How should New Hampshire handle national health care reform?
By: LFDA Editor
In March 2010, President Barack Obama signed into law the Patient Protection and Affordable Care Act, a federal statute that marks Congress's chief health care reform legislation. For the particulars of this act from the White House perspective, click here. Most of the Affordable Care Act (also known as "ObamaCare"), including the controversial individual mandate to purchase health care, was upheld by the U.S. Supreme Court in June 2012.
While there are many aspects of the Affordable Care Act, there are two major provisions that affect state government. First, each state must run an online health insurance marketplace (also called an "exchange"). Second, each state had to decide whether to expand eligibility for Medicaid.
Online Health Insurance Exchange
One of the primary requirements of Affordable Care Act was that every state establish an online health insurance exchange, often described as “one stop shopping” for consumers buying insurance. Each state had three options to establish the exchange: let the federal government create and operate the exchange, use federal funds to create and operate the exchange on the state level, or partner with the federal government on a limited basis.
HB 1297, passed by the New Hampshire legislature in 2012, forbid the state from using federal funds to create and operate the exchange on the state level.
In February 2013, New Hampshire agreed to partner with the federal government for the online health insurance exchange. Under the partnership the U.S. Department of Health and Human Service operates the exchange, while New Hampshire government regulates the insurance plans.
When the federal insurance exchange launched October 1, 2013, the website was plagued by problems. President Obama promised a fix by the end of November 2013.
The exchange was also criticized for only drawing one New Hampshire insurer, Anthem Blue Cross Blue Shield. Anthem was criticized in turn for offering a narrow network of health care providers. Anthem says the narrow network lowers costs and ensures quality. Opponents argue that the narrow network unfairly limits consumer choice.
The state Insurance Department is now studying the network adequacy rules that allowed the Anthem plans to be approved.
Four other insurers, Harvard Pilgrim Health Care, Minuteman Health, Assurant Health, and Maine Community Health Options are offering plans on the exchange for 2015.
New Hampshire also decided to expand Medicaid eligibility under the Affordable Care Act.
Originally the Affordable Care Act required states to expand Medicaid eligibility starting in 2014, or the federal government would stop matching state contributions to Medicaid. However, the U.S. Supreme Court ruled that the federal government could not deny matching funds if a state decided not to expand Medicaid.
As part of a budget compromise in June 2013, the New Hampshire legislature agreed to study Medicaid expansion over the summer. On October 8, 2013 that study committee voted in favor of expanding Medicaid. After three weeks of negotiations, a bipartisan plan broke down and the Republican-controlled Senate killed the expansion.
On February 6, 2014 a bipartisan group of Senators announced a new Medicaid expansion deal. The compromise relies on the use of private insurance. The program is set to expire December 31, 2016, unless the state legislature re-authorizes the program. This new Medicaid compromise, SB 413
, passed the House and Senate and was signed by Gov. Hassan March 27, 2014.
Ideally expanded Medicaid eligibility decreases the number of uninsured patients, which in turn decreases the shift of costs from uninsured patients to the insured. “Anytime you put more people into the pool, you maximize your ability to create efficiencies and control costs,” explained Ned Helms, former health and human services commissioner and co-chairman of President Barack Obama’s 2008 campaign in New Hampshire. The federal government is also reimbursing states for 100% of the cost of expanded Medicaid through 2016.
However, opponents of the Medicaid expansion argue that allowing government greater involvement in health care undermines competition in the market, therefore raising costs for everyone. Opponents also point out that federal reimbursement will decrease slowly over time, capping out at 90% in 2020. According to the Nashua Telegraph, “Medicaid is the single largest item in the two-year New Hampshire budget… New Hampshire’s cost is about $1 billion a year.” Opponents argued that cash-strapped New Hampshire cannot afford Medicaid expansion.
Enrollment for expanded Medicaid coverage opened July 1, 2014. Gov. Hassan urged the 2015 legislature to renew expanded Medicaid eligibility beyond 2016, but the House rejected her proposal.
Rep. Donald McClarren (R-Nashua) is the primary sponsor of HB 128, a 2015 bill that would allow individuals and employers with under 100 employees to purchase insurance out-of-state. Sen. Andy Sanborn is the primary sponsor of a similar bill in the Senate, SB 131. SB 131 would some individuals and businesses to purchase health insurance from out-of-state companies. Both bills are still in committee, and may be considered in the 2016 legislative session.
Rep. Charles McMahon is the primary sponsor of HB 330, a 2015 bill that establishes an oversight commission for medical cost transparency to monitor and further develop the NH HealthCost Internet website. Gov. Hassan signed that bill in July.
Rep. Keith Murphy is the primary sponsor of HB 596, a 2015 bill that prohibits public employers from offering employees any health care plan subject to the excise under the federal Affordable Care Act ("Obamacare"), unless the employee pays the cost arising from such tax. The federal excise tax is a tax on "high-end" health plans that may insulate workers from the high cost of care and encourage the overuse of care. The tax is scheduled to take effect in 2018. The Department of Administrative Services says that should the terms of HB 596 take effect while the current collective bargaining agreements are in place, the result will be a violation of those agreements. HB 596 is still in committee, and may be considered in the 2016 legislative session.
Sen. Jeb Bradley is the primary sponsor of SB 7, a 2015 bill that 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. That bill is also still in committee.
Sen. David Pierce was the primary sponsor of SB 185, a 2015 bill that renews the expansion of Medicaid eligibility, which is set to expire December 31, 2016. The Senate tabled that bill in March, and the legislature probably will not reconsider Medicaid expansion until 2016.
The House killed two other bills related to health care in 2015: HB 686 and HB 548. HB 686 would have established a single payer health care system to provide health care for the citizens of New Hampshire. HB 548 would have established the federally-facilitated health exchange as the online health insurance exchange for New Hampshire.
Several legislators hoped to change New Hampshire's implementation of the Affordable Care Act in 2014. The legislature killed all but two bills.
First, Sen. Sam Cataldo (R-Farmington) sponsored SB 340, a 2014 bill that requires the state Insurance Department to hold public hearings before approving any insurance plans to be offered on the exchange. Gov. Hassan signed that bill into law July 18, 2014.
Second, Senate President Chuck Morse (R) was the primary sponsor of SB 413, which established the Medicaid expansion compromise described above. Gov. Maggie Hassan signed SB 413 into law March 27, 2014.
The legislature rejected eight other 2014 bills related to health care.
Sen. David Pierce (D-Lebanon) sponsored SB 380, a 2014 bill "requiring an insurer participating in the health exchange to include access to a hospital in each county of the state." The Senate killed that bill March 27, 2014.
Sen. Peggy Gilmour (D-Hollis) was the primary sponsor of SB 412, a bill that would have repealed the prohibition on a state-run exchange. SB 412 would have also requireed insurers on the health exchange to offer at least one broad network plan. The Senate killed SB 412 on March 6, 2014.
Rep. Neal Kurk (R-Weare) sponsored HB 1158, a 2014 bill that would require health insurers to give members a small monetary benefit if the individual chooses a less expensive health care provider. Kurk also sponsored HB 1612, a bill which "requires hospitals to charge self-pay patients no more than the Medicaid rate for medical services." The House sent both bills to interim study - effectively killing the bills - on March 12, 2014.
Rep. Bill Nelson
(R-Brookfield) sponsored HB 1294
, a 2014 bill which requires insurers selling plans on the federal health insurance website (such as Anthem Blue Cross and Blue Shield) to include any willing health care provider in the insurance network. The House killed that bill on March 5, 2014.
Rep. Emily Sandblade
(R-Manchester) sponsored HB 1328
, a 2014 bill that would have required insurance navigators to be licensed by the state, including a background check, license fee, etc. The House sent that bill to "interim study," a quiet death for a bill.
Former House Speaker Bill O'Brien
(R-Mont Vernon) sponsored HB 1541
, a 2014 bill which allows insurance companies to sell insurance policies that do not meet state and federal requirements, provided that the Insurance Commissioner approves the policies. The House killed that bill on March 13, 2014.
Rep. John Cloutier
(D-Claremont) sponsored HJR 12
, a 2014 resolution urging Anthem Blue Cross and Blue Shield, the only insurer offer New Hampshire plans on the federal health insurance website, to include at least one hospital in each county in its insurance network. The House killed that bill March 19, 2014.