West Lebanon
New Hampshire pays its share of the cost of insuring the 50,000 additional residents who received health insurance through the expanded Medicaid program with voluntary payments into the New Hampshire Health Protection Program from hospitals and insurers. The federal government initially paid all of the cost to expand Medicaid in New Hampshire. The state is responsible for 5 percent of the cost of expansion this year and by 2020, it will be responsible for 10 percent of that cost.
The state’s share of the expanded Medicaid program has been estimated at $51 million over the next two years.
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Medicaid expansion can be supported by provider donations only if the donations have no relationship to Medicaid payments made to the providers. But there does appear to be such a relationship between the voluntary payments and the Medicaid payments New Hampshire hospitals receive, according to the July 25 CMS letter to state Department of Health and Human Services Commissioner Jeffrey Meyers.
The rules at issue here are complicated, said Steve Norton, executive director of the Concord-based New Hampshire Center for Public Policy Studies.
But, he summarized: “These voluntary contributions are in essence being given back to hospitals, which is in violation of CMS rules.”
It is up to state lawmakers to come into compliance with federal regulations so that the program can continue, CMS Director of the Department of Health & Human Services Brian Neale said in the letter.
“While CMS has concerns that New Hampshire may be out of compliance with federal requirements, we expect that by the end of New Hampshire’s next legislative session, changes will be put in place, effective during state fiscal year 2019, to bring the state’s non-federal share financing into compliance with applicable federal statutes and regulations,” Neale wrote.
In a news release on Monday, Republican Gov. Chris Sununu said he was grateful to the Trump administration for allowing the program to continue as is through 2018, giving state officials time to make a plan for the future.
“Regardless of whether you support Medicaid expansion or not, it would have been grossly unfair to strip medical coverage from the thousands of Granite Staters who rely on the program without a sufficient alternative in place,” he said in the release. “This transition period will allow New Hampshire’s leaders enough time to carefully consider and deliberate the future of Medicaid expansion given this new guidance from CMS.”
Policymakers only have a few options, Norton said.
First, he anticipates the state will appeal CMS’ determination that it is out of compliance. Then, if CMS continues to find the state in violation of federal rules, the state will need to decide whether it wants to continue the program. If it does, the state could opt to charge all hospitals and insurers at a flat rate or officials could try to find the money in the state budget.
“The answers are not all that many,” he said. And they “each come with political pain.”
State Sen. Bob Giuda, a Warren Republican whose district includes the Upper Valley towns of Haverhill, Piermont, Orford, Dorchester and Orange, said there is at least one more option for how the state might respond to CMS.
“Sometimes you just have to tell the federal government, ‘Tough, we’re doing it,’ ” he said. “I don’t think they would dare to stop the funding.”
Such defiance could be a test of President Donald Trump’s Cabinet, leading federal officials to see that New Hampshire’s approach is a good one, said Giuda, who sits on the Senate Ways and Means and Finance committees.
“People that need to be covered are being covered,” he said. “We’ve always prided ourselves on doing things the New Hampshire way.”
State Rep. Susan Almy, D-Lebanon, however, said she was concerned that the expansion could be at risk.
“It’s got a bunch of us worried,” she said.
Almy, who sits on the House Ways and Means Committee, said there is not going to be money in the state’s general fund to cover the cost of Medicaid expansion, in part because of recently instituted tax cuts.
It’s “highly unlikely there’s going to be any excess money around these next two years and for a long time to come,” she said.
Given the state’s financial constraints, Almy said she thinks the best bet for the expansion going forward would be to ask hospitals and insurers to pay a mandatory tax to cover the state’s portion of the cost. She was unsure whether the hospitals would be open to the idea.
“I don’t know if they’ve been approached about that at this point,” she said.
Rep. Sharon Nordgren, a senior Democrat overseeing health care funding on the House Finance Committee and the spouse of a retired pediatric neurologist at Dartmouth-Hitchcock Medical Center, said she takes solace in the fact that New Hampshire’s Medicaid expansion is safe through 2018.
“We probably just all need to take a breath and realize that we have time,” said Nordgren, a Hanover resident. “(I) wouldn’t want to create more worry for the people who depend upon this.”
Though there is some talk among legislators now, the real work won’t begin until the session starts in January, Nordgren said, noting that state legislators are preparing to discuss Medicaid expansion again. The Legislature will have to reauthorize the program in order for it to continue past 2018.
“That renewal has to happen, too,” Nordgren said. “It’s sort of a can of worms … Now this just adds another dimension to it.”
Nora Doyle-Burr can be reached at ndoyleburr@vnews.com or 603-727-3213.
