On July 4th, Congress passed H.R. 1, or what is also known as the One Big Beautiful Bill Act (OBBBA).
To help make sense of how the bill and other federal policy changes might affect your healthcare, Senior Director Courtney Tanner and System Vice President Matthew Houde of Dartmouth Health Government Relations hosted a series of Grand Rounds conversations with healthcare leaders and policy experts in New Hampshire and Vermont.
Together, they explained changes to Medicaid and the Supplemental Nutrition Assistance Program (SNAP), as well as the anticipated impact on the Affordable Care Act (ACA) marketplace.
They also provided information on where to get help.
What is Medicaid, and who is eligible for Medicaid coverage?
Medicaid is a joint federal and state program that provides health coverage for eligible low-income individuals, families, children, pregnant women, the elderly, and people with disabilities.
The program has different names in different states, so some people may not know whether they benefit from the program.
WellSense, New Hampshire Healthy Families, and AmeriHealth Caritas are three Medicaid managed care companies that provide Medicaid coverage in New Hampshire.
Vermont Medicaid programs are collectively branded as Green Mountain Care. It includes programs for adults; Dr. Dynasaur for children, teenagers, and pregnant women; prescription assistance plans; and other programs.
How will H.R. 1 impact Medicaid?
H.R. 1 will impact Medicaid program funding as it reduces the healthcare provider tax, which funds Medicaid together with matching federal funds. When the healthcare provider tax drops, the amount that the federal government provides to Medicaid also drops, leading to a reduction in overall funding.
In addition to this provider tax cut, changes to Medicaid also include new eligibility requirements based on work status (going into effect no earlier than 2027) and new enrollment processes that require submitting paperwork twice a year, instead of once.
How will Vermonters be affected, and where can you go for help?
The nonprofit policy organization KFF says that in Vermont, the healthcare provider tax will be cut by 2.5 percent. Based on spending in 2024, that could amount to about $208 million less in federal Medicaid funding in the state.
Vermont state officials estimate that funding cuts together with new enrollment and eligibility changes could result in over 30,000 people losing coverage.
To find out more about your eligibility, enrollment and renewal of Medicaid in Vermont, go to Medicaid Renewals or call 1-800-250-8427.
How will New Hampshire residents be affected, and where can you go for help?
Provider taxes will be lowered incrementally in New Hampshire from its current level of 5.4 percent to 3.5 percent by 2032, reports the nonprofit policy organization New Futures.
KFF says that based on 2024 spending, that would amount to a cut of $224 million in federal funding for the state.
Most of the people bearing the brunt of the changes set out in H.R. 1 will be adults aged 19 to 64 with incomes that put them at or near poverty level. These people are part of the Medicaid Expansion population who, in New Hampshire, are eligible for the Granite Advantage Health Care Program. As of the start of this year, that program had some 60,000 people enrolled. The Center on Budget and Policy Priorities and the New Hampshire Fiscal Policy Institute estimate the end result of changes to Medicaid could be that 20,000 people in New Hampshire lose coverage.
To learn more about Medicaid in New Hampshire, go to NHEasy. You can also call your WellSense, New Hampshire Healthy Families, or AmeriHealth Caritas telephone help line that should be listed on your member card.
Will there be additional federal funding to make up for less federal money going to Medicaid?
There will be some additional federal money to make up for the near trillion dollars in lost federal funding for Medicaid over the next 10 years. That money will come through the establishment of what is called the Rural Health Transformation Program.
Under H.R. 1, the federal government will dispense $50 billion over the course of five years from that fund. $25 billion of that will be distributed evenly to states. The rest will be discretionary and state-by-state.
The good news for Vermont and New Hampshire is that the first $25 billion is being distributed evenly, regardless of population size. That means these two states will likely get the same portion of the $25 billion as more populated states, such as New York and California.
But the portion Vermont or New Hampshire will receive of the remaining $25 billion is unclear. States recently completed applications for this federal funding based on specific criteria. The amount they receive will be subject to ongoing evaluation.
What is SNAP, and if you are on it, how will you be affected?
SNAP is monthly food assistance delivered through electronic cards. The program is funded by the federal government, but administrative costs to run the program are typically split 50/50 with the states.
The federal government is not committing to covering all SNAP costs, starting around 2028. Instead, each state will have to pay a greater share of the administrative costs, which will likely force states to find new ways to cut program costs.
Requirements for participating in the program will also change. In the past, veterans, former foster youth, and individuals who were homeless didn't have to meet work requirements. In the future, they likely will.
Estimates suggest that thousands could lose eligibility for SNAP in New Hampshire, where it is also known as the New Hampshire Food Stamp Program, and also in Vermont, where it is called 3SquaresVT.
If you want to apply to SNAP or are currently enrolled in Vermont, go to 3SquaresVT for help.
If you are on SNAP in New Hampshire or want to learn more, go to NHeasy.
Will you pay more in Vermont and New Hampshire for ACA coverage?
The ACA marketplace is another name for the Health Insurance Marketplace established under the Affordable Care Act.
Premium costs are going up due to marketplace uncertainty, changes to funding and access, and rising costs. Specifically, to date, Congress has not reauthorized the enhanced premium tax credits due to expire at the end of the calendar year.
KFF reports that ACA insurers are currently increasing premium costs by an estimated 26 percent for 2026.
Congress has also so far failed to renew premium tax credits (PTCs). PTCs are refundable tax credits designed to help eligible individuals and families with low-to-moderate incomes afford health insurance purchased from the ACA marketplace.
If these premium tax credits are not renewed, KFF estimates that currently subsidized enrollees will see their monthly premium payments more than double, with an average increase of about 114 percent.
Additionally, under H.R. 1, immigrant eligibility for subsidies is likely to be narrowed, meaning some immigrants will not be able to use the marketplace at all. There are also other measures designed to save costs and reduce fraud, which are anticipated to impact enrollment.
If you need help, New Hampshire provides this information on the open enrollment period and other support resources.
Vermont Health Connect provides this information about deadlines and other resources.
Will there be other impacts of H.R. 1 on Vermont and New Hampshire overall?
The reduction in federal medical student loan options may make paying for medical schools in both states more difficult.
Less money from the federal government will also put strain on state budgets, hospitals and other healthcare providers. Less federal funding could ripple throughout the system, affecting Vermonters, hospitals, and community providers.
Additionally, if community providers are unable to provide services, more people will likely end up in emergency departments, further straining hospitals.
All of these changes could lead to more community healthcare closures.
Watch the 3-Part Series: “Medicaid: A Shifting Landscape”
- Session 1 - Introduction: What Happened in DC?
- Session 2 - The Impact on Patients and the Communities We Serve
- Session 3 - Medicaid and Medicare Reforms – Regional Impacts and Federal Policy Shifts
If you are enrolled in a Medicare Advantage plan, please see our letter regarding plan changes. Open enrollment for Medicare closes on December 7, 2025.
