New Hampshire Must Get Serious About Health Care Costs
As Governor Kelly Ayotte prepares to deliver her State of the State address on February 5, rising health care costs are front and center for families, employers, and communities across New Hampshire. In a just-published opinion piece in the New Hampshire Bulletin, Professor Lucy Hodder explains that affordability will not improve without deliberate, coordinated policy action.
Hodder—Director of Health and Life Sciences Law at UNH Franklin Pierce School of Law and Board of Contributors to the NH Health Cost Initiative—writes that “the health care system will not fix itself. We need accountability, transparency, and a long-term budget.” Her op-ed builds on themes recently explored at the UNH School of Law Health Law & Policy Symposium, Illuminating the Path: Equity and Affordability in Healthcare.
Hodder places New Hampshire’s challenges in a national context. Health care spending in the United States is nearing $5 trillion annually, driven by rising prices, increased utilization, and structural inefficiencies. New Hampshire mirrors this trend, spending an estimated $13 billion each year on health care, with inpatient and outpatient hospital services accounting for more than half of that total.
Her argument is clear: without stronger oversight, transparency, and a shared strategy to manage cost growth, health care will continue to strain household budgets, employers, and the state’s broader economy.
Affordability is in Crisis
Despite New Hampshire’s relatively low uninsured population, about 4.5% of residents, costs continue to rise for those with coverage. More than half of commercially insured Granite Staters face deductibles over $1,500, and 41% of insured adults rate their insurance as poor due to high out-of-pocket costs.
Employers are among those feeling the strain most acutely. A 2025 survey of Exeter-based New Hampshire businesses found health care costs to be one of their top concerns, averaging 4.5 out of 5 in severity. Many report difficulties with employee retention and recruitment, and nearly one-third cannot afford to offer employer-sponsored insurance at all.
At the same time, medical spending trends are accelerating. Total medical expenses in the commercial market are projected to rise 9.1% in 2026, and pharmacy spending, particularly for GLP-1 drugs, continues to surge. All while investment in primary care remains low, at just 5.8% of total spending in large employer plans.
Consolidation and Overexpansion Drive Costs
Rising costs are deeply tied to how New Hampshire’s health care system is structured. Growing consolidation means that a small number of hospital systems control the majority of health care spending in the Granite State, often under out-of-state ownership. For example, 4 of NH’s acute care hospitals are owned by the for-profit, publicly traded company, HCA Healthcare Inc, based in Tennessee. And only 4 acute care hospitals out of 13 in NH are governed by parents or owners that only operate in New Hampshire.
“NH spends over $13 billion on healthcare each year,” stated Hodder. “And at the same time, we don’t really have our arms around who our partners are or who’s making decisions about our care.”
In addition to changes in hospital ownership, New Hampshire has experienced rapid growth in high-cost, episodic care sites with little oversight. The number of licensed urgent care centers grew from 18 in 2015 to 48 in 2025, alongside the expansion of freestanding hospital emergency departments— which represent the most expensive form of same-day care — often strategically located by one hospital within the service areas of other existing hospitals.
“We’ve created competition in some areas with an unchecked overabundance of infrastructure, while cutting family planning clinics, starving community health providers with cuts to Medicaid, and pulling away grant dollars,” Hodder said.
Private Equity Needs Oversight
Nationally, private equity firms have invested more than $1 trillion in health care over the past decade, acquiring physician practices and specialty providers, contributing to significant price increases following these acquisitions, particularly when firms gain substantial local market share.
“When private equity comes in, their goal is to leverage the investment and sell services at a profit,” Hodder said. “ If our system is up for sale with no oversight for who buys it, we don’t have control over what they decide to do.”
While New Hampshire has created the Health Care Consumer Protection Advisory Commission to benefit consumers, many states are moving further to strengthen oversight of their health care systems. Across the country, states are increasing corporate transparency, setting targets for overall health care spending, and expanding protections for patients facing medical debt.
A Worsening Federal Backdrop
At the same time that healthcare affordability and access dwindle, federal support is shrinking. Major Medicaid cuts, totaling $1.2 trillion nationally, are expected over the coming years, alongside new enrollment restrictions, work requirements, and reductions in ACA marketplace subsidies.
In New Hampshire, most of the $2.5 billion annual Medicaid spend comes from federal dollars. As those funds decline, the pressure will intensify and spread. “We have an impending Medicaid crisis that is going to put enormous pressure on providers, employers, and patients who can’t afford to make up the difference,” cautioned Hodder.
While the state’s recently awarded Rural Health Transformation grant represents an important opportunity to strengthen primary care and behavioral health integration, it might not be enough to address all the gaps in New Hampshire’s health care system.
What New Hampshire Can Do Now
New Hampshire’s small size is an advantage. With just 1.4 million residents, the state has a real opportunity to bring clarity and coordination to its health care system, if leaders choose to act.
“New Hampshire’s affordability challenge comes down to accountability,” stated Hodder. “We don’t have clear spending targets, shared priorities, or transparency. We need a compass for patients and employers, and reassurance that we’ll have the state government as a partner.”
Key priorities for New Hampshire include:
Increased transparency and oversight around ownership, financing, and market consolidation
A statewide approach to controlling cost growth, such as an Office of Healthcare Affordability
Stronger consumer protection, including meaningful tools to help patients navigate care and avoid unnecessary costs
Greater investment in primary care, where long-term savings and better outcomes are well-documented
As the Governor sets the tone for the year ahead, our choice is clear: we can continue reacting to rising costs, or finally address their structural drivers head-on. Band-aids are not enough to fix an issue that has been decades in the making, but a transparent, accountable, and coordinated approach might be.
Lucy Hodder serves as a professor and Director of Health and Life Sciences Law at the University of New Hampshire Franklin Pierce School of Law. Her work focuses on health law, bioethics, and health care policy. She serves on the Board of Contributors of the New Hampshire Health Cost Initiative and lives in Hopkinton, New Hampshire.