Brought to you in part by: Dartmouth-Hitchcock

Sometimes, even thoughtful planning for the end of one's life can't foresee all the possible outcomes.

That was certainly the case for Reverend Canon Randy Dales of Wolfeboro, and his father-in-law. Canon Dales is a vocal advocate for the use of advance directives to maintain dignity in death, with his position formed by four decades of ministry and 30 years of work in a hospice he co-founded.

We continue our series on advance directives in New Hampshire with this audio postcard.

Other Stories In Our Series

Todd Bookman / NHPR

This week, we’ve been looking at end-of-life planning in the Granite State, and some efforts to streamline and increase the use of  advance directives--the legal documents that let people name who can make medical decisions for them and what treatments should be avoided to preserve dignity. We continue our series with this look at what can happen when there is no plan in place, forcing the medical system to turn to the legal system for answers.

Dr. Tim Lahey prefers to spend his days in hospitals and clinics, not courtrooms.

Todd Bookman / NHPR

A survey from the National Hospice Foundation finds that Americans are more comfortable talking to their kids about sex than they are talking to their elderly parents about death. End-of-life remains simply a taboo subject in many households. But these important conversations are necessary to create the living wills that can help keep dignity in dying. We continue our 3-part series on advance directives with this look at efforts around the state to get more people talking, and planning, for their end-of-life.

Sara Plourde / NHPR

The terms used in advance directive forms can be tough to understand and have the possibility for misinterpretation, given that their specific legal definitions can sometimes clash with common usage. Understanding the terms on the forms is vital to creating an advance directive that is properly representative of one's wishes.

As part of his series looking at the issues and changes around advance directives in New Hampshire, NHPR's health reporter Todd Bookman explains the following terms as they relate to end-of-life planning:

Todd Bookman / NHPR

New Hampshire’s advance directive form got an update Monday. Governor Hassan signed a bill that seeks to streamline and simplify the document.

A group of developmentally disabled residents is taking the state to court over a proposed plan to transition coordination of their treatment to private companies.

The complaint was filed just a day after the Department of Health and Human Services announced the state will officially launch Medicaid Managed Care on December 1st. Under the managed care model, three companies will effectively take over administration and coordination of medical services for Medicaid recipients.

U.S. Attorney's Office


David Kwiatkowski entered the federal courtroom in shackles, wearing a Strafford County Department of Corrections jumpsuit. The 34-year defendant looked heavier than last July, when he was arrested on 14 federal charges, including tampering with a consumer product and obtaining a controlled substance by fraud.

When asked by the judge why he changed his plea, the clean shaven Kwiatkowski said, “Because I’m guilty.”

Medicaid Managed Care is a go.

That’s the message from the Department of Health and Human Services, after the three managed care organizations were able to show their provider networks can meet the needs of the state’s Medicaid patients.

Commissioner Nick Toumpas says managed care will go live Dec. 1.

That will be the first day of coverage of the state’s 130,000 Medicaid patients, who will now have to choose between the three managed care vendors.

The state approved a $2.2 billion contract for managed care last summer, the largest contract in state history.

A former hospital employee charged with spreading Hepatitis C in New Hampshire and seven other states is pleading guilty to federal charges.  

34-year old David Kwiatkowski was arrested last July for stealing syringes filled with fentanyl, a powerful pain medication. Officials say he would inject himself and then reuse the needles on patients inside Exeter Hospital, infecting at least 32 people with Hepatitis C.

Facing 14 federal charges including tampering with a consumer product and illegally obtaining controlled substances, Kwiatkowski is changing his plea to guilty. 

If you’ve got health insurance, you know it can be hard to get a routine doctor’s appointment.

Representative Neal Kurk (R-Weare), who sits on the commission studying a possible Medicaid expansion, worries it could get harder.

“As a public official, will I start getting calls from my constituents saying, I had to wait another seven weeks for my doctor’s appointment? My operation took much longer on the left hip that it did on the right hip,” says Kurk.

The commission tasked with deciding if New Hampshire should expand its Medicaid program heard from a panel of experts Tuesday.

Speakers from the National Conference of State Legislatures and National Governors Association were in Concord to discuss options for Medicaid expansion, and to detail what other states are pursuing.

NHPR Health reporter Todd Bookman sits down with All Things Considered Host Brady Carlson to recap the hearing.


The state’s University System says it saved $10 million last year by switching how it provides health insurance for employees.

Rather than paying an insurance company a fixed amount per employee for health coverage, the University System now uses a self-insured plan, where it pays out of pocket as health bills come in.

Self-insured plans put more risk on the employer, but Todd Leach, Chancellor of the University Stem, says the model made economic sense for his institution.

After a $0.10 cut two years ago, smokers in New Hampshire will again pay an extra dime in tobacco taxes starting today. 

Republicans in the statehouse lowered the tobacco tax in 2011, saying the cut would spur cross-border sales and boost state revenues. But tax receipts have come in $56 million lower in the past two years than the prior biennium.

Lawmakers included an automatic trigger to reset the tax if revenues fell, so today, the tax goes back up to $1.78 per pack.

Todd Bookman / NHPR

The New Hampshire Insurance Department took an overwhelmingly positive view on expansion during its presentation to the Medicaid Expansion Study Commission, the body that will decide if the state grows the health care program for the poor under so-called Obamacare.

Department officials told the nine-member body that expansion would benefit a wide range of groups, including insurance companies, hospitals and employers with low-paid workers.

Tyler Brannen, a health policy analyst with the Department, testified that people who buy their own insurance also stand to gain.

Todd Bookman / NHPR

    Infants who suffer from malnutrition are more likely to have poorer physical health when they grow up.

Research also finds more emotional problems, including anxiety and attention deficit disorder.

But even as the negative long-term impacts of infant malnutrition become clearer to scientists, Dr. Janina Galler is working to push the field of study even further.

When An Emergency Room Closes Its Doors

Jul 22, 2013
Todd Bookman / NHPR

Back in December 2008, with the town of Lyndeborough still frozen from an ice storm, Sue Carita and her husband went to check on a neighbor. Good deed done, they would both slip and fall on the return trip.

“We went home and called our doctors and of course, it was 4:30pm, 5:00pm on a Saturday afternoon, and there was no one there,” she recalls.

In pain, the Caritas sought care at the nearby Milford Medical Center, where x-rays showed she had a broken wrist, her husband a cracked hip.

One key aspect of the federal health overhaul law is a transition away from a fee-for-service system, where hospitals and doctors get paid, for example, per lab test or re-admission. To help test new models under so-called Obamacare, 32 hospitals nationwide launched an alternative system called an Accountable Care Organization (ACO).

Results released today looking at the first year of the program show Dartmouth-Hitchcock as one of 18 hospitals that succeeded in lowering costs compared to a control group of Medicare patients.

Todd Bookman / NHPR

As head of Dartmouth’s mission control center for Medivac flights, Mark Pippy spends a lot of time grappling with New England weather.

“Oh, wait ten minutes: it is going to change,” Pippy jokes. “It is always partly cloudy to partly sunny, with a chance of showers, and there will be darkness. And you got it 100% of the time.”

Pippy has spent the past 19 years dispatching copters from Dartmouth’s Lebanon campus and a unit based in Manchester. Together, they fly around 1,400 calls each year. Now, he’s a got a new GPS tool to help.

Special Medicaid Commission Gets To Work

Jul 8, 2013

A special commission looking into a possible expansion of the state’s Medicaid program met Monday for the first time.

The body consists of nine voting members, including five Democratic appointees and four by Republicans.

They put partisanship aside during the first meeting, unanimously selecting Jim Varnum to chair the group. He was tapped to serve by Governor Hassan after leading Mary Hitchcock Memorial Hospital for nearly three decades.

“I appreciate the opportunity and the confidence you have,” says Varnum. “This is such an important task for all of us.”

Some New Hampshire businesses say they welcome news of a recent delay in a key part of the Affordable Care Act. 

On Tuesday, the Obama Administration announced it is postponing the so-called employer mandate by a year, citing a need for more time to simplify regulations. 

It was this provision that Senator Kelly Ayotte, speaking at the Republican National Convention last summer, offered  as a reason why she thinks Obamacare won’t work.

The final four members have been named to the state's Medicaid Expansion study committee.

Dartmouth-Hitchcock is agreeing to join the Medicaid managed care program.  The state's largest health care system had been a key hold out in the new effort.

A transition from traditional Medicaid to so-called managed care is already a year behind schedule, costing the state an estimated $15 million in expected savings. One problem has been a lack of participation from hospitals. They’ve voiced concerned that the arrangement could pay them less for treating Medicaid patients.

Quirk In Health Law Creates 'Coverage Canyon'

Jun 25, 2013
istock photo

At 60-years old, Wendy Rogers considers herself lucky. She’s healthy, her kids are grown. There’s just one thing that gets her down: health insurance.

“I really don’t let myself think about it, because it overwhelms me.”

Rogers lives in Franklin, in a tidy apartment decorated with framed photos of friends and family. She lost her insurance three years ago, after getting laid off from a local school district  where she was a kindergarten aide. Now she works part time at a child-care center.

Rogers says she relies on family for medical expenses.

State public health officials today released their final report looking into the outbreak of Hepatitis C at Exeter Hospital. The document provides new information into just what took place inside the hospital’s cardiac catheterization lab, where a former employee stands accused of stealing narcotics and returning tainted needles. 

NHPR’s Todd Bookman tells All Things Considered Host Brady Carlson about the important new information in the case.

Medicaid Expansion Left Out Of Next State Budget

Jun 20, 2013
Todd Bookman / NHPR


The heavy lifting on the state’s next two year budget wrapped up a little past 3 a.m. Thursday. So when the two sides gathered less than twelve hours later to make it official, House budget leader Mary Jane Wallner was happy to call it a day.

“That’s it. I think we’re done. We’re adjourned!”

But despite that celebratory flourish, lawmakers are far from done when it comes to Medicaid.

Leaders in the Democratically-controlled New Hampshire House are seeking to cut a deal with Senate Republicans that would expand the state’s Medicaid program.  But hours after receiving the proposal Tuesday, members of the upper chamber said they can’t move forward with the plan, and offered their own course of action.

Medicaid expansion remains a key sticking point as lawmakers seek to finalize the state’s next budget by Thursday’s deadline.

New Hampshire can withdraw from an expanded Medicaid program at any time, according to a letter received Thursday from the Centers for Medicare and Medicaid Services, or CMS.

The letter comes as legislative negotiators are poised to meet to finalize the state’s budget.

A point of impasse between the Democratically-held house and Republican-controlled Senate has been an expansion of the state’s Medicaid program.

Todd Bookman / NHPR

 Women’s health advocates took to the statehouse today, calling for an expansion of the state’s Medicaid program under the Affordable Care Act. The issue remains a sticking point as lawmakers work to finalize the state’s budget.

Planned Parenthood’s Jennifer Frizzell estimates that 61% of those able to sign up for an expanded Medicaid program are women, and she accuses GOP lawmakers of being oblivious to what they want.

Governor Hassan today announced the reopening of 12 psychiatric beds at New Hampshire Hospital. They'll be used to treat adults over the age of 55 in need of both psychiatric help and medical attention, and are meant to shore up a mental health system that the Governor calls deeply strained.

New Hampshire's Health Exchange Monopoly

Jun 10, 2013
via WUKY

It wasn’t exactly a victory lap, but the president was in California last week praising an early success of the Affordable Care Act.

Speaking in San Jose on Friday, Obama touted the California health insurance exchange--one of the new online marketplaces where individuals and small business employers can shop for coverage and apply for subsidies starting October 1.

California's exchange will have 13 companies competing for business and rates far below what experts predicted.