Brendan Williams is the president and CEO of the New Hampshire Health Care Association.

As Gov. Chris Sununu leaves office, his legacy will no doubt be subject to bouquets and brickbats, depending on one’s partisan view. However, from the perspective of long-term care, there is no denying the gains made during his tenure, and the challenge for governor-elect Kelly Ayotte will be to continue this progress.

With the nation’s second-oldest population, New Hampshire for too long subjected our long-term care system to a sort of benign neglect consistent with our well-known state budgetary frugality. However, particularly in the wake of the COVID-19 pandemic, it was clear that would no longer do.

The current state budget was a rare bipartisan feat, with additional Medicaid rate increases added on top of the 3% annual increases Sununu had proposed. Importantly, it played no favorites. Too often one sees a “Hunger Games” scenario where vulnerable constituencies are pitted against one another.

During Sununu’s tenure, I was very pleased by the collaboration between those care constituencies reliant upon Medicaid funding. In no small part, the excellent leadership of the Department of Health and Human Services, for which Sununu can take credit, has been very helpful.

Long-term care is an interdependent system. Through 2021, a recent report commissioned by the U.S. Centers for Medicare and Medicaid Services found New Hampshire ranked 11th in the proportion of its Medicaid long-term care spending dedicated to home and community-based settings (HCBS), narrowly edging out Massachusetts.

However, since then there has been a greater investment in HCBS, with home care providers running a very successful informational campaign in 2023 as legislators considered New Hampshire’s budget.

As my wife works as a homemaker with Medicaid clients, I have seen firsthand the results of this investment. And representing nursing homes, it is vitally important for nursing homes to have a robust system of in-home care to be able to discharge residents to in cases where their health needs have improved and can be served in a lighter-care setting.

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Regrettably, not as much progress has been made in improving assisted living facility rates. Consequently, very few assisted living facilities choose to have Medicaid contracts, and some who did have closed due to their financial losses caring for residents on Medicaid. This makes assisted living care largely inaccessible for those on Medicaid who desire a social setting with activities. That challenge must still be addressed.

For a long time the gap between Medicaid payments and care costs for New Hampshire’s nursing homes was among the nation’s worst, and a May 2024 policy report from the Federal Reserve Bank of Boston found New Hampshire nursing homes easily had New England’s worst median operating margin in 2022-23 at -5.2 percent.

Yet the current state budget made a solid down payment on bolstering nursing home care, culminating in a final adjustment this coming January that allays the fears of many providers that the fiscal year’s increase would fall short of the expectations that they, and policymakers, had. That is an enormous relief.

To be sure, funding challenges remain, and Ayotte and new legislative leaders will have to meet them despite declining business tax revenue, the elimination of the century-old Interest and Dividends Tax, and the absence of interest income from American Rescue Plan Act funds. However, long-term care providers can be grateful that Gov. Sununu leaves a stronger funding commitment upon which to build.