New Hampshire is about to find out what happens when a federal law designed in Washington collides with the daily realities of a state where 280,000 adults are already caring for someone who can’t fully care for themselves.

A report published in March by the Robert Wood Johnson Foundation and the Urban Institute estimates that between 14,000 and 29,000 Granite Staters will lose their Medicaid coverage as a result of the One Big Beautiful Bill Act — the sweeping omnibus legislation signed into law last July that touched nearly every corner of the federal government. Medicaid, the public health program that covers more than 180,000 New Hampshire residents with low incomes and disabilities, stands to absorb some of the heaviest blows.

The range in that estimate — 14,000 on the low end, 29,000 on the high end — isn’t a matter of speculation. It depends almost entirely on choices that Concord makes in the coming months about how to implement the law. And some of those choices have already been made.

The Work Requirement Gap

The federal law requires most non-disabled adults enrolled in Medicaid to prove they are working, volunteering, or attending school for at least 80 hours per month — roughly 20 hours per week — in order to keep their health coverage.

New Hampshire went further. Through the state budget signed by Governor Kelly Ayotte on June 27, 2025, the Granite Advantage Health Care Program will require 100 hours per month of qualifying activity — 25 hours per week, or 25 percent more than the federal floor. The state has until December 31, 2026 to implement these requirements, though it can move earlier.

This isn’t the first time New Hampshire has tried work requirements for Medicaid. In 2019, the state imposed a 100-hour monthly mandate on expansion enrollees. Compliance rates were low. A federal court struck down the requirements, ruling that they didn’t advance Medicaid’s core purpose of providing healthcare coverage. The U.S. Supreme Court later remanded the case after the requirements were withdrawn.

Now, backed by explicit federal authorization, the state is moving to reinstate what the courts once rejected — with less legal vulnerability and more administrative infrastructure.

The Caregiver Blind Spot

Perhaps the most consequential gap between the federal and state versions of the law involves caregivers.

The federal One Big Beautiful Bill Act exempts family caregivers from the work requirement. This makes intuitive sense: if you are spending your days managing medications, driving a parent to dialysis, or supervising a child with complex medical needs, you are working — just not in a way that generates a paycheck or a W-2.

New Hampshire’s state law does not include this exemption. That is a policy choice, not a necessity.

That omission collides with a demographic reality that is difficult to overstate. According to AARP and state data, an estimated 280,000 Granite Staters are caregivers of adults — people making daily, high-stakes decisions about the finances and health of a loved one. Many of these caregivers are themselves Medicaid enrollees. They are disproportionately women, disproportionately lower-income, and disproportionately living in the rural parts of the state where alternative employment is hardest to find and transportation is most burdensome.

As AARP New Hampshire’s Christina FitzPatrick has noted, caregivers often cannot find jobs that provide private health insurance and are flexible enough to allow them to care for loved ones.

When New Hampshire attempted to enforce work requirements in 2019, approximately 17,000 residents were at risk of losing coverage. In Arkansas — the only state to fully implement Medicaid work requirements before the courts intervened — more than 18,000 enrollees, roughly one in four, lost coverage within seven months.

The Premium Squeeze

Work requirements are not the only new barrier. Starting in July 2026, some Medicaid enrollees will be required to pay monthly premiums to maintain coverage — a first for the program in New Hampshire.

Enrollees in the Granite Advantage program earning at or above the federal poverty level will pay between $60 and $100 per month, depending on family size. Families with children on the Children’s Health Insurance Program earning 255 percent of the poverty level or more will pay between $190 and $270 monthly. For a family of three earning $68,000 a year, that amounts to roughly $230 per month — nearly $2,760 per year — for coverage that was previously free. CHIP premiums were also scheduled for January 2026, but the state is still awaiting federal guidance before implementation can begin.

For context, New Hampshire is in the middle of its second consecutive severe flu season. Seventy-one residents have died of influenza this year, including two children. When people lose coverage, they don’t stop getting sick. They stop getting treated early. They show up in emergency rooms sicker and later, at greater cost to themselves and the system. Steve Ahnen, president of the New Hampshire Hospital Association, has warned that the state’s hospital system will feel the downstream effects as patients who lose coverage delay or forgo care until their conditions become emergencies. As of late December, New Hampshire hospitals were running at roughly 94 percent bed capacity.

What Comes Next

The Robert Wood Johnson Foundation report makes clear that the final impact depends on how New Hampshire answers a series of implementation questions in the months ahead: How will the state define medical frailty? What documentation will be required to prove work status? How frequently will compliance be verified? Will the caregiver exemption gap be closed?

These are not abstract policy questions. They are decisions that will determine whether tens of thousands of New Hampshire residents keep or lose their health insurance — and, by extension, their access to the medications, treatments, and preventive care that keep them employed and out of emergency rooms.

The One Big Beautiful Bill was written in Washington. But its consequences will be lived in Laconia, in Berlin, in Claremont, in Manchester, and in every corner of a state that already asks its most vulnerable residents to do more with less.

New Hampshire has until the end of this year to decide how much more it will ask.