All Sections

Home | State House Dome

Dave Solomon's State House Dome: Medicaid expansion's uncertain future

August 05. 2017 9:41PM

WITH A TWO-YEAR budget in place, the fate of Medicaid expansion in New Hampshire is likely to be the biggest policy issue facing the Legislature in 2018, and like everything else surrounding health care, it's shrouded in uncertainty and confusion.

The future of this federally funded health insurance program for low-income populations is a big deal in New Hampshire, with implications for the entire population, not just the 50,000 who were added to the rolls when the program was expanded to embrace more people in 2014.

Hospitals and other health care providers are big employers in New Hampshire and, for better or worse, have come to rely on the fact that an extra 50,000 people have health insurance, which means fewer people turning up in their emergency rooms without the ability to pay.

On top of that, the additional coverage has enabled thousands of people ensnared in the state's opioid epidemic to obtain treatment and recovery services.

With the advent of Obamacare in 2014, one way to ensure that more people had health insurance was to expand Medcaid qualifications to embrace more of the population. In New Hampshire, that meant low-income, able-bodied adults with no other qualifying factors could start to qualify for government-funded health insurance, and 50,000 did so.

The health care industry in the state is so invested in the program that hospitals, for the most part, pay the non-federal share through an opaque program administered by an affiliate of the New Hampshire Hospital Association.

Terminating Medicaid expansion would send shock waves through the health care and recovery community in the state, not to mention the 50,000 people who would once again find themselves without health insurance. That possibility looms large as of Dec. 31, 2018, when the current authorization for the expansion in New Hampshire expires.

Here are some of the issues that will have to be settled:

Work requirement: When Medicaid expansion was approved for 2016-17, the state requested a waiver from federal rules to impose a 30-hour work requirement on any able-bodied adults in the program. The waiver was denied, but the program continued anyway.

The recently approved state budget includes a measure that requires the state to request the waiver again. This time, if the work requirement is denied, the state could end its form of Medicaid expansion, known as the New Hampshire Health Protection Program.

Non-federal share: While the federal government paid 100 percent of the cost of Medicaid expansion for 2014 through 2016, the share fell to 95 percent in 2017. It will drop to 94 percent in 2018, 93 percent in 2019, and levels off at 90 percent for 2020 and beyond.

Will the hospitals continue to pick up the state's share as it doubles from what they are paying today? No one can say for sure.

Political calculations: The vote in March 2016 to continue the program for another two years was 16-8 in the Senate, with all 10 Democrats and six Republicans voting in favor. With all 10 Democrats likely to vote for expansion in 2018, at least three Republican votes will be needed.

Only two of the six Republicans who voted in favor of expansion in 2016 are still in the Senate for 2018 - Majority Leader Jeb Bradley, R-Wolfeboro and Senate President Chuck Morse, R-Salem. Gone are moderates David Boutin, Sam Cataldo, Gerry Little and Nancy Stiles.

"What we lost from the last Senate to the current one is Republicans that we could sit down with and work out problems with," says Minority Leader Jeff Woodburn, D-Whitefield. "We now have a group that's less inclined to compromise."

Future of the marketplace: New Hampshire is one of only two states - the other being Arkansas - that sends its expanded Medicaid population to the online Obamacare marketplace at to buy health insurance, with Medicaid paying the premiums.

If the online exchange collapses, a possibility according to Insurance Commissioner Roger Sevigny, the program will have to be discontinued, or the state will have to find another way to have it administered.

Then there's the fate of Medicaid expansion as a component of Obamacare. The Affordable Care Act remains the law of the land, and Medicaid expansion along with it, at least for now. Should Congress revive its repeal efforts, all bets are off.

Like the President said, "Nobody knew health care could be so complicated."

Health Politics State House Dome State Government

More Headlines