State facing tough health care issues

Friday afternoon was set aside for the Commissioner of the Department of Health and Human Services to brief the Senate Finance Committee on the key health care issues facing New Hampshire in his proposed budget for the next two years.

After a couple of hours of discussion, it was clear there is a determination by the department, as part of our state’s efforts to reform health care, to implement expansion of the number of people eligible to receive health care benefits under the federal Affordable Care Act or what most call Obamacare. Medicaid is a joint state-federal program, launched in the 1960’s, to provide benefits to indigent residents.

Medicaid expansion could add between 40,000 and 63,000 to the 130,000 residents who already receive Medicaid benefits. That means that instead of one in 10 residents receiving benefits, it could be around one in seven.

Questions from senators, led by Senate President Peter Bragdon, suggested that there is disagreement with the department over Medicaid expansion. Gov. Maggie Hassan is a strong advocate of expanding Medicaid and included it as part of her budget proposal. The House also supports expansion as part of its version of the budget. Now it will be left to the State Senate to make its decision. If the Senate decides not to go along then Medicaid expansion could be the biggest issue separating Republicans from Democrats and the Senate from the House and governor as budget negotiations move to a late June conclusion.

As background, the original Obamacare legislation mandated states add newly eligible uninsured people to Medicaid rolls with 100 percent of the costs being absorbed by the federal government for the first three years. By 2020 the federal share of the costs would decline to 90 percent.

The Supreme Court ruled in a landmark case that states cannot be mandated to sign on for Medicaid expansion and about half the states have decided not to join up for now. Issues raised at Friday’s Senate Finance session included what costs might be shifted to the state down the road and could the state count on the federal government meeting its financial commitments.

Sen. Bragdon, a long time school board member in Milford, noted that the federal government never has provided the 40 percent of the cost of providing special education services in schools. Instead, the federal government has provided less than 20 percent of the cost of services mandated by Washington. Sen. Bragdon estimated that local school districts over the years have added $1.5 billion dollars to property tax payers’ burden for the promise not kept by Washington. This concern that the federal government, with its own financial struggles, would push costs back to the states down the road was underlined in a discussion earlier in the Senate committee discussions. The issue was a now disbanded congregate housing services program.

The program, started in 1987, was to provide services to mostly elderly adults living in federally approved housing. The costs were to be shared 50 percent by the state, 40 percent by the federal government and 10 percent by the participant.

After a major commitment by the state to organize the program in six cities, the federal government “shifted away from supportive services in public housing” according to a background paper provided by HHS. Federal funding ended and all government costs were shifted to the state.

Just as the federal government has backed away on its special education and congregate housing commitments, can it be trusted not to shift costs for Medicaid expansion back to states?

Health care policy is complex and difficult to understand in its totality. And Medicaid expansion, while very important, is only one part of the changes surrounding health care today.

Another key element is managed care. This is an effort being tried in many other states to improve patient outcomes while reducing the costs for those already on Medicaid.

New Hampshire’s managed care program was to start last year. Now, the predictions are it could start up late this year. The three managed care companies selected by the state to run the program have had difficulty signing up providers including hospitals. Senators are being told the logjam may be breaking and managed care will go forward.

The managed care concept had wide support in the legislature when it was passed into law in 2011. Many of those who supported it were leaders in the anti-Obamacare effort. Those legislators, in my opinion, never saw managed care connected to New Hampshire participating in elements of Obamacare.

Some Senators were surprised on Friday to hear from the leadership of the Department of Health and Human Services that managed care had always been tied to implanting Medicaid expansion. That disconnect in understanding how the new federal program is essential to what many thought was a stand-alone state managed care program could be significant.

Approving Medicaid expansion could be major issue next month in the committees of conference as senior House and Senate budget writers try to find consensus on the revenue and spending issues facing New Hampshire over the next two years. There is an option of approving or turning down expanded Medicaid expansion in the heat of other budget battles: wait a year and make the decision outside of the budget debate after more thorough discussion and debate.

Bob Odell, a Republican, is the New Hampshire senator representing Antrim, Bennington and Francestown, among other towns.

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