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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.

Manchester has been operating without an independent auditor for years, despite a city charter requirement, and Mayor Jay Ruais said that needs to change.

“It’s been six years since the city had a charter-required independent auditor,” Ruais told NHJournal. 

The position has been vacant since Kevin Buckley, the last independent city auditor, retired in 2018 during Mayor Joyce Craig’s administration. After Buckley left, the job was never filled, leaving a gap in Manchester’s fiscal oversight system.

“I want to make sure we’re providing the oversight,” Ruais said.

Manchester does get an annual audit from the Melanson Marcum firm, but that’s a process that is supposed to be managed by the auditor under the city charter. The auditor’s position is assigned to work in the City Solicitor’s Office per charter rules.

The auditor is also tasked with regular analysis of all city departments as well as the operations of the ski area, golf course, civic center, MTA, MCTV, and baseball stadium to make sure the finances are transparent, and that the services provided using taxpayer funds are done efficiently.

The auditor is also to perform any particular investigations or research into aspects of city government as requested by committees and the Board of Aldermen.

“The city auditor can examine individual contracts and departments as needed,” Ruais said. 

Ruais doesn’t know why Craig left the position open, but he said Manchester voters and business owners deserve to have a city auditor on staff making sure their taxes are being used correctly, and that their city is running as it should.  

“I don’t know why Mayor Craig never hired for the role, but it’s certainly a priority for me. And with increased inflation and taxpayers fighting different headwinds, it is the kind of accountability we need to provide,” he said.

The city tried to hire a new auditor twice since Buckley’s retirement, but two different hiring committees came up short finding a candidate to take the job. 

Ruais wants to include $135,000 in the upcoming city budget starting July 1, 2025 to cover the $90,000 salary and benefits for the auditor’s position. The proposal so far won approval with the Committee on Community Improvement. Under his proposal, the first year for the position would be paid for with American Rescue Plan Act funds, with the city taking over the costs starting the following year.

In 2023, the Illinois-based nonprofit Truth In Accounting gave Manchester a “D” for its city budgeting practices, reporting the city didn’t disclose the level of debt taxpayers were carrying.

“We really believe that our representative forms of government are being harmed because citizens are making decisions on tax policy, spending policy, and who they even vote for based on misleading or wrong financial information,” said Sheila Weinberg, co-founder and president of Truth in Accounting.

“We have worked for years to recast government’s financial reports to show a truer picture of their financial condition, bringing business accounting to these financial statements instead of the political math that is used by the governments,” she said.

Manchester High School students dropped out at an alarming rate under former Manchester Mayor Joyce Craig’s watch, but that isn’t stopping the state’s largest teacher’s union from backing her bid for governor.

According to data from the Manchester School District and the state Department of Education, while Craig was in office, the district’s drop out rate was more than four times higher than the state average. And about one in four students failed to graduate each year, much higher than the state average.

But the NEA-New Hampshire is still on board. Union president Meg Tuttle told her members Democrat Craig will spend more on public schools, get them pay raises, and end New Hampshire’s Education Freedom Account (EFA) school choice program.

“New Hampshire’s students and educators deserve a governor who will have their backs. That means adequately funding our public schools, fighting for pay raises for educators, and making sure every child in our state can thrive,” Tuttle said.

Granite State taxpayers are currently spending an average of more than $20,000 per public school student, higher than many private schools in the state.

Tuttle also praised Craig for pledging to “put an end to the state’s current voucher scheme that is gouging taxpayers,” a reference to the EFA program. With Republican Kelly Ayotte promising to keep the EFA program going, Tuttle and the teachers unions see Craig as the obvious choice.

But what about her record on student achievement? How did Manchester students perform while Craig was mayor?

Craig took office in January 2018 as both mayor and chair of the Manchester School Committee. In 2019, Manchester reported a total graduation rate 17 percent below the statewide average, 73.8 percent vs. 88.42 percent.

And while the state’s dropout rate was 2.74 percent, Manchester’s was more than four times higher at 12.44 percent.

Under Craig’s tenure, the numbers got worse.

Manchester reported graduation rates of 73.01 percent in 2020. The following year, 2021, was directly impacted by the COVID pandemic, and the graduation rate plummeted to 67.85. But even when the rate rebounded, it was still well below the state average of around 88 percent. It was 72.23 in 2022, and 72.97 percent in 2023, the most recent year of data available.

The dropout rates in 2020 were 10.45 percent, 13.26 percent in COVID-plagued 2021, 11.84 percent in 2022, and 12.99 percent in 2023. The state averages for dropout rates in those same years ranged from 2.4 to 3.4 percent.

On top of overseeing an expensive public school district that failed students and their families, Craig raised city taxes several times as mayor, and repeatedly tried to override the tax cap. Raising taxes to spend on public schools is part of Craig’s platform.

Craig, who has not taken the no income tax pledge, recently admitted she would push to bring back an income tax on interest and dividends if elected governor. She says that, despite record spending on public schools, New Hampshire needs the tax to spend even more.

Craig’s tax increase does have at least one fan in New Hampshire politics. U.S. Sen. Jeanne Shaheen told radio host Jack Heath on Tuesday raising taxes is a solid idea.

“Well, nobody in New Hampshire likes taxes,” Shaheen said. “But if we want to fund our schools, if we want to have roads and bridges that we can drive on, if we want to have safe commerce, if we want to provide health care, then we have to raise revenue.”

Shaheen first won the governor’s office in 1996 by signing the no-new-taxes pledge. But she raised taxes as governor, which haunted her in her first failed bid for the U.S. Senate.

Ironically, Shaheen had to answer for her record on education in 2002. New Hampshire’s abysmal dropout rates under her watch helped sink her run. 

As three-term Mayor Joyce Craig prepares to leave office later this year — possibly to run for governor — she’s leaving behind $276 million in debt, a hole in city budgeting most taxpayers know nothing about.

That is the finding of the nonprofit Truth in Accounting project, which analyzes government budgets and reveals what the public books would show if industry practices were followed.

The Illinois-based 501(c)3 recently looked at the financial reports for New Hampshire’s two biggest cities, Manchester and Nashua, and found both laden with debt that isn’t always disclosed to residents. That type of debt and tax hiding is hurting taxpayers and harming communities, said Sheila Weinberg, co-founder and president of Truth in Accounting.

“We really believe that our representative forms of government are being harmed because citizens are making decisions on tax policy, spending policy, and who they even vote for based on misleading or wrong financial information,” Weinberg said.

On a grading scale of A through F, Manchester and Nashua got D’s from Truth in Accounting, partly due to the lack of transparency.

Looking at the 2021 audited financial reports for each city, Weinberg found Manchester taxpayers face $276 million in debt, while Nashua residents have $272 million thanks to practices like inflated revenue projections, understating the true cost of government functions, and counting borrowed money as income.

In Manchester, clearing out that debt would cost $5,800 per resident. According to the report, it would cost $7,300 for each Nashua resident.

The biggest accounting problem Weinberg found is how the two cities report retirement and healthcare benefits for city employees. In Manchester, the city only recently started including total employee compensation costs in financial reports. Before that, the city would not report how much taxpayers would be paying to fund the pensions and healthcare of employees once they retire.

“That is going to have to be paid by future taxpayers. So these employees are gonna retire, these employees are not gonna be working for future taxpayers, right,” Weinberg said. “But those taxpayers will be responsible for paying for their healthcare when they retire.”

Manchester taxpayers are shouldering a $267.5 million bill for unfunded pension obligations and $54.3 million in unfunded “other post-employment benefits,” or OPEB. Nashua’s split is $221.9 million in unfunded pension obligations and $76.4 million in unfunded OPEB benefits.

Manchester Mayor Joyce Craig announced she is leaving office after years at the helm, letting the next mayor deal with the more than $300 million in unfunded taxpayer obligations.

Jay Ruais, the Republican candidate for mayor, called the report a wakeup call on the need for a fiscally-responsible chief officer in the Queen City.

“A mayor has a responsibility to be a steward of the taxpayer’s dollar and to manage the city’s finances responsibly,” Ruais said. “Our city cannot reach its full potential if we treat taxpayers like a piggy bank and fail to properly plan and prioritize our budgeting, both now and in the future. Using one-time funds for long-term projects, the routine increase in taxes and spending, and the inability to make difficult choices put the city on a dangerous fiscal path.”

Neither Ward 2 Alderman Will Stewart nor At-Large Alderman June Trisciani, both Democrats running to replace Craig, responded to a request for comment.

According to Weinberg, elected politicians tend to spend money that should be going to pensions and OPEB obligations to keep taxes low and fund more popular government programs. This cost-shifting just pushes the bill onto future taxpayers, while politicians appear to be balancing their budgets while keeping taxes low and funding services, she said.

Truth in Accounting’s mission is to show taxpayers the real cost of their government.

“We have worked for years to recast government’s financial reports to show a truer picture of their financial condition, bringing business accounting to these financial statements instead of the political math that is used by the governments,” she said.