Michael J. Cohen is a principal consultant at MJC Health Solutions, LLC. He previously served as the executive director of the New Hampshire chapter of the National Alliance on Mental Illness. He lives in Amherst.

As a former executive director of NAMI NH and a member of the Board of Contributors to the NH Healthcare Cost Initiative, I understand, very clearly, how important Medicaid funding is to our state’s health and mental health care system.

At the end of 2024, there were 186,000 Granite Staters enrolled in Medicaid, or about 13% of the state’s population. On average, about 55,000 people who have Medicaid Insurance receive mental health and or substance use treatment services through the community mental health center service system. Medicaid is the largest insurance provider of mental health and substance use disorder treatment in New Hampshire, and as we know from the news, it is planned to take large cuts.

What happens to Medicaid impacts the entire New Hampshire healthcare system. All health insurances, whether public, private or self-insured, are inextricably linked. The approximately 65,000 residents enrolled in the Affordable Care Act (Obamacare) because of enhanced tax credits under the Biden American Rescue Plan and Inflation Reduction Act are likely to lose that benefit by the end of this year.

Combine this fact with the proposed cuts to Medicaid both federally and in New Hampshire and the continued rising cost of insurance, the impact on the individuals, families, businesses, hospitals and health and mental health providers can be nothing like ever experienced in my 30 years working in New Hampshire.

New Hampshire’s network of ten nonprofit Community Mental Health Centers (CMHC) relies heavily on Medicaid to support its programs and operations and help support their ability to offer low-cost or free care on a sliding scale. They receive the largest amount of their total revenue from the Medicaid program, between 70& and 90%, depending upon the particular center.

In the past few years the Department of Health and Human Services has moved forward two important mental health initiatives within the CMHC system that are in great jeopardy with proposed budget cuts: the 10-Year Mental Health Plan, which envisions a mental health system that provides access to a full continuum of care for all populations across the state, and the Mission Zero initiative, intended to eliminate ER boarding-housing mental health patients in a hospital emergency room without treatment until a psychiatric bed is available.

These two initiatives are in jeopardy if the Medicaid system is undermined by budget reductions proposed by our legislators. Combine these mental health program impacts with other factors: 1) that payments for inpatient psychiatric services in New Hampshire have not kept pace with actual costs to deliver those services which has meant that over the past decade a number of psychiatric inpatient facilities have closed and therefore psychiatric beds, when needed, are not available, and

2) that there is a shortage of mental health workers, many unfilled positions in the CMHC system, which makes it harder to get an appointment, longer wait times and more untreated illness. This is especially the case for psychiatric and child and family services;

3) the cost and affordability of healthcare overall for NH residents is out of reach and many individuals, families and businesses think they are no longer getting their money’s worth from insurance.

All of these factors, combined with cuts in Medicaid fundin,g don’t just hurt individual recipients or community mental health centers, they ripple through our entire state.

When people can’t get the care they need, they defer care and they’re more likely to end up in emergency rooms, long-term care facilities or crisis situations that could have been prevented. The burden on law enforcement and EMT system will likely increase because they are likely to be engaged in many more mental health and health emergencies.

People are likely to be held in jail on minor charges stemming from their mental illnesses or addictions, when they did not commit a crime and what they needed was treatment. Overall, lack of mental health services places a heavier burden on hospitals, law enforcement, county jails and social services — often at a greater cost to taxpayers and many in rural communities far from providers and the centers of care.

The ripple effects are especially impactful in rural hospital communities, which rely heavily on Medicaid payments because the population is poorer, for the medical services they deliver. These payments have not kept pace with the increasing workforce and operational costs. Over the years, hospitals and provider practices have closed or consolidated because they were no longer financially viable. Inadequate payments and hospital consolidation is likely to be accelerated by the changes in Medicaid funding.

Getting the right care at the right time in the right place can make all the difference to one’s health and well-being. I ask federal and state legislators to reject proposals that would outright cut Medicaid or restrict access to Medicaid by establishing work requirements that have been not shown to reduce costs but just eliminate insurance enrollees because of administrative and procedural burdens.

I am sure there are places to improve efficiencies in our healthcare system and save money, and I am confident that providers and health advocates would be willing to work with legislators to find those inefficiencies. But, to just cut Medicaid and not subsidize the ACA doesn’t solve the problem, it makes it worse.

Our healthcare insurance and financing systems are interconnected. Cutting Medicaid will put a financial burden on other private and self-insured health insurance systems because providers will need to raise prices to make up the difference to cover their costs from the loss of Medicaid patients. The health of public insurance patients impacts the health of all, especially those in rural areas of the state.

The quality of New Hampshire’s mental health and overall health rests with our legislators and governor. They need to do the right thing.