New Hampshire’s health care landscape is facing a pivotal moment as two major forces—Medicaid nursing home reimbursement changes and the future of hospital-at-home programs—collide to shape care for the state’s most vulnerable residents. On January 1, 2026, nursing home providers across New Hampshire experienced the first average Medicaid rate cut in over a decade, a move that has sent ripples of concern through the industry and left many facilities grappling with the consequences. Meanwhile, on the national stage, the fate of the Acute Hospital Care at Home (AHCAH) waiver program hangs in the balance, with Congress debating whether to extend, update, or let lapse a pandemic-era innovation that has transformed how acute care is delivered beyond hospital walls.
The story begins last November, when New Hampshire’s nursing home providers learned that the state’s Medicaid appropriation could not sustain a rate increase granted at the start of the fiscal year on July 1, 2025. As reported by New Hampshire Bulletin, this would have meant an average rate cut of 3.91%, or $10.36 per resident, per day—the first such decrease since January 2015. Recognizing the looming crisis, the state’s Department of Health and Human Services devised a creative solution. Nursing homes had already volunteered a fee increase to fund a contractor who would help clear a backlog in Medicaid applications. When the contractor completed the work for far less than anticipated, the department recommended redirecting the surplus to soften the blow of the rate cuts.
This strategy, approved by Governor Kelly Ayotte, the Executive Council, and the legislative Fiscal Committee, turned what would have been a painful cut into what, on paper, was an average increase of two cents per resident, per day. But as the Bulletin pointed out, averages can be deceiving. The intricacies of New Hampshire’s Medicaid reimbursement system mean that the actual impact varies dramatically from facility to facility, depending on the medical complexity of their residents as measured on a specific “picture day” (August 31, 2025) and compared to an all-payor case mix index from August 31, 2023. For many, the numbers simply didn’t add up.
Consider the real-world consequences: a small nonprofit nursing home facing a staggering loss of nearly $46 per resident, per day; a for-profit facility in Keene with local ownership losing $34.49 per resident, per day—a cut amounting to 11.49% of its funding; and Rockingham County Nursing Home, one of the state’s largest, losing $26.77 per resident, per day. Across New Hampshire, both nonprofit and for-profit homes are absorbing enormous hits to their budgets, with little to no margin left to shield them from further financial pain.
Feeding, housing, and caring for hundreds of residents every day is no small feat, especially in an environment where the cost of basic goods continues to rise. As the Bulletin noted, the price of eggs and beef has climbed considerably, and nursing homes have seen hourly earnings for staff increase by over 35% since the COVID-19 pandemic began. Yet, despite these wage hikes, facilities are still struggling to rebuild their pre-pandemic workforces. The same staffing woes plague New Hampshire’s hospitals, creating a competitive—and sometimes adversarial—landscape for attracting and retaining skilled health care workers.
This workforce crunch has a domino effect. Inadequate staffing in nursing homes means hospitals have fewer discharge options for patients who no longer need acute care but cannot safely return home. The result? Bottlenecks in hospital beds and longer waits for patients in need of rehabilitation or long-term care. It’s a cycle that strains the entire health care system, from emergency rooms to end-of-life care.
There is, however, a glimmer of hope. Governor Ayotte recently secured a $204 million federal Rural Health Transformation Program grant, aimed at bringing some relief to the state’s beleaguered health care workforce. While this funding is expected to help in the long term, immediate solutions are still needed. As the Bulletin warned, unless the 2026 legislative session finds a way to support the hardest-hit facilities, care access will become even more restricted—many homes already have waiting lists—and outright closures could follow.
Amid these local challenges, the national debate over the future of hospital-at-home programs is taking on new urgency. According to STAT News, the Acute Hospital Care at Home (AHCAH) waiver, launched by the Centers for Medicare and Medicaid Services (CMS) in 2020 during the depths of the pandemic, has allowed nearly 400 hospitals in 39 states to deliver high-acuity care to patients in their own homes. This model, once a stopgap for overwhelmed hospitals, has become one of the most significant care-delivery innovations of the last six years.
Patients recovering from pneumonia, heart failure, infections, and other serious conditions now routinely receive daily virtual physician visits, intermittent nursing support, intravenous therapies, diagnostics, and continuous monitoring—all without ever setting foot in a hospital. The benefits are striking: a 2024 CMS evaluation found lower mortality, reduced post-discharge spending, and high patient satisfaction. However, the program is not without its flaws. Readmissions varied, data reporting was inconsistent, and the flexibility that made the program so adaptable during the pandemic now makes it difficult to compare outcomes across different hospitals and patient populations.
With the AHCAH program’s authorization set to expire on January 30, 2026, Congress faces a critical decision. The House has already passed a five-year extension, but the Senate’s path forward remains unclear. Dr. Lee Fleisher, former chief medical officer at CMS and a leading advocate for the program, argues that now is the time to update the waiver to reflect advances in technology and care delivery. "If Congress wants a rigorous, reliable evaluation that can support a permanent national model for a more widespread implementation of hospital at home, it must standardize reporting and transparent quality metrics; integrate current monitoring technology; expand to rural and underserved communities where clinically appropriate; create stronger national comparative studies across diverse hospital types; and allow more direct admissions from outpatient settings within integrated systems," Fleisher wrote in STAT News.
At present, the AHCAH program operates under a patchwork of short-term extensions and emergency-era rules, including strict geographic limits that no longer reflect the capabilities of modern remote monitoring technology. Many providers can now safely monitor patients far beyond the original 30-minute hospital radius, potentially transforming access for rural communities like those in New Hampshire. Yet, without updates, the program risks being locked into outdated models, hindering its potential for permanent adoption and broader impact.
The stakes are high. If Congress simply extends the waiver as-is, it will be studying a model frozen in time—one that may not capture the full promise of today’s technology or the evolving needs of patients and providers. As Dr. Fleisher put it, "We should not let an outdated waiver define the next decade of care innovation."
Back in New Hampshire, the intersection of Medicaid funding woes and the uncertain future of hospital-at-home programs underscores the urgent need for policy solutions that are both innovative and responsive to the realities on the ground. Whether in a rural nursing home or a patient’s living room, the ultimate goal remains the same: delivering safe, high-quality, and accessible care to those who need it most.
As lawmakers in Concord and Washington, D.C., weigh their next moves, the choices they make in the coming weeks and months will reverberate through the lives of patients, families, and health care workers for years to come.
