New Hampshire occupies a singular position in American disability policy — it is the only state in the country to have closed all of its state psychiatric hospitals, converting entirely to a community-based mental health service model following decades of litigation and advocacy. The State Community Integration Index (SCII) evaluates New Hampshire across six domains measuring genuine Olmstead compliance, HCBS infrastructure depth, and the civil and economic rights of disabled residents. New Hampshire’s 2026 profile reflects a state that made the most radical structural commitment to community integration in the nation’s history, while simultaneously confronting the limitations of what happens when deinstitutionalization outpaces community service capacity — producing emergency department overcrowding, boarding, and a mental health system under structural strain.
SCII Scorecard
| SCII Composite Score | 67 |
| Judicial Posture Modifier | +2 (Protected — First Circuit) |
| Adjusted Final Score | 69 |
| Tier Classification | Tier 2 — Progressing |
| National Rank | #12 of 50 |
| Trajectory | Advancing |
Domain Scores
| Domain | Available | New Hampshire |
|---|---|---|
| Domain 1: Institutional Population Burden | 20 | 17 |
| Domain 2: HCBS Infrastructure | 20 | 14 |
| Domain 3: Olmstead Compliance & Legal Posture | 15 | 12 |
| Domain 4: Criminal Justice Diversion | 15 | 9 |
| Domain 5: Housing & Economic Self-Determination | 15 | 9 |
| Domain 6: Voice, Oversight & Civil Rights | 15 | 6 |
| Composite Total | 100 | 67 |
Critical Population Counts
| Population | Estimated Count |
|---|---|
| Nursing facility residents under 65 | ~1,800 |
| State psychiatric hospital beds | 0 (no state psychiatric hospital) |
| ICF/IID residents | ~420 |
| Incarcerated with disabilities | ~2,900+ |
| Unhoused with disabilities | ~2,400 (est.) |
| DD waiver waitlist | ~520 |
Three Strengths
1. No State Psychiatric Hospital — Unique National Achievement. New Hampshire closed its last state psychiatric hospital (New Hampshire Hospital’s inpatient wing) following the landmark Garrity v. Gallen litigation and its long-running successor proceedings. New Hampshire is the only state in the nation to have made this structural commitment, funding instead a network of community mental health centers, crisis stabilization units, and peer-supported respite programs (Disability Rights Center-NH, 2024).
2. Developmental Disability Services — Regional Support Networks. New Hampshire’s developmental disability services are delivered through a network of Regional Support Networks (formerly Area Agencies), locally governed organizations that coordinate HCBS waiver services, employment supports, and residential options for individuals with intellectual and developmental disabilities. This governance structure provides local accountability and flexibility (Bureau of Developmental Services, 2024).
3. First Circuit Judicial Posture — Protected. New Hampshire falls within the First Circuit’s jurisdiction, which has maintained favorable precedent on integration mandate enforcement. The First Circuit’s rulings in cases arising from Massachusetts and Maine have supported private plaintiff enforcement of Olmstead rights, providing a judicial backstop for integration advocates in New Hampshire (Disability Rights Center-NH, 2024).
Three Critical Gaps
1. Emergency Department Boarding — Mental Health Crisis. The absence of inpatient psychiatric beds has contributed to New Hampshire’s documented emergency department boarding crisis, in which individuals experiencing psychiatric emergencies wait in ED bays for days or weeks because no appropriate community placement is available. A 2021 court ruling found that the state was violating the rights of individuals boarded in emergency departments, and the state has been under judicial oversight for its ED boarding practices (Disability Rights Center-NH, 2023).
2. DD Waiver Waitlist — 500+ Individuals. Despite New Hampshire’s overall HCBS orientation, its DD waiver waitlist has persisted at approximately 500 individuals, with average wait times of several years. The waitlist disproportionately affects individuals who are aging out of the school system and entering adult services without a smooth transition to community supports (Bureau of Developmental Services, 2024).
3. Housing Affordability — New England Cost Pressure. New Hampshire’s housing market has experienced the same cost pressures as the broader New England region, with rents in the Manchester and Nashua markets far exceeding SSI income. The absence of New Hampshire’s own state supplement to SSI (New Hampshire has no state supplement) compounds the housing access problem for disabled residents in transition (National Low Income Housing Coalition, 2024).
Key Insight
New Hampshire’s story is the most instructive in the SCII: it made the most radical structural commitment to community integration of any state, and the result is both a genuine achievement (lowest institutional population burden in the SCII) and a cautionary tale about what happens when the institutional alternative is removed before the community alternative is fully built. New Hampshire’s #12 ranking reflects the gap between structural commitment and operational completeness.
References
[1] Disability Rights Center-NH. (2024). Annual report 2024: Mental health system monitoring and enforcement. https://drcnh.org/
[2] New Hampshire Bureau of Developmental Services. (2024). Regional support network performance report FY 2024. https://www.dhhs.nh.gov/
[3] Disability Rights Center-NH. (2023). Emergency department boarding: 2023 monitoring report. https://drcnh.org/
[4] National Low Income Housing Coalition. (2024). Out of reach 2024: New Hampshire. https://nlihc.org/oor/
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