N.H.'s Medicaid Expansion: Where It Stands, and Where It Could Be Heading

Jan 28, 2016

Credit Sara Plourde for NHPR

Discussions over the future of New Hampshire’s Medicaid expansion kick off in earnest this week, setting the stage for one of the biggest policy debates before state lawmakers this year.

The question of whether to reauthorize the expansion, known officially as the New Hampshire Health Protection Program, has loomed over the State House for much of the last year.

A public hearing is scheduled this morning for a mostly Republican-backed proposal to extend the program through 2018, with some new requirements for program recipients and a plan to have health providers cover the state’s share of program costs for the next two years.  

Another proposal, backed by a group of mostly Democrats, would extend the program indefinitely, but doesn’t contemplate how to pay for it without dipping into the state’s general fund. That second proposal doesn’t yet have a hearing date.

Here's an overview of New Hampshire's current expanded Medicaid program, and where things could be heading.

The political context

The expansion first went into effect under a bipartisan compromise plan in 2014 — after months of negotiations and legislative squabbling. But it was only on a temporary basis. Unless lawmakers decide to renew it, the program will end in December.

The program extends Medicaid coverage to adults between ages 19 and 64 who earn less than 138 percent of the Federal Poverty Level. (That's less than $16,243 a year for a one-person household or $33,465 a year for four-person household.)

According to the most recent data from the New Hampshire Department of Health and Human Services, more than 47,000 people were enrolled in the program as of mid-January. Three-quarters of them reported incomes below the federal poverty level, and 57 percent were unemployed.

A major question holding up plans for the Medicaid expansion’s renewal has been how to pay for it starting next year and beyond.

As an incentive to get states to sign onto expanding Medicaid, which is part of the Affordable Care Act, the federal government offered to pay 100 percent of the costs of covering newly enrolled patients through the end of 2016. After that, the federal government will incrementally decrease its share of the funding, leveling off at 90 percent by 2020. 

Gov. Maggie Hassan tried unsuccessfully to get legislators to set aside money for its reauthorization in the latest state budget, but Republicans said they wanted to wait to debate the issue separate from budget negotiations. Since then, Hassan has said repeatedly that she wants to see the program continue.

Senate Majority Leader Jeb Bradley, flanked by lawmakers and other proponents of the Medicaid expansion, outlines plans for an extension of the program through 2018.
Credit Casey McDermott, NHPR

Senate Majority Leader Jeb Bradley, a Republican who was a major force behind negotiating the original Medicaid expansion plan, announced a deal on Wednesday meant to extend the program without requiring the state to pay for it.

Under that plan, the state’s share of the Medicaid expansion costs in 2017 and 2018 would be covered by a combination of revenue from the existing insurance premium tax plus new contributions from hospitals and insurers. The hospitals and insurers would split their share evenly, Bradley said Wednesday.

House Speaker Shawn Jasper, who voted against the current Medicaid expansion plan in 2014, said this week that he plans to support its reauthorization — particularly now that there’s an alternative funding plan.

“We hope that enough members will come to see the wisdom in doing this that the votes will be there,” Jasper said. “As I started saying last January, I would not support expansion that spent state money. This bill does not do that.”

As Jasper sees it, the Medicaid expansion makes good financial sense — alleviating the strain on local welfare offices at a time of dwindling budgets, as well as saving money at the state and county level.

The new expansion proposal would also ask DHHS to incorporate work requirements (for “childless, able-bodied adults”) into its eligibility standards. It also adds a fee for unnecessary emergency room use.

“The proposed modifications of the program are consistent with our New Hampshire values and principles,” Rep. Joseph Lachance, a Republican from Manchester and one of the bill’s sponsors, said Wednesday.

According to the Kaiser Family Foundation, the federal government has told other states (like Pennsylvania) that it wouldn’t approve work requirements as part of their Medicaid expansion plans.

But Bradley’s optimistic that New Hampshire’s approach — which is modeled after the requirements in the Temporary Assistance for Needy Families program — will go through. Plus, Bradley said, the people overseeing these decisions are likely to turn over relatively soon.

“Look, let’s face it: Here we are, less than two weeks from being the political center of the universe. There’s going to be a new president. There’s going to be a new CMS director,” Bradley said. “We will have the chance… to fight for work requirements that are somewhat different than what any other state has asked for.”

Benefits touted, but questions remain

Lawmakers aren’t the only ones rallying around an extension of the Medicaid expansion. Business groups, healthcare providers and substance abuse prevention advocates, among others, have all spoken up about the program’s benefits.

Credit New Hampshire Hospital Association

The New Hampshire Hospital Association has been tracking the program's effects on hospitals for the last year. Hospitals surveyed by the association reported that emergency room visits between October 2014 and September 2015 were down by about 30 percent from the previous year.

Hospital Association President Steve Ahnen, in a statement issued Wednesday, said the organization supports both the reauthorization as a whole and the plan to ask hospitals to kick in some of the costs of continuing it.

“Data collected from the first year of operation clearly shows that fewer uninsured patients are seeking care in hospital emergency departments; patients are getting better care in a more appropriate and loss costly setting; and we are reducing the amount of uncompensated care provided by hospitals to those without insurance,” Ahnen said.

The Business and Industry Association of New Hampshire backs the program, too. A group of 15 business leaders also signed on to a letter this week urging lawmakers to reauthorize the program.

“A healthy workforce is a productive workforce,” the letter reads. “The health of New Hampshire’s residents is tied to the state’s economic prosperity. NHHPP invests in the vitality of our growing workforce, begins to address the ever-increasing costs of coverage for all of us, and stimulates economic development in the Granite State.”

New Futures, a drug and alcohol prevention organization, has also been a vocal proponent. At a press conference Wednesday with other Medicaid expansion proponents, New Futures Director Linda Saunders Paquette called the program “the most important tool New Hampshire has in its fight against the opioid epidemic and more broadly the substance misuse crisis we are facing in our state.”

Saunders Paquette lauded the program for its coverage for substance use disorders and its ability to support the expansion of treatment programs in New Hampshire. About 6,000 people got substance use treatment through the Medicaid expansion program during the first 13 months of the program, she said.

“Failure to reauthorize this program will result in more stories about young people dying from overdoses, more stories about mothers passing out behind the wheel due to heroin use with their toddlers in the backseat, and more stories about our public spaces being littered with needles,” Saunders Paquette said. “To those legislators who do not support reauthorization, what is your plan that people with substance use disorders will be able to access the treatment they need?”

The New Hampshire Municipal Association board of directors voted at its January meeting to support the reauthorization, citing savings in local welfare offices and its benefits in tackling the state’s drug crisis

Even for all of these initial benefits, there are still some unanswered questions and room for further analysis.

Steve Norton, executive director of the New Hampshire Center for Public Policy Studies, said it’s important to keep in mind that the expansion is still relatively new. That makes it hard to measure, for example, whether it’s having any effects on the state’s chronic disease burden.

And while the data so far shows that uncompensated emergency room visits are down, Norton said that only tells part of the story. It will also be important to consider what’s happening to ER usage overall, and what kind of trends hospitals are seeing at a bigger level in terms of uncompensated care.

“Everyone agrees, it’s essentially doing what it was originally intended to do,” Norton said. But there’s still room to dig deeper into what kind of impact it’s really having on the state as a whole.