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Bar Journal - March 1, 2003

Strengthening the Health Care 'Safety Net' in New Hampshire


Access to health care services is essential to preventing disease and maintaining good health. The health care delivery system is made up of a mix of organizations and professionals that have developed over time because of funding and reimbursement practices, traditions in medicine and nursing, geographic and population patterns and public policies to make health care available. Health care ‘safety net’ providers form a patchwork of entities committed to ensuring that everyone has access to the fundamental elements of health care. In New Hampshire, the ‘safety net’ includes physicians, hospitals, community health centers and other health providers who offer emergency care, primary care, specialty care, in-patient care and dental care.

The NH Health Access Network is a new statewide voluntary initiative of the Foundation for Healthy Communities to help address changes in meeting the ‘safety net’ needs of those without adequate resources for health care. The problems associated with decreasing insurance coverage, increasing health care costs, the shifting health care needs of an aging population and public expectations are all influencing ‘safety net’ health providers to look at how they can maintain and enhance their commitment to provide health care to the poor.


Private health insurance offered through employers is the foundation for health care coverage for most people and their families. However, this coverage is threatened as costs escalate. In New Hampshire, 80% of the non-elderly population receives coverage through private employers, compared to 72% nationally. Another 5% of the population is covered through individual insurance and other sources.1 The number of people who are uninsured is increasing. In November 1999, the NH Department of Health and Human Services estimated that 95,803 people or 9.3% of the non-elderly adult population in the state was uninsured.2 This overall state figure masks variations within the state. In 2001, 17% of the population in Carroll County was not insured in contrast to a rate of 5.9% in Rockingham County. In general the more rural northern counties had higher rates of uninsured than the more populated southern counties.3 According to a report by the Josiah Bartlett Center for Public Policy, about 59% percent of New Hampshire families earning $28,000 or less have health insurance compared with 93% earning more than $56,000. The majority of the uninsured are working but do not have coverage because it is not offered by their employer or it is not affordable. Current figures from the Kaiser Family Foundation estimate the NH uninsured at 100,390 people.4

The health insurance problem in New Hampshire is not unique. National trend data show a steady increase in the number of Americans without health insurance. In 1995, 37.1 million Americans under 65 years of age were without health insurance. This number increased to 40.5 million in 2000.5 The Census Bureau estimates that the number of uninsured rose to 41.2 million in 2001.

In 1999, the N.H. legislature passed S.B. 183 to create the Adult Coverage Subcommittee, chaired by Rep. John Hunt, to research options for coverage of low-income working adults. The subcommittee concluded that families with income less than 300% of the federal poverty level would not be able to purchase adequate health insurance without some assistance.6 Hospitals participate in the Adult Coverage Committee; and they, together with other health providers, were encouraged by Rep. Hunt to think about private sector strategies that might help with the public policy challenge of providing adequate health care coverage.

In addition to the problems of those without health insurance, many other people have inadequate coverage or are under-insured. An indicator of this problem can be found in a Commonwealth Fund report that identified 41% of non-institutionalized Medicare beneficiaries in 1998 had either no prescription drug coverage or only partial coverage during the year.7 The N.H. Medication Bridge Program, a program to help people who need prescription medications for chronic illness, has found that about half of the 12,000 persons served in 2002 are younger, non-Medicare eligible recipients.

People without adequate health insurance often rely on emergency rooms to receive episodic health care, and they are usually categorized as ‘self-pay’. According to the New Hampshire Uniform Hospital Discharge Data in 2000, 17% of all emergency room visits were ‘self pay’. Another indicator of the "access problem" is measured by ambulatory sensitive conditions or medical conditions that could have been handled in a less intensive medical setting (e.g., physician office) rather than utilizing a more intensive setting such as a hospital emergency room. In 2000, 16.5% of all New Hampshire emergency room visits were for ambulatory care sensitive chronic conditions (e.g.; asthma; ear, nose and throat infections; bacterial pneumonia; gastroenteritis; etc.) Access to health care grows increasingly complex as the economy remains weak and employers confront escalating insurance premiums that often result in cutbacks in coverage or larger employee deductibles and co-payments.

The consequences of not having health insurance coverage are serious. The Institute of Medicine found that the uninsured are much more likely to forgo needed care and less likely to report being in good or excellent health than those with coverage. Clinical preventive care screening for cancer, hypertension or elevated cholesterol is much less likely for those without coverage.8 A report by the Kaiser Commission on Medicaid and the Uninsured found that the uninsured have a higher mortality over time (1.2 to 1.5 times more likely to have died after 5 years than those who were insured) and those with intermittent insurance coverage were 1.4 times more likely to experience a major health decline.9


Total personal health care per capita expenditures for New Hampshire in 1998 were $3,870 compared to the United States at $3,760 and the New England states at $4,535. The average annual percent change for New Hampshire between 1991-1998 was 6%. Hospital and physician services account for the largest portion of per capita personal health spending, although nursing home, home health and drug cost components had the greatest increases during this period.10 The average annual per capita personal health expenditures rose 7.5% in the period 1999-2002. Both medical costs and utilization equally drove the increase in the latest reporting period. The average annual increase from 2002-2010 is projected to be 6% with more attributable to medical cost increases than utilization.11

The average increase in health insurance premiums for large employers was 13.7% between 2001-2002. The major determinants of that increase, as a percent of the increase, were drugs, medical devices and medical advances (22%), general inflation (18%), provider expenses (18%), government regulation (15%), increased consumer demand (15%), litigation (7%) and other (5%).12 Between 1990-1997 the ‘out-of-pocket’ costs (e.g., money paid by an individual) for direct expenses to medical providers went down 7%, while ‘out-of-pocket’ premium expenses rose 29%.

Between 1991-1998, New Hampshire’s average annual growth in Medicare enrollee personal health care spending was 7%, and for Medicaid enrollees it increased 5%. Medicare and Medicaid, public programs serving the elderly and some of the poor, accounted for 31% of New Hampshire’s personal health care spending in 1998 (U.S. 35%).13 New Hampshire’s Medicaid program pays 68 cents on the dollar for hospital services, the lowest in the Unites States. Medicaid payments for nursing home care are the second lowest in the country.14

Chronic illness accounts for three quarters of the total national health expenditures.15 National trend data since 1970 are consistent in showing that 1 percent of the population accounts for more than a quarter (27%) of health care expenditures and the distribution of expenditures is very similar between the insured and uninsured. However, the actual amount spent on the uninsured is lower. The top 5 percent of spenders or sickest among the insured population have average annual expense of $17,871 while the top 5 percent of the sickest among the uninsured expend $6,651.16 These data support the observation that the uninsured receive less health care than the insured population.


The population of New Hampshire was 1.2 million in 2000, an 8% increase since 1990, making it one of the fastest growing states in the East according to the U.S. Bureau of the Census. While the in-migration of new residents represent a predominantly young population, the northern part of the state has a much older population (e.g., 23% of the population is age 65 or older in Berlin compared to only 6% in Derry). There is increasing racial and ethnic diversity in the state, with the minority population doubling from 2% to 4% between 1990-2000, particularly in the cities of Manchester and Nashua. The U.S. Bureau of the Census found that 23,800 people reported that they speak English less than "very well". Twenty percent of individuals younger than age 65 had family incomes at 200% of the poverty level (e.g., $30,040 for family of 3 in 2002) or lower while this statistic increased to 35% for persons age 65 and older.17

Medical care use over the past 15 years has shown significant trends: a) decrease in hospital discharge rates; b) an increase in emergency department visits increased slightly; c) an increase in nursing home and home health care discharges; and d) physician visit rates have not changed much.18

Increased longevity and chronic illnesses create a greater need for people to interact with different components of the health system. In addition to inpatient hospital services, there is often a need for more physician visits, prescription drugs and home care. For example, among the 88 million older Americans with a chronic health condition who do not live in a nursing care facility, they have an average of 5 physician visits annually, take 11 prescription drugs, about 8% require a hospitalization, and less than 1% receive home care. If they have a functional limitation with their activities of daily living, then home care needs increase to 11%.19, 20

Primary care is the model of a ‘medical home’ where a physician can manage a person’s health care needs over time. This model is under increasing stress as the complexity of health care puts greater demands on the coordination of care.21 The primary care provider must guide health care in an environment where new medications are regularly being introduced, home care services are expanding, and new knowledge in genetics, diagnostics and treatment modalities are introduced. There are about 2,000 primary care providers (e.g., family practice, internists, pediatricians, nurse practitioners, physician assistants, etc.) in New Hampshire. National data indicate that most physicians care for the uninsured and for Medicaid and Medicare patients, although there is a downward trend in accepting new patients among these groups and a greater concentration of these patients being cared for by fewer physicians.22

In 1995 the legislature (RSA 126 A:18) charged the NH Department of Health and Human Services with expanding access to primary care. A 2000 report by the Department identified that eight community health centers served 42,000 patients. Almost half of these patients (41%) were uninsured, 19% on Medicaid, 8% on Medicare and 32% were privately insured.23 The financial condition of the health centers in New Hampshire has declined since 1994, with a $750,000 revenue shortfall over the past 2 years.24 A recent national study of community health centers found that the uninsured make up the largest component (43%) of their service population. While health centers are able to provide most of the primary care services required by their uninsured patients, they are often unable to provide them with needed diagnostic, specialty and behavioral health services.25

The 28 community hospitals in New Hampshire provided 537,000 emergency room visits, 2.3 million out-patient visits and 116,000 in-patient admissions in 2001.26 They provided $36.1 million in charity care in 2000, about as much charity or free care was provided as a percentage of gross revenue nationally. Bad debt and Medicaid shortfalls are additional financial indicators for hospital services provided to those without health insurance.27 The N.H. Hospital Association reports that in 2000 about 39% of hospital patients were covered by Medicare, 10% by Medicaid, 4% were ‘self-pay’ and the remainder privately insured. About two-thirds of the hospitals had positive operating margins while nine had negative operating margins in 2001.


Healthy New Hampshire 2010 is the state’s first comprehensive health promotion and disease prevention policy agenda. It has two objectives that directly address access: increase the percentage of persons age 65 and under who have a usual source of care and increase the percentage of persons age 65 and under who have health insurance.28 New Hampshire has achieved progress in this effort with a 48% decline in the number of uninsured children between 1997 to 2001 in contrast to a 22% decline nationally. This puts the child uninsured rate in New Hampshire at 5.1% (U.S., 10.8%) in 2001.29 The N.H. Healthy Kids program is the reason for this success.

Consumerism, health-related advertising in print, on TV and billboards, and the widespread coverage of new medical discoveries are influencing public expectations about health care. For example, more than $1 billion was spent on direct to consumer advertising of prescription drugs in 1999. Increased consumer interest in advertised drugs leads to more office visits, more tests and demand for more prescriptions. There is insufficient evidence as to whether ad-induced prescriptions are cost-effective.30

In 1999, New Hampshire joined 10 other states in creating statutes requiring health care charitable trusts to prepare a community needs assessment (RSA 7:32-f) and develop a community benefits plan (RSA 7:32-e IV and VI). Unlike any other charitable trusts in the state, health care trusts must annually report on their community benefits and must assess their community’s needs every three years. The statute has put an added focus on the provision of charity care among non-profit health providers.

In 2001, New Hampshire health care charitable trusts identified a total of 422 community needs, with ‘access’ representing 25% of all needs addressed.31 The ‘access’ category was defined as free and/or subsidized medical services provided to low income or uninsured individuals or subsidies to providers that care for the poor and uninsured (e.g., hospital support for a community health center). Charity care or financial support made up the largest component of service programs in the ‘access’ category (22 out of 76 programs offered statewide). Dental, pharmaceuticals, primary care and specialty care were identified as other service programs in response to access needs.

Many individual health providers or health care organizations are willing to help people with difficulty paying for care, but there is little consistency among policies and practices that govern free or discounted care. Public awareness and knowledge about how to access needed health care and appropriately use services is often not well known.


Low income people who need health care are the focus of the N.H. Health Access Network. The Network is a voluntary statewide effort of hospitals and other health providers whose goal is to strengthen the health care safety net by improving access to care for low income, uninsured or underinsured children, seniors and adults statewide. The safety net includes primary care, emergency care, specialty care and inpatient care.

Planning for the Network was started during the summer of 2002, and it will be launched by the spring of 2003. Staff support is being provided by the Foundation for Healthy Communities, a statewide non-profit organization founded by hospitals, health insurers, physicians and home care agencies that works to improve health and health care delivery in New Hampshire through innovation and new partnerships.

The New Hampshire Health Access Network is a voluntary statewide initiative to create better access to comprehensive, high quality health care services for the medically indigent, regardless of ethnicity, culture, social position or economic status, by reducing or eliminating financial, structural and personal barriers that inhibit access. It is designed to narrow the gap between where we are and where we aspire to be, with respect to realizing universal coverage and equitable access to care for all people, everywhere.

Health care provider organizations in the N.H. Health Access Network agree to work together following four key principles:

  • Maintain an "open door", providing dependable access to care for vulnerable residents in our community, regardless of their ability to pay.
  • Offer levels of free and discounted care that meet or exceed thresholds adopted collaboratively through the Network, subject to any conditions that apply locally. The framework for free and discounted care are the federal requirements for community health centers.
  • Collaborate to reduce or eliminate structural and personal barriers to health care.
  • Collaborate to enhance the continuity and coordination of health care for those in need.

Most health providers currently offer some form of charity care or discount for those who lack adequate insurance, but the policies and practices are highly variable among providers (e.g., the range among hospitals before the N.H. Health Access Network was from a 90% discount at 100% of the federal poverty guideline to a 25% discount at 300% of the FPG). A key element in planning for the NH Health Access Network requires an understanding of local efforts already underway to address access problems. Healthlink in Laconia and SeaCare in the Exeter/Portsmouth area are two examples of local health providers organizing to improve access. Flexibility to build upon the success of these local efforts is a key feature of the Network’s planning effort.

There are 28 community hospitals in the state, 11 community health centers, 10 community mental health centers, about 40 home/VNA/hospices and approximately 300 medical practices. Any hospital, provider organization or individual provider is welcome to participate in the NH Health Access Network. Initial recruitment has focused on hospitals because their care is available 24 hours per day, every day, and most have a charitable mission. Also, hospitals are engaged in a broad continuum of care, network with other providers, are dispersed geographically, and have mature management and governance structures. Meetings with other provider groups (i.e., community health centers, physician groups, home care agencies, etc.) are taking place to invite them to join the Network.

All 24 non-profit community hospitals in N.H. have signed letters of intent to participate in the N.H. Health Access Network and four private for-profit or specialty hospitals also have joined. Interest among health providers is very strong and is requiring a greater staff commitment than anticipated. Network participants are assessing their current policies and practices to ascertain if their current policy needs revision and how they put into practice their policies on free and discounted care.


The NH Health Access Network formed three task forces in the summer of 2002 to conduct planning activities. The Administration and Training Task Force is examining how well each health provider organization currently screens for eligibility for health care access programs (e.g., Medicaid, Medicare, VA, charity care, etc.) and how they help complete enrollment processes for those who are eligible. This is a prerequisite to ensuring better continuity of care and more choices for the underserved. The Network efforts are predicated on maintaining public commitments to providing health care through programs such as Medicare and Medicaid.

General organizational procedures for determining ability to pay for care among the uninsured or under-insured are being examined by each Network member. On-site meetings with patient accounts, admissions, social work and other staff are designed to determine how policy is put into practice on the ‘front-line’ for those who interact with people seeking health care. This information is being compiled to identify ‘best practices’ and to share those with Network members. The knowledge and attitudes of staff who interact with those unable to pay is being reviewed to identify training needs.

The application form and process for seeking financial assistance are the focus of this task force. They have identified the key elements of a successful application form as: 1) consistency; 2) level of confidence; 3) ease/simplicity; 4) uniform income guidelines; 5) legal issues (e.g., reimbursement); 6) networking with other providers in community; and 7) confidentiality. Several desired outcomes for the process that have been discussed include: seamless process, portability of information, access to care, reduction of inappropriate emergency room use and identification of other places where patient has received care.

The Information Systems Task Force is studying current data sets that provide information on who is being served, how and by whom. They create a reporting system that can measure the Network’s progress over the next 3-5 years of its development. The Task Force has reviewed available statewide clinical and administrative databases on charity care and bad debt. Very few hospital Network members are currently tracking use of charity care other than gross dollar amounts so the Network decided to develop a prospective baseline survey to gain a better understanding of those who need help and how they are served. Preliminary results from a survey in September 2002 found that 1,147 applications for financial assistance were filed at 20 hospitals representing a total of 2,234 people seeking help. Most requests were from women (59%), most were filed after care was received (87%), and more than two-thirds of the requests (78%) were approved. Too much income was the most common reason for denial among the 98 applications that were turned down. Refusal to disclose income, too many assets, and eligibility for another program were other reasons for denial. Figure I shows that out-patient services followed by emergency room/walk-in care were most frequently provided.

Figure II shows that while a majority of those seeking financial assistance were uninsured, 44% were insured but applied for help because of difficulty paying for their care.

The results from the survey will be analyzed to better understand who is currently being served, who may be applying for help but not gaining approval, and to measure progress with the Network’s objectives over time.

The Communications Task Force is developing strategies to increase the number of Network members and to meet the communications objective. It has identified the key audiences as those who may be eligible for free or discounted care, those who refer people to care, health clinicians, administrative staff, and public policymakers. Specific information about the Network and the means of dissemination for each target audience will be developed. A common lexicon has been developed using the term ‘financial assistance’ or ‘financial help’ to refer to the Network’s focus. This will avoid the stigma associated with the term ‘charity care’ or the confusion associated with other terms such as ‘community care’, ‘community service’. Individuals who use services offered by Network members will be referred to as ‘participant’ since they may or may not be a current patient. The task force recognizes internal education for Network members as key to changing attitudes or perceptions about charity care. Communications will be essential within the N.H. Health Access Network since it is evolving and all those who are involved, as either a health provider or participant, will need to be aware of new developments.


The work ahead includes recruiting more health providers to participate so all areas of the state are covered for all components of the safety net, addressing the more complex issues related to coordination of care and measuring progress. The project has the potential to change policies and practices of health provider organizations and create access to a more seamless system for people who lack adequate health insurance coverage. Use of preventive care services may increase and the need for more intensive services or inappropriate use of emergency services may decline. These efforts are underway in a dynamic health care environment where the promise of new diagnostic and treatment possibilities are rapidly expanding but the ability for a significant number of New Hampshire residents to access them is uncertain. The N.H. Health Access Network is a commitment by health providers to address this uncertainty while recognizing that a need for a societal commitment to ensure that essential health services are available and affordable to those with low incomes.



NH Department of Health and Human Services, Health Insurance Coverage in New Hampshire, Issue Brief 2002.


NH Department of Health and Human Services, Health Insurance Coverage and the Uninsured in New Hampshire, November 1999, p. 6.


NH Department of Health and Human Services, Health Insurance Coverage in New Hampshire, Issue Brief 2002,.


The Henry J. Kaiser family Foundation, State Health Facts Online, New Hampshire Insurance Status.


Centers for Disease Control and Prevention, National Center for Health Statistics, Health United States, Chartbook on Trends in the Health of Americans, 2002, p. 312.


NH Adult Coverage Subcommittee Report to the Governor, Speaker of the House and Senate President, November 28, 2000, p. 4.


Briesacher, Becky; Stuart, Bruce and Shea, Dennis. Drug Coverage for Medicare Beneficiaries: Why Protection May Be in Jeopardy, The Commonwealth Fund, Issue Brief, January 2002.


Institute of Medicine, Coverage Matters, 2001.


The Kaiser Commission on Medicaid and the Uninsured, Sicker and Poorer: The Consequences of Being Uninsured, May 2002, p. 7.


Health United States, 2002, p.331-335.


Heffler, Stephen, et. al., Health Spending Growth Up in 1999; Faster Growth Expected in the Future, Health Affairs March/April 2001, vol. 20, no. 2, 193-203


Price, Waterhouse & Coopers, The Factors Fueling Rising Healthcare Costs, Washington DC, American Association of Health Plans, April 2002,


Martin, Anne, et. al. Health Care Spending During 1991-1998: A Fifty state review, Health Affairs, July/August 2002, vol. 21, no. 4, pp. 112-126.


Perspectives on Health Care Access 2002, NH Hospital Association.


Bodenhaimer, T., Wagner, E., and Grumbach, K. Improving Primary care for Patients with Chronic Illness, Journal of the American Medical Association, October 9, 2002, vol. 288, no. 14, pp.1775-1779.


Berk, Marc and Monheit, A. The Concentration of Health Care Expenditures, Revisited, Health Affairs, March/April 2001, vol. 20, no. 2, pp. 9-18.


AARP Public Policy Institute, Reforming the Health Care System: State Profiles 2001, pp. 126-129.


Bernstein, Amy, et. al., Trend Data on Medical Encounters: Tracking A Moving Target, Health Affairs, March/April 2001, vol. 20, no. 2, pp. 58-72.


Anderson, Gerard and Knickman, James. Changing the Chronic Care System to Meet People’s Needs, Health Affairs, November/December 2001, vol. 20, no. 6, p. 154.


Grumbach, K and Bodenheimer, T. A Primary Care Home for Americans, Journal of the American Medical Association, August 21, 2002, vol. 288, no. 7, 889-893.


Cunningham, Peter. Mounting Pressures: Physicians Serving Medicaid and the Uninsured, 1997-2001, Center for Studying Health System Change, Tracking Report No. 6, 2002.


NH Department of Health and Human Services, Strengthening the Safety Net, A Financial Analysis of New Hampshire’s Community Health Centers, October 2000.


NH Charitable Foundation, Stronger Medicine Restoring the Financial Health of NH Community Health Centers, October 2001.


Gusmano, M.,, Exploring the Limits of the Safety Net: Community Health Centers and Care for the Uninsured, Health Affairs, November/December 2002, vol. 21, no. 6, pp. 188-194.


American Hospital Association, Hospital Statistics 2003, p. 107.


NH Department of Health and Human Services, The Health of New Hampshire’s Community Hospital System, December 2000, p. 33.


NH Department of Health and Humans Services, Healthy People 2010, March 2001


NH Healthy Kids Annual 2001 Report.


Wilkes, M. et. al. Direct-to Consumer Prescription Drug Advertising: Trends, Impact and Implications, Health Affairs, March/April 2000, vol. 19., no. 2, pp. 110-128.


Office of the Attorney General, Division of Charitable Trusts, NHDHHS and CHI, Telling Our Story: New Hampshire Community Benefits, November 2002, 14-17.



Shawn V. LaFrance is the Vice President for Planning and Development at the Foundation for Healthy Communities in Concord.


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