ABSTRACT
The very nature of the ACA and its core elements conflicted with New Hampshire’s rich political traditions of limited government. The Granite State has a strong embedded preference for local control of policy issues and the initial reaction to the ACA was predictably negative. Further complicating matters, New Hampshire has a unique government structure in which an Executive Council oversees the actions of the governor, limiting the influence that role plays in high-profile policy issues such as the ACA. However, upon her election Governor Maggie Hassan was able to negotiate a Medicaid expansion through a Section 1115 waiver that allowed federal dollars to be used to purchase private policies for those that qualified. This strategy gave the appearance of limited federal involvement while allowing thousands of uninsured New Hampshire citizens access to healthcare. This moved New Hampshire from absolute opposition to moderately in support of the ACA. One of the first orders of business on Governor Sununu’s, Governor Hassan’s successor, agenda was applying for a separate Section 1115 waiver that added a work requirement to the Medicaid expansion that was quickly approved by the Trump administration. The New Hampshire case study exemplifies the struggle to find the proper role of the federal government in state decisions.
