make their case, they point to facts that rarely make it into the current debate about the generosity of New Hampshire’s Medicaid system.

Critics focus on the increase in costs for Medicaid users, such as adjusting the cost-sharing from $1 or $2 per prescription to $4 to reflect the impact of inflation.

What’s overlooked is the fact that New Hampshire has the fifth-highest income limit in the country for eligibility in Medicaid’s Children’s Health Insurance Program (CHIP).

Families earning up to 323 percent of the federal poverty line can qualify for CHIP in New Hampshire, while the national median is 255 percent. Families who earn more than that aren’t eligible for any benefits in 25 other states.

And so, when Democrats label Ayotte’s plan to have some families pay a monthly premium a “Medicaid income tax,” they fail to note those families wouldn’t even be eligible for Medicaid in most other states.

“This is something that’s going to preserve the eligibility for Medicaid, and we have some of the highest eligibility in the country, and I thought it was really important that we preserve that eligibility,” Ayotte told NHJournal.

Another key detail: only about 10 percent of children covered by CHIP are in households earning enough to pay the monthly premiums. And those costs are capped at five percent of the family’s annual income.

The big picture story of Medicaid in New Hampshire is similar to the one told across the U.S. During the COVID crisis, the federal government used its emergency power to impose “continuous eligibility” on the states’ Medicaid benefits. Instead of having eligibility evaluated annually, anyone who qualified for Medicaid once simply stayed on the system, regardless of their personal situation.

An obvious example is a worker whose workplace was locked down during the pandemic and who qualified for Medicaid, only to return to work six months later. Without eligibility evaluations, he stayed on Medicaid.

As one person involved in New Hampshire’s Medicaid debate told NHJournal, “You could literally win the Powerball and keep getting free healthcare.”

During that period, enrollment in New Hampshire Medicaid reached record levels, growing almost 42 percent above March 2020. The spending was massive. While New Hampshire’s overall state spending grew about 40 percent over that period, state spending on Medicaid is now up by 60 percent — one-third faster than overall spending.

To fill the gap, Ayotte is eyeing a savings of up to $30 million from Medicaid by adding some cost sharing to the plan.

Ayotte’s premium proposal would not be universal. What Democrats attack as an “income tax” is actually a floor to ensure the neediest recipients are protected.

For people on Granite Advantage, the premium doesn’t kick in until 100 percent of the federal poverty level of income. That’s $15,650 for an individual, or $32,150 for a family of four. People earning up to 138 percent of the federal poverty rate would continue to qualify for Granite Advantage under Ayotte’s plan. That’s $21,597 for an individual, or $44,367 for a family of four.

Under the Affordable Care Act, any changes to the Granite Advantage program would have to be cleared at the federal level first. Therefore, no changes could be implemented until 2027.

For children covered by CHIP, premiums do not take effect until their family reaches 255 percent of the federal poverty level. A single parent with one child earning $52,875 is at 250 percent of the federal poverty rate and would not pay a premium for CHIP. A family of four earning $80,375 is also at 250 percent.

According to the nonprofit Kaiser Family Foundation, New Hampshire has about 18,000 children covered by CHIP. Of those, between 8,000 and 8,500 are in families who would see premiums introduced to their healthcare plans.

Inside the State House, Democrats argue no cost savings would be necessary if not for GOP-backed tax cuts. They’ve called for a return of the income tax on interest and dividends to increase revenue.

Outside the State House, the activist group NH Medicaid Matters says poorly thought-out plans for federal and state budget cuts in Medicaid would land hardest on the poor and working families. 

“The proposed cost-sharing measures would shift more costs to families and enrollees, imposing additional financial burdens and barriers to care,” the group states. “For a family of three making $68,000 per year, the monthly premium could be over $280 each month, with $4 co-pays per prescription. A single individual on Medicaid expansion making around $15,000 per year could also be subjected to increased costs.”

Ayotte said the proposal she’s backing would make sure there are carveouts for people who fall between the income cracks.

“We’re also going to have a hardship provision to make sure that if there’s a hardship and you’re unable to pay, you still receive coverage,” Ayotte said.

In an attempt to reach a compromise with reluctant House Republicans, the Senate Finance Committee Tuesday added a seven-year sunset clause to the proposed reauthorization of Medicaid Expansion.

“From where I sit, seven years is pretty darn good,” said Senate President Jeb Bradley (R-Wolfeboro).

The committee added the seven-year sunset as it moved SB263 to become part of the biennial budget and a major part of the GOP majority’s Family First platform.

“We have allocated resources to support key areas such as education, our economy, health care, infrastructure, and public safety, all while delivering more financial support to our communities. Further, the Senate Finance Committee accomplished all this while reducing spending by three-quarters of a billion dollars less than the budget was brought to us,” Bradley said.

The budget includes $169 million for education, $30 million for the Housing Champions program, an additional $10 million for local homelessness programs, and a $134 million increase to the Medicaid reimbursement rate. Senate Finance Chair Sen. James Gray (R-Rochester) said that was all being done without adding to the tax burden.

“Throughout the budget process, we have remained mindful of the diverse needs of our state, listening to the concerns of our constituents and working diligently to address them. This budget reflects our efforts to serve New Hampshire families without harming the financial stability of our Granite State,” Gray said.

Bradley is the main GOP driver behind SB263, the bill to continue New Hampshire’s Granite Advantage Medicaid program. It provides medical insurance for about 60,000 low-income residents and is scheduled to end next year without another reauthorization.

The bipartisan bill, already passed by the Senate, would have created a permanent Medicaid program as part of the Affordable Care Act. Though it is supported by New Hampshire’s medical and business communities, the bill ran into opposition from the slim GOP majority in the House.

House leadership under Speaker Sherman Packard (R-Londonderry) tried to limit the expansion to five or six years when SB263 went to the chamber earlier this month.

With the measure now heading to the House Finance Committee later this week, pressure was on to reach a compromise that could get to Gov. Chris Sununu’s desk. Sen. Cindy Rosenwald (D-Nashua) agreed to Bradley’s amendment limiting the expansion to seven years, saying it could always be changed next year.

“If the House retains the bill, we can override the seven-year sunset next year,” Rosenwald said.

Bradley said the seven-year extension allows the state to seek the best deal with managed care companies to administer the insurance. Any shorter time frame could add about 10 to 15 percent to the costs, he said. The bill also includes a clause to revive a commission that will investigate the future of the expanded Medicaid program.

“The seven-year sunset, I believe, is an acceptable compromise,” Bradley said.

Sen. Regina Birdsell (R-Hampstead) said the budget protects families while strengthening the state’s economy.

“By extending our innovative Granite Advantage Health Care Program for seven years and increasing Medicaid reimbursement rates by $134 million, this budget will not only safeguard the health and well-being of New Hampshire’s most vulnerable populations but also provide financial stability to our state’s health care sector,” Birdsell said.

Steve Ahnen, president of the New Hampshire Hospital Association, praised the compromise.

“We are pleased with the agreement on reauthorization of Medicaid expansion for the next seven years as part of the state budget for fiscal years 2024 and 2025 currently in Senate Finance,” Ahnen said. “This agreement will provide much-needed stability for the program that will serve our patients, providers, and the state well. The Granite Advantage Health Care Program has successfully helped to ensure our patients are able to receive the right care, at the right time, in the right place, and this compromise agreement will continue to help people access the care they need, when and where they need it. We appreciate the bipartisan leadership in both the Senate and House in reaching this important compromise.”

Under the Affordable Care Act, 90 percent of Granite Advantage is paid for by the federal government, with the remaining 10 percent getting funded by an insurance premium tax and other sources. In 2022, Granite Advantage cost a total of $558 million, but the federal government covered $502 million.

Expanding Medicaid to low-income residents has created savings for hospitals and led to more people being healthier and able to enter the workforce. It is also driving the costs of private insurance down by cutting the amount of money hospitals lose providing uncompensated care.

According to the New Hampshire Hospital Association, Granite Advantage has led to a 63 percent decrease in the number of uninsured people going to emergency rooms. There has also been a 57 percent drop in uninsured people being admitted to hospitals and another 41 percent reduction in the number of outpatient visits by uninsured people.

In 2014, hospitals reported $174 million in uncompensated care costs before Granite Advantage went into effect. In 2021, that figure dropped to $69 million, according to the NHHA.

Granite Advantage has also helped close to 30,000 people have been able to access mental health care. Another 9,000 have been able to seek treatment for substance use disorders.

New Hampshire ranks as one of the best states in the country to be a nurse, even as providers like hospitals and assisted living facilities struggle to staff up.

A new WalletHub analysis ranks New Hampshire as the fifth best state to be a nurse based on the strong opportunities for advanced training, high pay, and good working environments. Jan Carney, associate dean for Public Health and Health Policy at the University of Vermont, said this is an excellent time to enter nursing.

“The long-term outlook for the nursing field is outstanding,” Carney said.

Though Maine came in as the second-best overall state, the Granite State easily outperformed the rest of New England. Connecticut ranked 13, Rhode Island 25, Massachusetts 29, and Vermont is near the bottom at 42.

Among the data points used for the rankings, New Hampshire placed first when it comes to the number of nursing job openings per capita. The Granite State isn’t alone in New England when it comes to needing more nurses. Massachusetts, Maine, and Vermont all land in the top five states with the most openings per capita.

According to Susan Reeves, the executive vice president of Dartmouth-Hitchcock Medical Center, the state’s nursing shortage is driven by an aging population, high housing costs, and a lack of affordable child care. 

Reeves recently told WMUR that Dartmouth-Hitchcock, the state’s largest healthcare system, uses temporary staff and employment agencies to fill as many as 400 nursing positions because it cannot find permanent staff. New Hampshire faced a nursing shortage before the COVID-19 pandemic, and factors like the state’s lack of workforce housing have only worsened the situation.

“We’re dealing with issues such as child care and housing, which is a huge constraint to bring talent to our areas to serve in our hospitals,” she said.

Dartmouth-Hitchcock Medical Center in Lebanon is in the middle of one of the more expensive housing markets in the state. The healthcare leader is taking the housing issues head-on, developing its workforce housing developments in the hospital’s surrounding area.

Brendan Williams, president of the New Hampshire Healthcare Association, also saw a connection between housing and healthcare jobs. He supports Gov. Chris Sununu’s workforce housing initiative. 

“The governor is on the right track working to increase housing stock, though that will not produce immediate relief, obviously,” Williams said. But it is not enough by itself, he added.

“In the near term, the Medicaid increase the House authorized is essential to making caregiving more attractive. Wages have soared to record highs and are outside Medicaid means. The Senate, we hope, will do as much as the House, if not more.”

And more should be done to bring new nurses into the field and keep them working, says Rebecca Sutter, George Mason University nursing professor. Between the nurses in the Baby Boom generation retiring and the high burnout rate for new nurses, the need for nurses will continue to be a concern for years to come. Public policy leaders and healthcare facilities need to focus on a sustainable strategy to train and retain nurses.

“Healthcare organizations and policymakers need to address the nursing shortage through strategies such as increasing funding for nursing education programs, providing incentives for nurses to remain in the workforce, and improving working conditions for nurses,” Sutter said.

As the bipartisan bill to reauthorize New Hampshire’s Medicaid expansion program, Granite Advantage, moves through the legislature, backers are making a conservative case for the expansion.

Senate President Jeb Bradley (R-Wolfeboro) is one of the bill’s prime sponsors. He says expanding Medicaid has lowered healthcare costs, improved healthcare for Granite Staters, and helped get more people into the workforce.

“The program has worked as intended,” Bradley said.

The Granite Advantage bill, SB 263, won unanimous support in the Senate last month. It’s scheduled for an executive session discussion on Wednesday before the House Health, Human Services and Elderly Affairs Committee. If approved, the bill will then head to the full House for a vote.

Granite Advantage was last reauthorized in 2018 and is set to expire at the end of the year without SB 263’s passage. Enrollment in the program was around 94,000 residents at the start of the year, though the national COVID-19 emergency inflated those numbers. Those figures are expected to return to around 60,000 residents in the coming months.

SB 263 would reauthorize the program and remove the requirement that the legislature pass legislation to reauthorize it every few years, instead relying on a study commission to send an annual report to the legislature reporting on the effectiveness of the program. Even if SB 263 were to pass, the legislature could sunset this program at any time by a vote of the legislature.

According to Bradley, providing coverage through Granite Advantage is taking a bite out of healthcare costs. The program is driving down the cost of uncompensated care hospitals are required to provide to people without insurance. That protects people with private insurance from being stuck picking up the tab when someone without insurance goes to an emergency room for treatment, he said.

“[Uncompensated care] is a hidden tax on any individual or any business with private insurance,” Bradley said.

According to the New Hampshire Hospital Association, Granite Advantage has led to a 63 percent decrease in the number of uninsured people going to emergency rooms. There has also been a 57 percent drop in uninsured people being admitted to hospitals and another 41 percent reduction in the number of outpatient visits by the uninsured.

In 2014, hospitals reported $174 million in uncompensated care costs before Granite Advantage went into effect. In 2021, that figure dropped to $69 million, according to the NHHA.

Sen. Lou D’Allesandro (D-Manchester) said permanently expanding Granite Advantage makes sense beyond the numbers.

“I just feel it’s the right thing to do,” D’Allesandro said. “We take care of a lot of people.

And, he pointed out, the bill does not use any money from the state’s General Fund.

The bill’s costs are 90 percent covered by the federal government. In 2022, Granite Advantage cost $558 million, but the federal government covered $502 million. According to Bradley, the remaining $56 million was paid through healthcare taxes and fees, with money from the state liquor fund also available to cover costs.

New Hampshire Business and Industry Association (BIA) President and CEO Michael Skelton said abandoning Medicaid expansion would hurt both the state’s economy and the people who make New Hampshire’s growing economy possible.

“We benefit from an overall healthier population,” Skelton said. “Hospitals and other caregivers avoid catastrophic loss of revenue, and employers and employees across the state will benefit from individuals being healthy enough to work.”

In addition to the BIA, numerous other NH-based business organizations including the NH Retail Association and several chambers of commerce have advocated for the reauthorization of Medicaid expansion.

The bipartisan effort to make New Hampshire’s Medicaid expansion permanent got a push Wednesday as the Senate Health and Human Services Committee heard from people like Manchester’s Michelle Lawrence, who said the law allows her to get vital cancer care. 

Lawrence, who is suffering from a rare form of cancer, told lawmakers she was finally able to focus on her health once she received care through New Hampshire’s Granite Advantage plan.

“For the first time in my cancer journey, the primary focus in my care has not been on insurance and insurance costs,” Lawrence said. “I’m not getting up in the middle of the night having to think about delaying care or paying rent.”

Senate President Jeb Bradley (R-Wolfeboro) joined Nashua Democrat Sen. Cindy Rosenwald in urging the committee to approve SB 263, the bipartisan bill that would make Medicaid expansion permanent.

“I think our law is a good common-sense law and should remain in place,” Bradley said.

Making Medicaid permanent is part of Gov. Chris Sununu’s budget plan. Ben Vihstadt, Sununu’s communications director, said Sununu is ready to make sure the bill gets to his desk.

“Gov. Sununu worked with legislators in 2018 to deliver a five-year reauthorization of Medicaid Expansion in a fiscally responsible manner and supports this permanent step. He looks forward to working with the legislature this session to get this bill across the finish line,” Vihstadt said.

Granite Advantage, which currently provides health care to 94,000 residents, was last reauthorized in 2018 and is set to expire at the end of June. The current proposal will make the program permanent, meaning it will not have to come back for reauthorization if approved.

New Hampshire first expanded Medicaid in 2014 under President Barack Obama’s Affordable Care Act. Henry Lippman, New Hampshire’s Medicaid director, said the program is expected to decrease to about 64,000 enrollees by the end of the year as the COVID-19 emergency authorization is expected to be phased out.

Extending Medicaid to low-income Granite Staters has been economically beneficial to the state’s hospital system, according to Steve Ahnen, president of the New Hampshire Hospital Association. Uncompensated care for hospitals dropped to $69 million in 2021, down from $173 million in 2014.

Uncompensated care costs all Granite Staters, Ahnen argued, and the bills are generally passed on through higher premiums to those with insurance. Bradley said the program has cut this hidden tax while also bringing down the cost of insurance for everyone else. 

Business & Industry Association President and CEO Michael Skelton said keeping Medicaid expansion in place is good for businesses and people. Access to healthcare means employees won’t lose time to serious medical problems, and businesses that are already short-staffed will be able to4 remain open.

“A healthy population contributes to worker availability,” Skelton said.

And without Granite Advantage, New Hampshire could lose up to $500 million a year in federal funding while having to shoulder the costs of uncompensated care alone.

“We benefit from an overall healthier population,” Skelton said. “Hospitals and other caregivers avoid catastrophic loss of revenue and employers and employees across the state will benefit from individuals being healthy enough to work.”

Robert Dunn, director of public policy for the Roman Catholic Diocese of Manchester, made a moral argument for Medicaid expansion, saying the expanded coverage has likely saved lives. Speaking on behalf of Bishop Peter Libasci he urged the committee to support the permanent expansion.

“I think we can say it’s a pro-life measure,” Dunn said. 

Though the bill had bipartisan support in the Senate committee, there is resistance in the House of Representatives, sources say. And the influential Americans for Prosperity – NH opposes the move. State Director Greg Moore said the plan incentivizes people to earn less income in order to qualify for health care.

“This regressive policy works to keep people in poverty instead of lifting them out of – it is the opposite of the Live Free or Die way of life,” Moore said. 

But Moore’s position did not carry the day. The committee voted unanimously to approve the bill, sending it to the full Senate for a vote.

The end of the federal COVID Public Health Emergency is coming, and that could result in tens of thousands of New Hampshire residents without health insurance. 

When the pandemic hit, some Americans were left without jobs and health insurance. The COVID Public Health Emergency allowed people who lost their insurance to sign up for their state Medicaid plan. But that help is coming to an end soon.

The Granite State is ready, though, with organizations preparing people to sign up for coverage in the Affordable Care Act Marketplace.

“I believe New Hampshire is way ahead of most other states,” said Keith Ballingall, president of Market Health Connect. “The state right now contains different partners to make sure we’re all working together.”

Market Health Connect is one of several companies working in the state to get people signed up for health insurance ahead of the ending of the Public Health Emergency.

President Joe Biden recently extended the so-called Public Health Emergency until the middle of January, creating a perfect storm for Ballingall and his team at MHC. The end of the emergency coincides with the open sign-up period for the marketplace, meaning thousands more people will be looking for coverage.

Keith Ballingall, president of Health Market Connect

New Hampshire residents who are on Medicaid through the Public Health Emergency are now getting pink letters informing them they will lose their coverage when the emergency officially ends. Ballingall and his team are reaching out to those people now to get them ready to sign up for a new plan.

Ballingall said about 50,000 people are already anticipated to be looking for health care during the open sign-up period, and another 50,000 to 60,000 will be looking because they got pink letters from the state.

“When the Public Health Emergency ends we will have a 60-day window to help,” Ballingall said.

MHC has people, called navigators, positioned throughout the state serving specialized populations, he said. New Hampshire attracts people from all over the world, and there are dozens of languages spoken in the Granite State.

“I think we’re doing a very good job having a very diverse team ourselves,” he said.

The health care navigator program is community-driven, he said, with the navigators living in their regions, understanding the people there, and able to provide real on-the-ground help.

Donna Toomey, one of MHC’s healthcare navigators, is based in the Lakes Region and reaches out to people wherever she can find them.

“I have been doing this work for over 20 years,” Toomey said. “I am very rooted in my community.”

Toomey goes to public meetings and holds open hours at town halls and tax collector offices. She talks with local police and firefighters, goes to schools and attends wellness fairs and old home days, and even meets people at homeless shelters to connect with people who will need help in the coming weeks.

Navigators like Toomey can make sure people will still be able to go to the doctor and get care even if they get a pink letter.

“We’re starting applications for the Marketplace now if people are going to lose their coverage when the emergency ends. That way they won’t lose coverage,” Toomey said.

Ballingall said navigators at MHC can work with people now and do all the necessary paperwork so that they are prepared for the end of the Public Health Emergency, no matter how many people will need assistance.

“At some point, it’s going to go back to the traditional rolls, and we’ve got to find someplace for them to go,” Ballingall said.

Many people who got a pink letter will go to a new plan on the Marketplace, though some may remain signed up for state Medicaid, he said.

The challenge is to reach so many people before the end of the Public Health Emergency. Toomey said the state has made the process as easy as possible, and applications can be done in 15 minutes. The key is to be ready before the January rush.

“I think the name of the game is sooner rather than later,” Toomey said.

People who have received a pink letter can start the process by connecting with a navigator at MHC through the website, www.hmcnh.com.

People with anxiety and depression are disproportionately prescribed painkillers. That’s what new research from the Dartmouth-Hitchcock Medical Center suggests, adding a complex layer to the opioid epidemic ravaging the United States and encouraging calls from New Hampshire’s congressional delegation to not move forward with the repeal of the Affordable Care Act.

The findings, which appear in the July issue of the Journal of the American Board of Family Medicine, show that nearly 19 percent of the 38.6 million American adults with mental health disorders use prescription opioids compared to only 5 percent of those without a disorder. Adults with depression and anxiety receive 51 percent of the 115 million opioid prescriptions distributed each year in the U.S., the study found.

“Because of the vulnerable nature of patients with mental illness, such as their susceptibility for opioid dependency and abuse, this finding warrants urgent attention to determine if the risks associated with such prescribing are balanced with therapeutic benefits,” said Brian Sites, an anesthesiologist at Dartmouth-Hitchcock and one of the co-authors of the study.

Image Credit: Dartmouth-Hitchcock

Opioid prescribing in the U.S. quadrupled between 1999 and 2015, and during that time more than 183,000 people died from overdoses related to prescription opioids, according to the Centers for Disease Control and Prevention.

Sites also notes that because pain is subjective, “the presence of mental illness may influence the complex dynamic between patient, provider, and health system that results in the decision to write an opioid prescription.”

The study does not give a specific reason why people with mental disorders are more frequently prescribed opiates. The study encourages more research on this population to understand opiate addiction.

Those patients may have some form of physical pain, but their mental condition may cause them to feel that pain more acutely or be less able to cope with it, leading to increased requests for something to dull the pain. As a result, doctors trying to be empathetic to their patients’ complaints may tend to overprescribe opioid painkillers, Stiles said.

Research also shows that patients are more likely to take opioids when there aren’t specialists nearby. A study published earlier this year found that the number of seniors in rural America who take at least three prescribed psychotropic drugs ― including opioids and antidepressants ― tripled over a nine-year period. The study found that many of these prescriptions were given without a proper diagnosis.

Being able to identify a subset of the population that could be more likely to use opioids could help providers and policymakers address opioid use. It “suggests that there may be additional patient- and provider-related factors specific to those with mental illness that increase the likelihood of receiving prescription opioids,” the authors wrote.

U.S. Rep. Annie Kuster, D-N.H., was present for a press conference about the study on Monday. She said repealing Obamacare could be disastrous for New Hampshire’s opioid epidemic.

“This is critically important in New Hampshire, as we have gone from second in the nation in deaths from the opioid crisis and heroin to first for fentanyl,” she said. “That’s not what we want to be known as first in the nation for.”

The U.S. Congress is currently in a heated healthcare battle. The Senate is working on legislation to repeal the healthcare law, but a vote on the bill has been delayed due to opposition from Republicans. New Hampshire Democratic Sens. Jeanne Shaheen and Maggie Hassan have both stated their opposition to the healthcare overhaul and have sent many press releases condemning “Trumpcare.”

“This new study is yet another reminder that, to combat the devastating opioid crisis, we must make mental health treatment affordable and accessible,” Shaheen said in a statement.

Hassan said she opposes proposed cuts to Medicaid that would affect coverage of mental health and substance abuse services.

“As we work to combat the horrific substance misuse crisis that is devastating our communities and taking a major toll on our economy in New Hampshire, this study highlights how dangerous Trumpcare, which includes massive cuts to Medicaid, would be for our state,” Hassan said in a statement. “We need a comprehensive, holistic approach to combating this epidemic that addresses the underlying causes of addiction, including mental health issues.”

To address the overprescription problem within the mental health community, Sites has suggested physicians need more access to alternative medicine besides opioids, including acupuncture, massage therapy, physical therapy, and non-opioid pharmaceuticals.

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After Gov. Chris Sununu released his $12.1 billion biennium budget on Thursday, the overall sentiment among Democrats and Republicans was “the devil is in the details.”

Those details will be hammered out in the next few months as the House and Senate make their recommendations to Sununu’s 2018-2019 budget. Overall it appears both parties believe it’s a solid budget with room for improvement. Republicans praised it for being “a realistic, conservative budget which is transparent, forward thinking and strengthens education, supports our cities and towns and focuses on solving real problems that have plagued taxpayers for years,” according to Senate leadership.

Democrats were glad that Sununu kept some of his campaign promises, but were also critical that he didn’t provide too many details on proposals they deemed important, including Medicaid expansion and full-day kindergarten.

“I am very concerned about the $500 million cut from state agency budget requests and what that could mean to the citizens of New Hampshire,” House Minority Leader Steve Shurtleff said in a statement. “The governor’s budget address made no mention of the successful NH Health Protection Program, leaving serious unanswered questions for the 50,000 Granite Staters who rely on the program for their health care coverage.”

In his budget proposal, Sununu includes more than $50 million in spending to address an existing shortfall in the Department of Health and Human Services’ (DHHS) fiscal 2017 budget.

In January, DHHS projected a $65.9 million dollar budget shortfall. Commissioner Jeffrey Meyers pushed back against the accusation his department overspent, claiming instead Medicaid costs did not decline as the legislature expected during the last budget debate. That put Sununu in the awkward position of writing a budget with an unexpected hole in it, while also figuring out how to handle Medicaid for the state.

As for the deficit, Sununu is requiring the commissioner to make quarterly reports to him and members of the legislature leadership “about where we actually stand on our true costs, so we can become a more nimble government that’s responsive, not just reactive.”

“As governor, I won’t make people wait until after an election to discover we may have a shortfall,” he said in remarks during a Thursday joint legislative session. “We have to be transparent. We have to be honest with the people and honest with ourselves.”

Democrats’ claim he didn’t mention Medicaid expansion is true. He only mentioned the program when talking about the DHHS deficit, since that’s where the department says its money went.

“And where we have failed in the past, I am pushing for true accounting of our Medicaid program so we can reconcile estimated Medicaid payments to actual costs,” Sununu said. “And as we go forward, be sure that we won’t wait two years to check in on them again.”

He doesn’t say if he plans to expand, repeal, or replace NH Health Protection Program. The Medicaid program in New Hampshire received bipartisan support in the legislature last year when lawmakers extended the program until Dec. 31, 2018.

That legislation gives Sununu wiggle room as he attempts to balance politics and health coverage for the state. As Washington debates repealing the Affordable Care Act, several states including New Hampshire are waiting to see how Congress and President Donald Trump’s administration handles the issue.

Sununu was reluctant to say anything about Medicaid on the campaign trail, commenting he was worried about financing the program in the long-term, but didn’t mention repeal. Not wanting to permanently fund the program, he told voters it was better to let the federal government make the first move.

Before the budget speech, Democrats waited to see if Sununu would fulfill his campaign promise of funding full-day kindergarten. His proposal includes $9 million a year for full-day kindergarten, but after the speech Democrats sought clarity on determining which communities get funding.

.@ChrisSununu needs to explain targeted full day k. $9 million a year while giving $15 million to charter schools? #nhpolitics

— NH Young Democrats (@NHYoungDems) February 9, 2017

Sununu said funds, which will be awarded in addition to education adequacy grants, would target the communities that need it most based on a community’s property wealth, the number of students on subsidized lunch programs, and communities with a high number of English as a second language students.

“So I am proud today to be the first governor to deliver a real full-day kindergarten program for communities across the state,” he added.

There’s a big distinction to be made with the state “mandating” full-day kindergarten and simply funding full-day kindergarten. Several Democrats sought to require school districts to offer full-day kindergarten, but Sununu’s budget doesn’t make that a requirement. He’s leaving it up to the individual cities and towns, but they’ll receive more funds if they opt-in.

In towns that vote to implement full-day kindergarten, school districts presently only receive 50 percent of the state’s per-pupil grant for kindergarten students. Under Sununu’s plan, the neediest communities can apply for additional grants to make the program possible.

Rep. Victoria Sullivan, R-Manchester, who sits on the House Education Committee, said she wasn’t thrilled about Sununu’s full-day kindergarten funding proposal. Sullivan said it should be a local community’s decision, and could eventually lead to mandated full-day kindergarten.

I agree with @NHSpeaker. This is a huge issue 4 me. Parental & local control in jeopardy. Next step=Mandated K. #NHPolitics https://t.co/HuCwQVuCv9

— Victoria Sullivan (@VSullivan4NH) February 9, 2017

House Speaker Shawn Jasper told reporters Sununu’s full-day kindergarten proposal probably won’t be included in the House version of the budget.

“I think that is going to be a stretch,” he said. “I think if you looked around the hall, you probably didn’t see a lot of enthusiasm on the part of Republicans on that issue. We’ll have different priorities in some areas than the governor has, certainly. I don’t think there’s ever been a budget that’s gone into the House and come out looking the same way, but he’s given us a great starting point.”

The two-year budget must be passed by June 30 to go into effect on July 1 of the next fiscal year. The House Finance Committee will look at Sununu’s budget before making a recommendation to the full House. After the House passes its version of a budget, it goes to the Senate Finance Committee, which will recommend its own proposals to the full Senate, before going to the governor’s desk for his signature or veto in spring.

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