Medicaid Expansion

Citizens Count Editor

In 2010 President Barack Obama signed into law the Patient Protection and Affordable Care Act, also called “Obamacare.”  Part of that law allows states to expand eligibility for Medicaid, a program that gives states federal dollars to cover much of the cost of providing health insurance to low income individuals and individuals with disabilities.

Medicaid is a government-run health insurance program intended to help low income individuals, senior citizens, and individuals with disabilities pay for health care.  There are different types of Medicaid rules for who is eligible depending on income, age, and disability. 

Use the NH EASY gateway to find out if you're eligible for Medicaid in New Hampshire

New Hampshire’s expanded Medicaid program is called the Granite Advantage Health Care Program (formerly the New Hampshire Health Protection Program). 

Eligibility for expanded Medicaid in NH

Granite Advantage allows adults earning up to 138% of the federal poverty level to get coverage through one of the state's Medicaid managed care plans - New Hampshire Healthy Families or Well Sense Health Plan. In 2019, an individual earning up to $1,346 a month or a family of four earning up to $2,782 would be eligible for expanded Medicaid.

The program does have a work or community engagement requirement, which is currently scheduled to go into effect September 30, 2019. Every month, participants must complete 100 or more hours of a "qualifying activity". These include paid work, job search, education or job training, community service, or substance abuse treatment. Parents who take care of children under age thirteen, pregnant women, disabled or medically frail individuals, or people enrolled in a state-approved drug court program are exempt from the work requirement. Get more details about the work requirement.

At the end of January 2019, about 52,000 New Hampshire residents had insurance through Granite Advantage. In comparison, about 129,000 residents were enrolled in standard Medicaid. 

Learn more about eligibility or apply for expanded Medicaid

A unique approach to expanded Medicaid

After almost a year of negotiations, New Hampshire passed SB 413 to expand Medicaid eligibility in New Hampshire starting July 1, 2014. 

Rather than simply allowing more individuals to enroll in standard Medicaid, New Hampshire’s program — the New Hampshire Health Protection Program — subsidized private insurance for low income individuals.  A combination of federal and state money covered the cost of premiums, but enrollees were responsible for copays. 

Most other states that expanded Medicaid eligibility under the Affordable Care Act simply expanded their standard Medicaid rolls.  Only five other states — Arkansas, Indiana, Iowa, Michigan, and Montana — created a special expanded Medicaid program, like New Hampshire’s.

The New Hampshire Health Protection Program ran through to the end of 2018. At that point, it was replaced by the Granite Advantage program, which dropped the private insurance factor and instead covered participants through one of the state's standard Medicaid plans.

Funding for expanded Medicaid in NH

Under the Affordable Care Act, the federal government covered 100% of the costs for expanded Medicaid eligibility through 2016.  That reimbursement now decreases over time, dropping to 90% in 2020, where it is set to hold.

New Hampshire draws on a number of different funding sources to pay its share of expanded Medicaid costs. These include:

  • Taxes on insurance premiums paid for customers who are enrolled in the program;
  • A portion of liquor commission profits (these are designated to pay for substance abuse treatment or behavioral health services); 
  • Fees paid by health insurance companies (these are based on the number of expanded Medicaid enrollees who would have previously been considered part of the state's high-risk pool);
  • Additional gifts or donations.

The state is not permitted to use any general tax dollars to fund the program. If other funding sources don't raise enough cash, the program is to be terminated. 

New Hampshire's share of expanded Medicaid costs is projected to be somewhere between $35 and $39 million per year. 

Challenges for expanded Medicaid in NH

Objections to funding sources

When expanded Medicaid was re-authorized in 2016 for an additional two years, legislators had to think of ways to cover the costs. One way they did that was through inviting hospitals and healthcare providers to make voluntary donations to the program. Health providers were willing to do this because expanding Medicaid eligibility reduced the number of uninsured people seeking uncompensated care at their facilities. Donating to keep the program running was cheaper than paying the bill for that extra uncompensated care.

In August 2017 the Centers for Medicare and Medicaid Services published a letter to New Hampshire officials stating that it is against federal law to use voluntary provider donations to fund a Medicaid program. 

Federal law specifically outlaws any relationship between a donation from a health care provider and payments that provider receives from Medicaid. Without this law, it would be possible for providers to more or less get “kickbacks” of federal Medicaid dollars in exchange for making private donations.

According to the New Hampshire Department of Health and Human Services, there was no relationship between how much a provider donated and how much that provider got in Medicaid payments. The donations were managed by a charitable foundation, and so state officials had no knowledge of which hospitals donated or how much they donated. The Centers for Medicare and Medicaid Services said there was a relationship because state law required New Hampshire to terminate its expanded Medicaid program if providers did not donate enough money to cover costs.

The federal government ordered the New Hampshire legislators to devise a new way to fund expanded Medicaid if the state continued the program past December 31, 2018. The bill that extended expanded Medicaid past that deadline — SB 313 (2018) — used a different mix of funding sources and removed the specific provisions for voluntary hospital and provider donations, though the fund is still open to accepting general "gifts, grants and donations".  

Work requirements

When the New Hampshire Legislature reauthorized expanded Medicaid in 2016, they included a requirement for participants to work or attend school at least 20 hours per week.  The Obama administration rejected these work requirements. 

However, a second round of extending the life of expanded Medicaid in 2018 resulted in a new work requirement. With a different administration in Washington, the requirement was approved. 

Supporters argue that work requirements ensure the state is not providing welfare to able-bodied adults who should be able to support themselves.

Opponents argue that most participants in expanded Medicaid are already working or seeking work, and the requirements just add burdensome and expensive bureaucracy.

Other changes at the federal level

Despite several attempts, thus far Congress has not passed a bill to revise the Affordable Care Act. However, Republicans still want to try to change Medicaid into a block grant program. 

Under a block grant program, each state would get a set amount of money for Medicaid from the federal government.  Each state could decide how to spend that money, including who would be eligible for Medicaid benefits. This is different than the current system, which gives states only some flexibility to manage Medicaid, and matches state spending on Medicaid no matter what the final dollar amount is.

A block grant would probably decrease federal Medicaid funding overall in New Hampshire.  So far legislators have opposed drawing on any more New Hampshire tax dollars to fund Medicaid, so a federal block grant might mean the end of expanded Medicaid eligibility in the Granite State.

PROS & CONS

"For" Position

By Citizens Count Editor

“New Hampshire was right to expand Medicaid eligibility, using private insurance wherever possible.”

  • Expanded Medicaid eligibility covers the many individuals who are not poor enough to qualify for standard Medicaid but who cannot afford private insurance.  If New Hampshire ends its expanded Medicaid program, those roughly 50,000 citizens would be left without an affordable option for health insurance and without the money to pay for care out of pocket. It is unethical to deprive low income residents of access to affordable health care. 
  • Thus far New Hampshire has been able to fund Medicaid expansion without raising any taxes.
  • At the end of 2017, roughly 4,000 New Hampshire residents per month had paid for drug addiction treatment through expanded Medicaid. In the middle of a drug addiction crisis, it is critical that New Hampshire continues the program to ensure that residents have access to these treatment services.
  • According to a 2017 literature review in the New England Journal of Medicine, “coverage expansions significantly increase patients’ access to care and use of preventive care, primary care, chronic illness treatment, medications, and surgery. These increases appear to produce significant, multifaceted, and nuanced benefits to health.” The same report concluded that these positive health outcomes will ultimately save taxpayers money in the long run by lowering the costs to treat unhealthy citizens without insurance.

"Against" Position

By Citizens Count Editor

“New Hampshire was wrong to expand Medicaid eligibility, using private insurance wherever possible.”

  • So far the Legislature has been able to fund expanded Medicaid without raising any taxes. But it is possible that in the future, the federal government will make some changes to federal funding for expanded Medicaid, leaving states with a bigger price tag for the program. Even if the Affordable Care Act stays in place, federal funding for expanded Medicaid will decrease in the next few years.  All of these factors suggest lawmakers will need more money from taxpayers to fund expanded Medicaid eligibility in the coming years.
  • While studies may show that increased insurance coverage leads to increased access to care, that increased access comes with a price tag. For example, a landmark study from academics at Harvard and MIT found that expanded Medicaid programs are likely to increase emergency room visits, which are very expensive. Advocates of expanded Medicaid argue that over time participants will get healthier, leading to fewer hospital visits. However, these expanded Medicaid programs are still too young to conclude if participants will go to the doctor less frequently over time.  It is possible that access to cheap care will even enable participants to go to the hospital when they do not really need to.
  • The health costs for Medicaid expansion enrollees are higher than costs for other individuals who purchase health insurance. This may be because expanded Medicaid patients have very low copays. Those low copays might entice Medicaid expansion patients to visit the doctor more frequently than they really need to.
  • The all-or-nothing structure of eligibility for expanded Medicaid may actually incentivize some participants to keep their incomes low in order to avoid crossing the threshold where they would lose their coverage. This keeps people trapped in a cycle of dependency instead of empowering them to become more self-sufficient. 

LEGISLATIVE HISTORY

Killed in the Senate

Establishes a commission to study the benefits and cost of a "health care for all" program for New Hampshire.

Killed in the House

Establishes a commission to examine the feasibility of the New England states entering into a compact for a single payer health care program.

Passed House

Adds provisions of the federal Affordable Care Act to state law, such as mandatory coverage for preexisting conditions and the 10 "essential health benefits" insurers must cover.

Killed in the House

Requires health care practitioners and facilities to provide services for patients funded by Medicaid and uninsured persons, or pay a $10,000 annual fee per practitioner or full-time staff. The revenue from those fees would go to aid to people without insurance or enrolled in Medicaid.

Passed House and Senate

Adds provisions of the federal Affordable Care Act to state law, such as mandatory coverage for preexisting conditions and the 10 "essential health benefits" insurers must cover.

In Committee

Repeals the work and community engagement requirements for the Granite Advantage Health Care Program, commonly known as expanded Medicaid.

Killed in the House

Establishes a single payer health care system to provide health care for the citizens of New Hampshire.

Signed by Governor

Modifies the work and community engagement requirements for the Granite Advantage Health Care Program, commonly known as expanded Medicaid. For example, this bill extends the work requirement exemption for parents so that parents of children under age 13 are eligible for the exemption. This bill also gives the Department of Health and Human Services the authority to waive the work requirement until July 2021 if there is an inability to communicate with program participants.

Passed Senate

Requires the state to reimburse health care centers for services provided to a person whose Medicaid eligibility has been suspended for failing to comply with work requirements under the expanded Medicaid program.

Tabled in the Senate

Directs the Department of Health and Human Services (DHHS) to increase Medicaid provider rates by 5% in 2020 and 7% in 2021. Additionally, the bill clarifies the definitions and coverage of telemedicine under Medicaid. This bill also requires health care professionals to complete a survey or an opt out form collecting data on the primary care workforce. This bill then sets aside about $21 million for various programs and scholarships to improve care and access to care in rural and underserved areas of this state, and to enhance the health workforce in New Hampshire. The bill also requires the Department of Safety to accept and process background check applications online.

Killed in the House

Changes the notification deadline if federal funding for expanded Medicaid falls below a certain level, from "immediately" to "on or before June 15, 2018."

Interim Study

Extends New Hampshire's expanded Medicaid program; requires work requirements for expanded Medicaid to match those for Temporary Assistance for Needy Families; requires the Department of Health and Human Services to establish a procedure to handle "medically complex" enrollees in expanded Medicaid; eliminates the voluntary hospital donations to fund expanded Medicaid; and allows state general funds to be spent on expanded Medicaid.

Killed in the House

Requires the Department of Health and Human Services to seek a federal waiver reducing eligibility for expanded Medicaid coverage from 138% to 100% of the federal poverty level.

Interim Study

Requires insurance policies issued under New Hampshire's expanded Medicaid program to be kept in a separate pool from private individual health insurance policies. According to the Insurance Department, it is likely that this would result in higher premiums for expanded Medicaid participants - which are paid for by the state - and lower premiums for individuals who buy insurance on the Health Insurance Marketplace.

Signed by Governor

Continues New Hampshire's expanded Medicaid program. This bill makes several significant changes to the program. First, it moves participants off private insurance and into managed care, similar to traditional Medicaid enrollees. Second, it adds a work requirement for participants. Third, it removes funding from voluntary contributions by health care providers, which the federal government said is illegal. Instead, bill sponsors say the program will use revenue from alcohol sales to fund the program.  SB 313 also establishes the Granite Workforce program, which will use some federal welfare funding to establish a program that will help place low income individuals in jobs in areas with workforce shortages.  

Killed in the House

Repeals New Hampshire's expanded Medicaid program, called the New Hampshire Health Protection Program (NHHPP).

Tabled in the Senate

Continues expanded Medicaid eligibility, which would otherwise expire December 31, 2018.

Tabled in the Senate

Reauthorizes expanded Medicaid eligibility and pays for the program with insurance taxes and money from the Medicaid Enhancement Tax (MET) paid by hospitals.

Killed in the House

Continues expanded Medicaid eligibility, which would otherwise expire December 31, 2016.

Signed by Governor

Continues expanded Medicaid eligibility, with some revisions. This bill adds work requirements to eligibility for expanded Medicaid. Additional funding is provided by the insurance premium tax, paid by insurance companies.

Killed in the Senate

Requires the joint health care reform oversight committee - which was formed to oversee the implementation of the Affordable Care Act in NH - to provide oversight, policy direction, and recommendations for legislation regarding implementation of managed care and expanded Medicaid eligibility.

Killed in the House

Establishes a single payer health care system to provide health care for the citizens of New Hampshire. The Department of Administrative Service states the bill would provide universal access to health care for all New Hampshire residents and prohibits private health insurance companies from selling health care coverage.

Tabled in the Senate

Renews the expansion of Medicaid eligibility, set to expire December 31, 2016.

Signed by Governor

Expands Medicaid eligibility, using private insurance wherever possible.

Interim Study

Requires hospitals to charge self-pay patients no more than the Medicaid rate for medical services.

Killed in the House

Forbids NH from expanding Medicaid eligibility under the federal Affordable Care Act.

Was New Hampshire right to continue expanded Medicaid eligibility, using the traditional Medicaid system of managed care instead of private insurance?

FOR
REPRESENTATIVES

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Issue Status

The launch of NH's new work requirement for Medicaid expansion enrollees has been suspended through September to give DHHS more time to reach patients and tell them about the new rules. A bill passed this year gives DHHS the power to waive the requirement for up to two years if they can't get in touch with the participants.

NH is also being sued over its approval of work requirements for Medicaid expansion. The same lawsuit already challenged requirements in Kentucky and Arkansas. 

 

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