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Small New Hampshire Foundation Steps Up to Spark State Health Coverage Opportunities

August 2018

Patti Baum, Program Director, HNH Foundation

The HNH Foundation is a statewide health conversion foundation located in Concord, New Hampshire. It was established in 1997 following the purchase of a nonprofit health plan by New Hampshire Blue Cross Blue Shield. The foundation’s endowment is currently $25 million.

In keeping with its mission, the HNH Foundation has a long history of supporting health insurance coverage initiatives designed to improve the health and wellness of New Hampshire’s population, with a focus on the state’s most vulnerable children. This support spans playing a key role in establishing the New Hampshire’s Children’s Health Insurance Program 20 years ago to stepping up to significantly fund important Affordable Care Act (ACA) outreach and enrollment activities in New Hampshire last year.


The Roots of Coverage and Enrollment

In 1993, the New Hampshire Legislature passed the Healthy Kids Act and authorized an appropriation of $240,000 for administrative startup costs (known as NH Healthy Kids, or NHHK) to provide affordable health insurance to children through age 18. Shortly thereafter, in 1997, Congress established the Children's Health Insurance Program (CHIP), which allowed participating states to claim an enhanced federal reimbursement match rate (65 percent) in order to expand health insurance coverage to targeted uninsured children. States were required to commit the 35 percent match for federal CHIP approval.

With no state sales or income tax, however, New Hampshire has a long history of running a lean state government. It appeared unlikely that the state legislature would appropriate the matching funds.

In 1998, New Hampshire Governor Jeanne Shaheen asked the HNH Foundation board of directors to consider granting the 35 percent match funds needed to begin a New Hampshire CHIP (NH CHIP). After careful deliberation and consideration of several issues–the 5 percent payout requirement, the opportunity to leverage a large share of federal funding with HNH funding, and a path to significantly deliver on a stated purpose of the foundation–the board contemplated deeply what it meant for the foundation to assume a State responsibility. They also studied the quick growth of the NHHK program.

By 1996, 800 children were enrolled in NHHK, by June 1999, 1,295 children were enrolled, and by the end of 1999, enrollment reached 6,488 children. There was clearly a desire on behalf of New Hampshire low to moderate income parents to access quality coverage for their children. In 1999, the HNH board voted to approve a proposal from the New Hampshire Department of Health and Human Services for funding in the amount of more than $350,000 to leverage the 65 percent matching federal funds to establish a NH CHIP.

The popularity of NH CHIP soared. Enrollment numbers climbed rapidly and New Hampshire’s Department of Health and Human Services returned to HNH Foundation in 2000 with a request of $800,000. The board of directors again approved the request for matching funds to leverage federal dollars.

By 2001, the HNH board of directors communicated to Governor Shaheen that the foundation could not be counted on to continue funding the match. At that time, HNH assets totaled $12 million; at the rate of spending just for CHIP, drawing down from the foundation’s principal assets would soon be required to meet the match obligations.

With enough enrollment data to present to New Hampshire lawmakers, the governor was able to demonstrate the value of the state CHIP. Funding for the federal match was appropriated by the legislature and became available in July 2001. HNH Foundation continued to provide support for outreach and enrollment efforts, as well as some match dollars for moderate income families who were CHIP eligible. Between 1998 and 2009, HNH would provide more than $3.2 million to New Hampshire Department of Health and Human Services for direct support of CHIP.


Outreach and Enrollment: The Recent Years

By 2013, ACA activities appeared to be in full swing. However, the New Hampshire Legislature opted to create a state partnership marketplace which meant that federal funds were not available for ACA planning and implementation. Partners and stakeholders acknowledged the need for an outreach and enrollment strategy, informed by local level data on the uninsured.

HNH stepped in with funding for collection and analysis of demographic, geographic, income, and other indicators of the state’s uninsured. These data were used to create an interactive mapping tool, used to plan and continually update ACA outreach and enrollment efforts throughout the state.

By 2015, the HNH board experienced a sense of accomplishment stemming from contributions made on behalf of health insurance coverage transformation in New Hampshire. While coverage would remain part of the foundation’s DNA, the board of directors believed the issue was well on its way to becoming institutionalized at the state-level, enabling HNH to consider alternative funding priorities.

This sense of achievement would not last for long. Following the 2016 general election, New Hampshire, like other states, quickly came to terms with the fragility of ACA accomplishments.

In 2017, federal funding for New Hampshire outreach and enrollment was reduced by 90 percent and the enrollment period by was cut by 50 percent. The state’s federally qualified health centers (FQHC) received the bulk of outreach and enrollment funding, leaving thousands of others at risk for losing coverage.

The NH Health Care Coalition, a recently formed group of grassroots advocates, agreed to develop and implement an outreach and enrollment plan, even though they lacked resources for implementation. A proposal to mount an outreach and enrollment effort in a matter of weeks was presented to HNH Foundation. The board responded quickly, approving a nearly $100,000 off-cycle request in November 2017, despite the fact that it exceeded the annual grant budget. Together, with efforts by the FQHC parent organization and multiple volunteers throughout the state, New Hampshire’s ACA enrollment was nearly consistent with that of the previous year.


The Lesson

Over its history, the HNH Foundation’s board has recognized the inherent challenges of stepping up to fund what may be seen as State responsibilities. However, it has balanced that perspective with the understanding that using its resources as a catalyst to enable more state residents and their children to access health insurance coverage leverages a much larger, potentially sustainable, pool of funds. In the long term this has resulted in greater mission impact than the foundation could otherwise achieve.