What Home Care Really Costs New Hampshire Families

Who qualifies for help caring for a disabled child at home in New Hampshire?

Start here, because this is where most families stop. To get help caring for a disabled child at home in New Hampshire, that child needs Medicaid first. If your household earns above the limit, there is a second door — Home Care for Children with Severe Disabilities.

Here is how the state describes who qualifies for it.

Read it twice. To qualify for help keeping your child out of an institution, your child must first qualify to be in one. The rule sets the bar precisely: a child requiring “the same level of care as provided in a hospital, psychiatric hospital, nursing facility, or intermediate care facility for the intellectually disabled.”

Not significant needs. Not substantial support. Institutional level of care, or nothing.

So if your child needs a great deal of help but not quite that much, and you earn slightly too much for regular Medicaid, there is no program waiting. Not a waiting list. Not a queue you are slowly climbing.

Does home care cost New Hampshire less than institutional care?

This isn’t a case where the humane choice is the expensive one. New Hampshire’s own budget documents put the two side by side, in the same table, in the same year.

That is the adult waiver — Choices for Independence, for older adults and adults with physical disabilities. The state’s own waiver documents say it exists precisely to support people in their homes and communities rather than in institutional settings. The cheaper option is also the one the state says it wants. And there is no queue for it.

Everything above is New Hampshire describing its own program.

What wage does New Hampshire assume for a home-care worker?

Before the next number, understand the one underneath it. New Hampshire builds its care budgets on an assumption about what a direct support worker costs: $12.60 an hour, with a range from $10.00 to $15.50.

Here is a job posted in Manchester last week.

The entry-level floor at a coffee shop is above what New Hampshire assumes for caring for a disabled child at home. At the bottom of the care range, the gap is three dollars an hour.

The two jobs are not the same job, and that is the point. The Dunkin’ shift does not require documenting monthly progress against functional goals and reporting them to the state. It does not carry a chance of being bitten or hit. It ends when it ends.

So nobody takes the care job. Not because people don’t care — because you cannot ask someone to absorb documentation, physical risk and emotional weight for less than the drive-through pays and expect a yes.

Can families actually get the home care they qualify for?

Set that wage, and this is what follows. In a survey of all seven active Choices for Independence case-management agencies — every one in the state — the picture stops matching.

• All seven agencies reported that an individual might not receive CFI services because there weren’t enough workers available, either overall or at the times the services were needed.NHFPI, Long-Term Services and Supports in New Hampshire, July 2022
• Six of the seven reported that authorized services were not received in full because of unfilled positions and workforce shortages — “Very Often.” The seventh said “Often.”Same report
• The failure isn’t a queue. There is no queue. The services are approved, the person is eligible, and nobody comes.

What does the gap look like inside one family?

Two of my children were recommended for placement through the area agency system. I said no. I wanted them home.

What the state provides instead is an In Home Supports waiver allocation. At its own assumed wage of $12.60 an hour, that allocation buys a little over five hours a day — for two children who need all of it. I have not found anyone qualified willing to take that job at that rate. Not unreliable people. Any people.

So the money comes to me, because I am the one doing the work.

What followed — the arithmetic on my own household, a food benefit cancelled for accepting care funding, an appeal taken as far as it goes and upheld — is a separate account, written for the families living it.

Who absorbs the cost when approved care is never delivered?

Care that the state approves and doesn’t deliver doesn’t stop being needed. It gets absorbed — first by hospitals, then by families.

• On a single day in November 2021, 102 patients across fifteen New Hampshire hospitals had accumulated 3,977 additional days of hospital care because no appropriate discharge placement was available. Nearly half of those patients, and roughly three-quarters of the extra days, involved people waiting on long-term care.Snapshot by the NH Hospital Association, NH Health Care Association, and Home Care, Hospice and Palliative Care Alliance, reported by NHFPI
• 93% of delayed home-care referrals were affected by staffing shortages at home-health and personal-care agencies.Same snapshot
• 49% of New Hampshire people with disabilities live below the ALICE Threshold — 82,756 people who can’t afford the basics where they live.United For ALICE, ALICE In Focus: People With Disabilities, published July 2022 (2019 ACS data)

And then it lands where it always lands. A parent, a daughter, a spouse reduces their hours, or leaves the job, or never takes the promotion — because the care has to come from somewhere and the somewhere is them. That work is unpaid, uncounted, and invisible to every ranking New Hampshire is proud of.

It’s also the cheapest labor the state has ever gotten.

Why doesn’t New Hampshire’s home-care math add up?

Put the facts next to each other and they refuse to sit together. The state pays far more for the outcome nobody wants. It gates the cheaper one behind a test that requires a child to be sick enough for an institution. It funds the work at less than a coffee shop pays. And then every agency responsible for delivering it reports that people don’t receive it.

Nothing in that requires anyone to be a villain. It requires a workforce that doesn’t exist at the price offered, a budget that funds the expensive option by default, and a set of families willing to absorb the difference rather than watch someone they love go into a facility.

That willingness is the resource the whole system quietly runs on. Nobody has ever put a line item on it.

This is the same household The Scissor closes on, measured by the ruler that can’t see them, and pulled out of the workforce into The Drain. One failed support, two people gone — and this time one of them chose to be there.