Temporary licenses offer life support for N.H. health care system as permanent fix proves elusive

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On Feb. 1, amid a critical shortage of health care personnel in New Hampshire, the licenses of 22,328 medical workers were set to expire. That’s 26% of health care workers licensed to practice in the state. 

In January, the state’s Office of Professional Licensure and Certification (OPLC) prevented that disaster by issuing an emergency rule to extend the licenses — for four more months. 

When that rule expires on May 31, all of those licenses will expire with it. 

Unless the Legislature acts before then, Granite Staters will lose access to tens of thousands of medical professionals, including 951 mental health counselors, 1,064 social workers, 1,114 psychologists, 2,104 Advanced Practice Registered Nurses, and 14,920 physicians. 

Many of those, such as psychologists, are offering services remotely. Others, including a lot of physicians, were licensed under bulk applications and might have few New Hampshire patients. Others, such as nurses, fill staff positions in New Hampshire.

All of them were granted temporary emergency licenses during the pandemic. Those licenses were extended through January, then again through May. Legislators so far have refused to pass a law to make these licenses permanent, or to grant permanent recognition of out-of-state health care licenses. 

A health care system in crisis mode

Nearly two years after the first COVID case was documented in New Hampshire, health care in the state is being triaged through a rolling series of emergency professional license extensions. 

“We get calls all day saying, ‘We need you to approve this license right away,’” Lindsey Courtney, executive director of the OPLC said. 

“It’s mostly hospitals or residential or long-term-care facilities. And often it’s because they’re bringing in travelers. They’ll call a staffing agency and they’ll be told, ‘I can get you five people, but they have to be licensed tomorrow.’”

Because obtaining a permanent state license can take months, quickly licensing those new hires is done under a stop-gap fix the Legislature passed last year. It lets the OPLC offer temporary, 120-day licenses to health care workers.

“I would say that’s how the bulk of the traveling nurses get licensed,” Courtney said. “They don’t even seek a permanent license because they’re going to be here less than four months. If they had to seek a regular license, I’m not sure where we’d be.”

In seven health care fields, more than a third of licensed practitioners hold emergency licenses, a review of state licensing data shows. In two fields, the percentage is close to two thirds.

Percentage of licensed health care practitioners who hold an emergency license: 

Licensed Alcohol and Drug Counselors    36%

Advanced Practice Registered Nurse        39%

Licensed Independent Clinical Social Workers     44%

Licensed Clinical Mental Health Counselor           45%

Marriage and Family Therapists         47%

Psychologists        63%

Physicians             65%

Courtney has pressed legislators to provide a permanent fix by simply letting her office recognize out-of-state health care licenses. 

It’s hardly a new idea. The Journal of the American Medical Association published a brief arguing for medical license reciprocity in 1899. But every time it is proposed in New Hampshire, licensing boards object. 

Dominance of state licensing boards

Professional licensing in New Hampshire is conducted by 54 different state licensing boards. Thirty-five of those regulate health care occupations. 

In theory, giving current practitioners the ability to license new entrants into their field raises quality. In reality, it reduces the number of practitioners and gives established license holders the power to restrict competition.

For health care occupations, that is bad for patients, said Morris Kleiner, the AFL-CIO chair in labor policy at the Humphrey School of Public Affairs at the University of Minnesota, and an expert on occupational licensing.

If New Hampshire doesn’t make these licenses permanent, it could harm Granite Staters by suddenly and sharply reducing access to care, he said.

“Not having the licenses, or revoking them, reduces the supply of labor and reduces access of patients to these important, healing occupations,” he said.

Senate Bill 277, sponsored by Sen. Erin Hennessey, R-Littleton, would offer another temporary fix by extending the 22,328 emergency health care licenses, set to expire May 31, for another two years. That would stretch these “emergency” licenses out for four years in total. 

At a Jan. 11 Senate hearing on the bill, the OPLC offered an amendment to have the licenses made permanent. The Board of Psychologists opposed the amendment, saying it would amount to “rubber-stamping the approval of an out-of-state license” and therefore diminish the quality of care offered to patients in New Hampshire. 

Currently, 1,114 psychologists hold a temporary emergency license to practice in New Hampshire. They far outnumber the 645 psychologists who hold a permanent license. If these emergency licenses were to be made permanent, it would increase the number of permanently licensed psychologists by 73%. 

During the state of emergency, New Hampshire granted licenses in bulk to Massachusetts health care providers who accepted Medicare and Medicaid. This ensured that New Hampshire patients could see their caregivers remotely. In some cases, a large health care facility made a bulk application on behalf of its employees who might have New Hampshire patients. Bulk submissions can cover a lot of providers who don’t regularly see New Hampshire patients, or who don’t intend to move to the state. (Many of the emergency-licensed physicians fall into this category.)

About 35% of the emergency licenses for psychologists were part of a bulk submission. The rest of the applications came from individuals. That represents “a significant increase in the number of people who were actually practicing,” Courtney said. “Those were probably people conducting a lot of telehealth services with patients, probably a lot of cross-border care.”

“Mental health is continuing to operate in a largely telehealth platform,” she added.

Another bill, Senate Bill 330, sponsored by Sen. Bob Giuda, R-Warren, would authorize the OPLC to license practitioners who work in other states in which the requirements for licensure are substantially similar to those in New Hampshire. 

Both bills have bipartisan support in the Senate. But hostility to SB 330 from some licensing boards and licensed professionals suggests that a permanent fix to the problem is unlikely this year. 

It’s an uphill battle, given the political strength of licensing boards, Professor Kleiner said.

“The only state that has extended the temporary licenses and made them permanent is your neighbor in Massachusetts,” he said. “Most other states have let the temporary licenses expire, and that’s unfortunate given the spike in the number of COVID cases we’ve seen.”

An outdated system

State licensing boards typically meet monthly and approve license applications at their meetings. Though modern technology allows instant online application submissions, New Hampshire’s licensing system operates on a 19th century schedule of in-person meetings and infrequent reviews. Getting an application approved through the regular process can take months.

“Vermont’s doing it in 24 hours, and we’re competing for the same licensed person,” Courtney said. “You have to keep up with the times, and people are not going to wait around 60 days.”

Vermont a few years ago overhauled its professional licensure process to make it easier and faster to get a state license. (The reform was funded by a federal grant received in 2018.) 

The Green Mountain state processes all applications online and offers fast-track recognition for professionals who hold out-of-state licenses in many occupations. Under Vermont law, three years of experience practicing a regulated occupation in another state is considered sufficient experience to qualify for licensure.

“Colorado and Vermont are among the most efficient in the country at getting licenses processed,” Professor Kleiner said. “Vermont’s very efficient.”

Arizona passed a universal license reciprocity law in 2019. Since then, 4,000 people have used it to obtain state licenses. 

Such comprehensive reforms have never gotten far in New Hampshire. Some state boards have made improvements, for example by passing rules to allow the OPLC to process license applications between meetings. Others, including the boards for psychologists and licensed alcohol and drug counselors, haven’t. 

“We have a psychologist who lapsed his license,” Courtney said. “He’s been practicing for 30 years. He also practices in another state. It took him a month. If he had had patients, that would’ve been problematic because he would’ve had to choose between cutting them off or committing a violation.”

No serious complaints

Licensing boards often object to automatic reciprocity by arguing that it would jeopardize public health and safety. The record of the last two years suggests otherwise. 

The governor’s emergency order recognizing out-of-state health care licenses in New Hampshire took effect on March 23, 2020. Since then, 22,328 emergency licenses have been issued. Yet the state has received only two complaints about emergency license holders, Sen. Hennessey testified during the Jan. 11 meeting of the Senate Finance Committee. 

Neither of those complaints was serious enough to go to a hearing, Courtney said.

The number of practitioners operating under an emergency license varies by field. They include a single acupuncturist, six midwives, nine optometrists, 25 dietitians, and 92 licensed alcohol and drug counselors. In fields with significant shortages, the numbers can be substantial. Emergency licensees include 1,064 licensed clinical social workers, 2,104 Advance Practice Registered Nurses, and 14,920 physicians.

Far from creating a public health problem, these emergency licensees likely saved numerous lives by providing services that would not have been offered otherwise. Hospitals and nursing homes in particular have relied on emergency licenses to stay staffed during the last two years. 

Even with these additional health care workers, some facilities have had to close rooms and limit services. Were it not for the thousands of additional staff made available through emergency licensure, these closures would have been much worse. 

Despite the stressful conditions and difficult working environment that has prevailed for two years, only a few complaints have been made against emergency licensees, and none was serious enough to bring to a hearing. The tiny number of complaints is powerful evidence that the safety concerns regarding large-scale license reciprocity are unfounded, according to Courtney.

“I think we’ve shown that the world doesn’t end and the sky doesn’t fall when we remove some barriers for licensure,” she said. 

 

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After School Choice Week, legislators consider bills to limit choice

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In New Hampshire, School Choice Week 2022 (Jan. 24-28) highlighted some reasons why parents pursue educational options beyond their assigned public school. 

On Monday, School Choice Week kicked off with a new policy at Newmarket Junior-Senior High School: Unmasked students are to be removed from class, given detention, then suspended if they continue to attend school without wearing a mask. 

Recognizing the blowback such a policy would create, the principal told parents in a letter days earlier that if they didn’t like it they could switch their children to another school.

“We recognize that there are some who oppose the wearing of masks in schools,” the principal wrote. “In order to better meet the needs of these families, the New Hampshire Department of Education continues to provide alternative options for learning that can take place in the home through (Virtual Learning Academy Charter School) enrollment.”

So School Choice Week started with a public school principal urging parents to choose an alternative school.

The next day came the news that students in a Derry middle school would face detention for not wearing “properly-fitted” masks. In detention, they would be re-educated. 

“We will use this time in concert with our school nurse to provide more education for students to stress the importance of compliance,” the school principal wrote.

The same week these severe masking policies were implemented, The Washington Post, The Atlantic, The New York Times and National Public Radio ran pieces that called into question the efficacy and wisdom of school mask mandates.

This disconnect between some district policies and the evolving research on COVID mitigation protocols and practices has exacerbated tensions and frustrations, leading to additional pressure for families to have multiple educational options. 

Though masking happened to the the issue that blew up during School Choice Week this year, parents have expressed numerous other reasons for seeking alternative educational options for their children. 

In January, more than half of parents (52%) said they considered or are considering finding a different school for at least one of their children this year. Eighteen percent of parents said they did choose a new school for at least one of their children in the past year. 

The top reasons for considering a different school were higher quality education (36%), COVID disruptions (34%), safety or bullying (26%), the child is unhappy at school (23%). 

Before the pandemic, demand for educational alternatives was lower, but was still strong.

The National Center for Education Statistics’ Parent and Family Involvement in Education survey for the 2018-19 school year found that 36% of students had parents who indicated they had considered multiple schools for their child. Among that group, 92% listed quality of school staff as a factor, 74% said curriculum focus or academic programs, and 69% said safety.

Research by EdChoice shows that parental educational preferences differ from actual student enrollment. Though 36% of parents nationwide say they prefer to enroll their children in a district public school, that’s where 83% of students are enrolled. Though 40% of parents say they would prefer to enroll their children in a private school, only 5% of students are enrolled in one. Though 13% of parents say they’d prefer a charter school, only 8% of students are enrolled in one. 

Choice programs such as charter schools and New Hampshire’s Educational Freedom Accounts (EFAs) are designed to maximize family options so parents can use their own discretion to choose a school that best matches their children’s needs. 

EFAs have proven unexpectedly popular, with 1,837 students enrolling in the program by the time School Choice Week arrived, according to Children’s Scholarship Fund NH, which administers the program.

Yet as  families took advantage of the EFA opportunity, legislators introduced bills to weaken, limit, and even abolish the EFA program. 

Several of those bills will be heard in the  House and Senate Education Committees this week and next. The anti-EFA bills include the following:

  • House Bill 1115 would eliminate student assessment options currently included in the EFA program and require students to take state assessment tests (which might not be aligned with the curricula EFA students are being taught). 
  • House Bill 1120 would require an education service provider chosen by an EFA recipient be a state-approved non-public school education program and to have been in business for at least a year prior to receiving funding. 
  • House Bill 1637 would, as a condition of receiving an EFA, require parents to answer a survey detailing their reasons for wanting to leave their public school.
  • House Bill 1669 would move administration for the EFA program to the Department of Education. Current law has it administered by a private scholarship organization. The bill also would limit the amount of money parents can roll over in their EFA accounts. 
  • House Bill 1670 would prohibit families from keeping their EFA accounts open if a student returns to a public school, and would require unused funds to be collected by the state. It would require annual audits of all EFAs and terminate an EFA account if a parent spent a substantial portion of funds on unapproved expenses, even accidentally.
  • House Bill 1283 would repeal the provision in the EFA law that holds the EFA contributions to be tax-exempt. 
  • House Bill 1516 would prohibit local education dollars from ever being used for EFAs. 
  • Senate Bill 351 would require burdensome, detailed financial and other reporting for any private school that accepts an EFA student. 
  • Senate Bill 237 would make families prove that their income is below 300% of the federal poverty level each year to be eligible for an EFA.
  • House Bill 1684 would limit funding for the EFA program to $129,000 in this fiscal year and $3.3 million next fiscal year, those being early estimates for the state cost of the program. Currently, 1,837 students are enrolled in the EFA program. Were this bill to pass, approximately 1,811 children would lose their scholarships this year, and 1,120 children who have scholarships now would be unable to get them next year. (The average scholarship amount is $4,600.)
  • House Bill 1683 and Senate Bill 432 would repeal the EFA program. If either of these bills passed, 1,837 students would lose their scholarships, and the program would be killed, denying all students this option in the future. 

Efforts to limit and control educational options for families this year face an inevitable collision with the preferences of increasing numbers of parents.

Gallup’s tracking poll on education satisfaction last year found that 54% of Americans were dissatisfied with the quality of K-12 education. That’s not an anomaly. Only three times in 23 years has the poll found that a majority of Americans were satisfied with the quality of K-12 education.

A Real Clear Opinion poll last year found that 74% of Americans support school choice, and that includes more than 70% of Asian, black, Hispanic, and white Americans.

The poll also asked whether people would support giving parents a portion of K-12 public education funds “to use for home, virtual, or private education expenses.” Two-thirds said yes, and the breakdown among Republicans and Democrats was identical, with 66% of each party saying yes. 

Last October, as education became a top national political issue, school choice grew in popularity. Eighty percent of parents with school-age children said they supported Education Savings Accounts like New Hampshire’s Education Freedom Accounts.

The Josiah Bartlett Center’s poll of New Hampshire voters last year found a plurality of voters in favor of EFAs. 

Partly because of the record popularity of school choice, last year 18 states either established or expanded a school choice program. 

All indications are that the school choice moment has arrived. At this point, the smart political move is to find ways to accommodate that demand. Fighting it by attempting to legislate away parental options is like standing on the shore firing a squirt gun at a tsunami. 

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Why school choice is the most powerful education reform

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As School Choice Week kicks off, it’s worth considering why there’s no such thing as Grocery Choice Week. Or Clothing Choice Week. Or Home Choice Week. 

When it comes to the basic necessities of life — food, clothing and shelter — Americans have the freedom to choose from among whatever options the market provides. (Government limits housing choices, but not as much as it limits K-12 education choices.)

Education is a service provided by state and local governments, so of course it’s more limited, one might argue. But why is it provided by government, as opposed to funded by government?

Government finances or subsidizes some goods and services — food (through food stamps), medical care (through Medicaid and Medicare), higher education (through Pell Grants & other aid) — without providing the service itself. It’s perfectly feasible to do the same with K-12 education. 

There’s no reason government can’t convert what it currently spends on public education (about $20,000 per pupil per year in New Hampshire) into grants or scholarships that parents could use to purchase educational services from approved providers — including public schools.

One argument against this approach is that public schools are an important transmitter of community standards, values and beliefs from one generation to the next. But is this still true?

Parents are being told in no uncertain terms that they may not control the content of their children’s education. They are told that they have no say over what library books their children can access or what ideas, beliefs and facts their children are taught. 

This goes double for non-parents. Community members who object to what is being taught in their name are rarely taken seriously and invited to help ensure that schools uphold community standards. 

On top of this, COVID-19 has shown the damage that can be done by one-size-fits-all school policies that don’t meed families’ needs. Forced remote instruction has had devastating academic and psychological consequences. 

In New Hampshire, more than 8,000 students left the public school system in 2020, and they haven’t come back. That represents 4.5% of the entire student population. Though private school enrollment in New Hampshire for years has tracked closely with public school enrollment, that changed during the pandemic. Private school enrollment shot up as public school enrollment plunged. 

That indicates that parents fled a system that left them with no satisfactory options. Private schools mostly stayed open, attracting thousands of families who weren’t getting what they needed from their local public schools.  

Nationwide, most parents said in a January poll that they’re looking for a new school for their children. If local public school systems offered families a variety of educational options, this number likely would be much lower. Parents don’t leave systems that are meeting their children’s needs. They leave when they feel like those needs aren’t being met.  

Opponents of school choice fear the consequences of giving families control over their education dollars. They claim it would destroy the public education system. But the opposite is true. 

Making the system more responsive to individual student needs will strengthen it in the long run. This is how market forces work. They prompt adaptation. 

Some public schools already operate this way. Charter schools cannot force the children who live near them to attend. These public schools have to attract students. They do this by offering programs that parents want. And it works. Some attract students from dozens of towns. Charters prove that public schools absolutely can compete successfully with private schools. 

The only thing keeping traditional public schools from functioning in a similar way is the design of the system. As long as district schools don’t have to attract nearby students, but can essentially conscript them, reform is going to be extremely difficult to achieve. 

Let families have more control over their education dollars, and schools will improve quickly. This isn’t just theory. It’s already happening in states that have school choice. 

School choice empowers families and improves student outcomes, even for students who remain in traditional schools. It’s the most powerful and effective education improvement method for the simple reason that it’s the only one to match each individual student with the specific services he or she needs. 

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Impeding the expansion of new telecom technologies would hurt New Hampshire

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A House bill considered in committee this week would deny much of New Hampshire access to the most advanced telecommunications technologies.

House Bill 1644 would require “telecommunications antennas” to be placed “at least 1,640 feet from residentially zoned areas, parks, playgrounds, hospitals, nursing homes, day care centers, and schools.”

The bill’s stated purpose is to protect people from the “significant public health risk associated with the cumulative effects of radio frequency radiation which is growing every day with the proliferation of cell tower transmitters.”

Some people who believe that cell phone radiation causes cancer think that 1,640 feet, or 500 meters, is the minimum safe distance from a cellular network antenna. 

But this fear is unfounded, according to hundreds of studies and numerous public health agencies and organizations: 

  • The Food and Drug Administration concluded in February of 2020 that “there is no consistent or credible scientific evidence of health problems caused by the exposure to radio frequency energy emitted by cell phones.” The FDA report noted that brain cancer cases have declined as mobile phone use has grown.
  • An Australian study published in March of 2021 reviewed 138 studies of radio frequency fields consistent with 5G networks. It found “no confirmed evidence that low-level RF fields above 6 GHz such as those used by the 5 G network are hazardous to human health.”  
  • The World Health Organization concluded in 2014 that “no adverse health effects have been established as being caused by mobile phone use.”
  • The Centers for Disease Control and Prevention has concluded that “we do not have the science to link health problems to cell phone use” at this time.
  • “At this time, there’s no strong evidence that exposure to RF waves from cell phone towers causes any noticeable health effects,” the American Cancer Society has concluded. 
  • The National Cancer Institute notes that cell phone radiofrequency “energy is too low to damage DNA” and that the “only consistently recognized biological effect of radiofrequency radiation absorption in humans that the general public might encounter is heating to the area of the body where a cell phone is held (e.g., the ear and head). However, that heating is not sufficient to measurably increase body temperature. There are no other clearly established dangerous health effects on the human body from radiofrequency radiation.”

Were legislators to pass the bill out of a misplaced sense of caution, the economic and quality of life effects would be substantial — and negative. The Town of Amherst shows how. 

Amherst’s zoning map shows that residential/rural zoning covers 62.7% of the town, and “Northern Rural” zoning, where single-family homes are allowed, covers another 24.43%. That leaves little room for new telecommunications antennas. The bill would shrink the remaining zones by 1,640 feet from any side that touches a residential zone, and it would create no-antenna zones around every park, playground, hospital, nursing home, day care center, and school.

Further, if “residentially zoned areas” means any zone that allows any residential use, then the areas where antennas would be allowed would shrink to a tiny fraction of available land in any given community.

Consider Charlestown, a community in dire need of economic development. A look at its zoning map shows that the vast majority of the town is zoned either “mixed use” or “residential/rural.” Residential dwellings are permitted in the mixed use zone. 

Residences are allowed in the “Town Center,” “North Main Street,” and “Business” zones as well. Residences are prohibited only in a tiny section of town zoned for industrial use, and at the Fort at No. 4 historic site. 

Were HB 1644 to become law, Charlestown likely would be carved out of the state-of-the-art 5G cellular network that soon will connect much of the planet to ultra high-speed wireless broadband service. 

This scenario would be repeated in town after town throughout New Hampshire. The bill would risk wiping chunks of New Hampshire off the 5G map, creating large gaps in coverage and exacerbating the digital divide that already holds rural areas back economically.   

If that weren’t bad enough, the bill violates the federal Telecommunications Act of 1996.

New Hampshire’s Commission to Study The Environmental and Health Effects of Evolving 5G Technology concluded in its final report that “this Act says, among many other things, that the siting of any antennae cannot be denied due to health concerns.”

HB 1644 explicitly attempts to deny siting of antennae due to health concerns. It plainly violates federal law. 

Remote parts of New Hampshire are already economically disadvantaged relative to places located closer to commercial and technological hubs. Impeding the expansion of advanced communications technologies to these areas would hurt them, not help them. 

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The case for commuter rail in N.H. got worse, not better, in the last seven years

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The case for taxpayer-subsidized commuter rail from Manchester to Boston has grown weaker, not stronger, in the seven years since the state released its major study of the proposed Capitol Corridor project. 

The New Hampshire Department of Transportation’s December, 2014, report on the Capitol Corridor project projected that a commuter rail line from Manchester to Boston would attract 3,120 riders per weekday. It predicted also that demand for commuter rail would grow as highway traffic increased in the coming years. 

In November of 2021, the department released an updated analysis of the Capitol Corridor project. It projects a peak ridership of 2,866 passengers per weekday, which is an 8% decline from the 2014 report.

That 8% decline in ridership occurs even as the number of trips per day to Manchester doubled, going from 16 in the original report to 32 in the 2021 update.

Making matters worse, as ridership falls, costs rise. 

The 2021 presentation noted that the price tag for the rail line would be higher than originally estimated due to inflation and the need for additional infrastructure beyond what was originally planned.  

The 2014 report estimated $246.5 million in capital costs, plus $10.8 million in annual operating costs. Both of those costs are expected to be significantly higher. 

Adjusted for inflation alone, the 2014 cost projections would come to $292.7 million for capital expenditures and $12.8 million for annual operating expenses.

In sum, if the Capitol Corridor project were to proceed, New Hampshire taxpayers would pay millions more dollars to transport thousands fewer people. 

Where would the money come from? The DOT’s 2021 analysis includes a breakdown of non-federal funding sources for other U.S. commuter rail operations. The largest sources of revenue are sales taxes.

The DOT projects that, if New Hampshire’s commuter rail were funded in the same way other similar operations are funded, the largest source of non-federal revenue would be a “transit sales tax” at 33%, followed by a “city/local sales tax” at 18%, a “state transportation tax” at 12%, “state other” contribution at 11%, and state “GO bonds” at 8%.

Without a sales tax, it is unclear how New Hampshire could possibly fund the construction and operation of a commuter rail line. 

As the math for the Capitol Corridor project grows worse, viable alternatives to commuter rail are expected to enter the market within just a few years, possibly before any rail project could even break ground: 

  • At the Consumer Electronics Show in Las Vegas last week, automakers announced aggressive timelines for the release of autonomous vehicles. General Motors announced it planned to make an autonomous vehicle available for the consumer market by the middle of this decade. Volvo announced that its autonomous driving system would be made available as soon as it clears safety reviews in California. 
  • Mobileye, an autonomous vehicle company owned by Intel, announced that it has teamed with China’s largest automaker to put an autonomous vehicle on the market in that country by 2024.   
  • And, to demonstrate advancements in self-driving technology, companies are already showing off autonomous race cars that compete at speeds up to 175 miles per hour.

The automobile industry is at the beginning of an autonomous vehicle revolution. It’s a safe bet that by the time any Manchester-Boston commuter rail line is completed and operational, autonomous vehicles will be available on the consumer market. 

Once the technology becomes advanced enough to allow large-scale consumer adoption, Granite Staters will have the option of taking a self-driving vehicle from their front door directly to the front door of a Boston office, restaurant, theater, ballpark or medical facility. This represents a tremendous advancement over rail, which requires obtaining transportation to a train station, taking the train along a fixed route to another station, then catching another form of transportation to one’s final destination. 

Perhaps the ultimate advantage of autonomous vehicles is that they will be made available to consumers (including as taxis and ride share vehicles, and eventually vans and buses) without the expenditure of hundreds of millions of dollars to build a new transportation system and the annual expenditure of millions more to run it.

Self-driving vehicles offer all the commuting benefits of a passenger train — the ability to work, read, or relax on the trip, rather than drive — without the taxpayer expense. Once they become widely available, the already shrinking demand for commuter rail is likely to collapse.

From an investment standpoint, it makes no sense at this moment in history to spend hundreds of millions of dollars to build and operate an increasingly obsolete, 19th-century mode of passenger transport.  

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N.H. business tax revenues’ stunning surge

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New Hampshire’s booming economy continues to fill state coffers with excess cash drawn from business taxation, with impressive numbers posted each month. But a longer look back illustrates the stunning sums businesses have contributed to the state budget in the past decade. 

From Fiscal Year 2012 through Fiscal Year 2021, business tax revenues exceeded budget projections by $649.6 million — or 100.1 percentage points. 

That is, over that time businesses gave legislators an additional $649.6 million to spend beyond what lawmakers had budgeted. 

State Fiscal Year 2022 began last July, and so far the trend continues.    

Since the start of the fiscal year in July, business tax revenues are $109.5 million (27.9%) above the prior fiscal year and $72.7 million (16.9%) above budget.

Add this to the total from FY 2012-2021, and business tax revenues have come in over budget by $722.3 million since FY 2012. 

To get an idea of just how much larger state business tax revenues are today, consider that in FY 2012, Business Profits Tax revenue from July-December totaled $140.5 million. 

Adjusted for inflation, that $140.5 million would be approximately $166 million in 2021.

Actual BPT revenues for July-December of 2021, however, were a record $381.2 million — 240.7 million (171%) higher than in 2012.

Combined BPT and BET revenues in the first six months of FY 2012 were $231.7 million. 

In the first six months of FY 2022, they were $501.8 million, a 216.5% increase.

The historical context shows that state is playing with house money, so to speak, when it comes to business tax revenues. It shows further that additional small reductions to business tax rates are not only affordable, but fully justified. 

The state has taken in nearly 3/4 of a billion dollars in unanticipated business tax revenue since 2012. Claims that tiny rate reductions will bankrupt the state or devastate essential services are laughably unfounded. 

Business tax rate reductions that began in the 2016 fiscal year did not cause business tax revenue to fall below previous levels, as critics had predicted. Then-Gov. Maggie Hassan said the rate cuts would reduce business tax revenue by $90 million. Instead, business tax revenues were $132.8 million (23.4%) above plan in FY 2016. 

From FY 2012-2021, business tax revenues came in below budget for the year only twice: in 2014 (before the start of the business tax cuts) and in 2020 (when businesses were hit by the pandemic). The huge gains in other years more than made up for those relatively small declines (2% and 13%, respectively). 

Businesses in New Hampshire have fed the state budget astonishing sums over the last decade. Yet every time anyone suggests slight reductions in corporate tax rates, advocates of higher taxes attack businesses as greedy, selfish, avaricious, even unpatriotic. 

In truth, New Hampshire employers have enabled the state’s ever growing social welfare spending, and most have remained in New Hampshire despite the lure of lower corporate tax rates in other states. They should be thanked for their contributions, not vilified. Adjusting their rates to let them keep a little more of their income would be a reasonable way to say thank you.

 

 

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State laws have limited the supply of new hospital beds for decades

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New Hampshire is scrambling to find enough staffed hospital beds to handle the current surge in COVID-19 patients. Suddenly, politicians on the left and the right are deeply concerned about the low number of hospital beds in the state. Which is kind of maddening because they’re the ones who created the shortage in the first place.

For decades, state laws have severely restricted the state’s hospital capacity. They still do. 

Before 2016, New Hampshire was one of many states with a Certificate of Need (CON) law that essentially required businesses to prove that a large medical equipment or facility investment was needed before it could be approved by the state. That law suppressed investment in new facilities and services. 

In 2016, the CON law was repealed, but it was replaced with laws that created additional restrictions on hospital capacity. Senate Bill 481, passed that year, added three major requirements into state law that restrict hospital competition. 

  1. RSA 151:2-g mandates that every hospital “shall operate an emergency department offering emergency services to all individuals regardless of ability to pay 24 hours every day, 7 days a week.” This law prohibits the creation of any competing hospital services that don’t also include a 24/7 emergency room. Conveniently, this law “shall not apply to any hospital licensed and operating prior to July 1, 2016, which does not operate an emergency department.” Incumbent hospitals are protected from this anti-competitive law. 
  2. RSA 151:4-a prohibits the establishment of any “ambulatory surgical center, emergency medical care center, hospital, birthing center, drop-in or walk-in care center, dialysis center, or special health care service” within 15 miles of an existing critical access hospital if the new facility “will have a material adverse impact” on the incumbent hospital. That is, if it would hurt the hospital’s business, it is prohibited from state licensure. A 15-mile radius might sound small, but it equals 706.9 square miles. 
  3. RSA 151:2-f mandates that every hospital, infirmary, “outpatient rehabilitation clinic, ambulatory surgical center, hospice, emergency medical care center, drop-in or walk-in care center, dialysis center, birthing center, or other entity where health care associated with illness, injury, deformity, infirmity, or other physical disability is provided” accept all forms of payment. This law mandates that medical facilities accept Medicare, Medicaid and private insurance — which means that it bans any facility designed to cut costs by accepting only cash payment. This inflates the cost of services and eliminates competition. 

In addition, RSA 151:2 VI (a.) imposes a moratorium on new beds for nursing and rehab facilities. It states that “there shall be no increase in licensed capacity of, any nursing home, skilled nursing facility, intermediate care facility, or rehabilitation facility, including rehabilitation hospitals and facilities offering comprehensive rehabilitation services.”

State laws ensure that it is much easier for incumbent hospitals and other medical facilities to expand than for new competitors to enter the New Hampshire market. The results are exactly what one would expect. 

Since 1980, New Hampshire’s population has increased by 49.6%. But in that time, only one new acute care hospital, Parkland Medical Center in Derry, has been built, Greg Moore, state director of Americans for Prosperity-NH has pointed out.

The current COVID-induced crunch on hospital capacity has many causes. The media have reported, accurately, that a surge in patients combined with a staffing shortage has put severe strain on the system. 

But that system entered the COVID-19 pandemic with a capacity already artificially constrained by anti-competitive state laws. Going forward, politicians who insist that New Hampshire needs to improve its hospital bed capacity can start by removing unnecessary barriers that make it extremely difficult for new competitors to enter the New Hampshire market. 

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New Hampshire ranks first in freedom in new Cato report

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A week after New Hampshire placed first in the Fraser Institute’s Economic Freedom in North America report, the state scored a first place finish in another prestigious freedom ranking, the Cato Institute’s 2021 Freedom in the 50 States report. 

In Cato’s report (written by Will Ruger and Jason Sorens), New Hampshire ranked third in economic freedom, second in personal freedom, and first in overall freedom. 

In economic freedom, New Hampshire ranked in the top five in state tax burden, government consumption and lawsuit freedom, but was far behind in numerous other metrics, including local tax burden (43), land use freedom (40), labor market freedom (27), health insurance freedom (19), cable and telecommunications freedom (20), and state and local assets (43).

In overall regulatory freedom, New Hampshire placed near the middle of the states at 23rd, showing that the “Live free or die” state has areas where government imposes significant economic constraints on citizens. 

In personal freedom, New Hampshire performed better than in economic freedom, ranking second in gun rights, fifth in education freedom, and fourth in asset forfeiture. The state finished in the top ten in travel freedom, mala prohibita (acts that are crimes in statute but not common law, such as firework and raw milk bans), and incarcerations and arrests for victimless crimes. 

Low rankings in personal freedom included gambling freedom (41), tobacco freedom (21), alcohol freedom (38), and campaign finance (45). 

As in the Fraser Institute’s Economic Freedom in North America, New Hampshire holds its top ranking by a narrow margin. 

The top five states for overall freedom:

  1. New Hampshire
  2. Florida
  3. Nevada
  4. Tennessee
  5. South Dakota

The difference between New Hampshire’s and Florida’s scores was just four hundredths of a percentage point (0.592 vs 0.552). 

In the Fraser Institute report, New Hampshire held its top place by one one-hundredth of a point (7.83 vs. 7.82). 

The top fives states for economic freedom in Fraser’s rankings:

  1. New Hampshire
  2. Tennessee
  3. Florida
  4. Texas
  5. Virginia

The Cato report shows how rapidly other states have been gaining on New Hampshire. Since Cato’s last ranking for 2018-19, New Hampshire ranked No. 8 for growth in overall freedom, but many of the states with which it now competes for population growth and business location posted similar or larger gains. 

Tennessee and North Carolina ranked 11th and 13th in overall freedom growth since the last report, while Kentucky ranked sixth, Connecticut fifth, Michigan fourth, Florida second and South Dakota first. 

The data are more concerning for New Hampshire when looking back at the last 20 years. Since 2000, the top fives states for freedom growth were:

  1. Florida
  2. Michigan
  3. Wisconsin
  4. Oklahoma
  5. Georgia

New Hampshire ranked 29th, well behind states that have been aggressively cutting taxes and deregulating, such as North Carolina, West Virginia, Tennessee, Texas and Arizona. 

As a state that already ranked high on overall freedom, New Hampshire has set an example with policies that have been copied by other states. But as both reports show, there are areas where New Hampshire can make significant improvements to increase personal and economic freedom. 

Making those improvements would accomplish the primary goal of maximizing individual autonomy for Granite Staters, thus living up to New Hampshire’s promise of being the “Live free or die” state. It also would improve the conditions for economic growth, which would gradually raise New Hampshire’s standard of living. 

While these back-to-back reports give Granite Staters cause to boast about our relatively high level of economic and personal freedom, they also offer a warning that this position is threatened and will not be maintained without a continued effort to remove barriers to freedom that exist at the state and local levels. 

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During COVID, student performance has been worse in districts that spent more time online

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School districts that offered less in-person instruction last year saw fewer students pass end-of-year standardized tests, a new academic study of student performance in 12 states has found. 

Pass rates declined across the board compared to prior years, but “these declines were larger in districts with less in-person instruction,” conclude researchers from Brown University, M.I.T., and the University of Nebraska at Lincoln. 

During the 2020-21 school year, passing rates in math declined by 14.2 percentage points on average, and passing rates in English Language Arts declined by 6.3 percentage points on average, in the 12 studied states (which included Massachusetts, but not New Hampshire).

However, “offering full in-person instruction rather than fully hybrid or virtual instruction reduces test score losses in math by 10.1 percentage points (on the base of 14.2 percentage points). In ELA, the loss is reduced in fully in-person settings by 3.2 percentage points.”

Moreover, academic losses in English Language Arts were more pronounced in districts with larger populations of minority students.

“Specifically, among districts with a larger share of Black and Hispanic students, districts with less in-person schooling saw a greater decline in ELA test scores than those with more in-person schooling. Although the impact of schooling mode on ELA is fairly small for districts which are majority white, it is large for those districts with a majority of students of color. Meanwhile, the impact of access to in-person learning had a similar effect on math scores for all districts, regardless of their racial composition.”

The results support the conclusion that in-person instruction produces larger learning gains, on average, than hybrid and remote instruction, the authors write.

“…our analyses demonstrate that virtual or distanced schooling modes cannot support student learning in the same way as in-person schooling. As such, educational impacts of schooling mode on students’ learning outcomes should be a critical factor in policy responses to future pandemics or other large-scale schooling disruptions,” they conclude.

The authors are Emily Oster and Clare Halloran of Brown University, James Okun of M.I.T., and Rebecca jack of the University of Nebraska at Lincoln.

The study is not the first to find that remote and hybrid instruction produced large drops in academic performance. 

One from the Netherlands in April found that “students made little or no progress while learning from home.”

A meta-analysis this fall of 11 studies of COVID-related school closures on student performance found “a negative effect of school closures on student achievement, specifically in younger students and students from families with low socioeconomic status.”

These findings suggest that school closures probably were a significant factor in the drop in student test scores in New Hampshire last year. New Hampshire scores in math and reading dropped by percentages similar to those in other states. 

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New Hampshire again rated most economically free state, but the gap is closing

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New Hampshire has once again retained its status as the most economically-free state in North America in this year’s Economic Freedom in North America report published by the Fraser Institute, an independent, non-partisan Canadian public policy think tank.

In both the continental and in-country rankings, New Hampshire finished first. Within the United States, Tennessee leapt past Florida to pull within a fraction of a point of the Granite State, showing how vulnerable New Hampshire’s position has become.

New Hampshire scored 7.83 out of 10 in this year’s report (down from 7.84 last year), beating out second-place Tennessee (7.82).

Economic freedom — the ability of individuals to make their own economic decisions about what to buy, where to work and whether to start a business — is fundamental to prosperity.

“When governments allow markets to decide what’s produced, how it’s produced and how much is produced, citizens enjoy greater levels of economic freedom,” said Fred McMahon, the Dr. Michael A. Walker Research Chair in Economic Freedom at the Fraser Institute and co-author of this year’s Economic Freedom of North America report, which measures government spending, taxation and labor market restrictions using data from 2019, the latest year of available comparable data.

“New Hampshire ranks as the freest state in the union again this year, but just barely,” Josiah Bartlett Center for Public Policy President Andrew Cline said. “As other states aggressively liberalize their economies, New Hampshire risks falling behind.”

Tennessee, ranked the 5th most economically free U.S. state in last year’s report, shot to within one one-hundredth of a point of tying New Hampshire for first place this year, Cline pointed out. The rankings are based on 2019 data. Tennessee’s interest and dividends tax was eliminated on Jan. 1 of this year, which will give it an advantage over New Hampshire in upcoming rankings, as our I&D tax lingers for five years until fully phased out.

Though New Hampshire leads all of its New England neighbors in economic freedom, Southern states are catching up by cutting taxes, spending and regulations. Rounding out the top five freest states are Florida (3rd), Texas (4th) and Virginia (5th).

At the other end of the index, New York (50th) is once again the least-free state followed by California (49th), Vermont (48th), West Virginia (47th) and New Mexico (46th). New York ranked last in the report for the seventh year in a row.

The other New England states are ranked as follows: Massachusetts (19th), Connecticut (21st), Rhode Island (41st), Maine (43rd), and Vermont (48th).

Across North America, the least-free quartile of jurisdictions had an average per- capita income 1.0 percent below the national average compared to 7.5 percent above the national average for the most-free quartile.

“Hundreds of independent studies have produced overwhelming evidence that higher levels of economic freedom are associated with more opportunity, more prosperity, greater economic growth, more investment and more jobs,” said Dean Stansel, report co-author and economist at Southern Methodist University.

The report measures the ability of individuals to act in the economic sphere free of undue restrictions by ranking states on 10 variables in three areas: 1. Government Spending; 2. Taxes; and 3. Labor Market Regulation.

The Economic Freedom of North America report (also co-authored by José Torra, the head of research at the Mexico City-based Caminos de la Libertad) is an offshoot of the Fraser Institute’s Economic Freedom of the World index, the result of more than a quarter century of work by more than 60 scholars, including three Nobel laureates.

Detailed tables for each country and subnational jurisdiction can be found at www.fraserinstitute.org.

Or you can read the full report here: EFNA-2021-US-POST

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