Dispute over work rules throws wrench into Medicaid expansion

Dec. 20--CONCORD -- The future of New Hampshire's expanded Medicaid program has been thrown into uncertainty after a key legislative committee rejected federal changes to a work requirement that was negotiated in a bipartisan compromise at the State House.

The current program is scheduled to expire on Dec. 31.

Lawmakers spent much of the past two years crafting the compromise to continue the program that provides health insurance to nearly 50,000 low-income New Hampshire residents with the addition of a work requirement for certain able-bodied applicants.

But the Trump administration two weeks ago approved a tougher work requirement than New Hampshire originally proposed.

A joint committee of House and Senate members from both parties unanimously rejected those changes on Thursday, throwing into question exactly how the state will proceed in sustaining a health care benefit that many say has been critical in combating the opioid epidemic.

All four Republican members on the 10-member Joint Legislative Committee on Administrative Rules (JLCAR) voted with the six Democrats to reject the revised rules for the work requirement that were presented Thursday.

"Senate Democrats made it clear last session that we would not vote for a Medicaid expansion program that kicks anyone off of their coverage. Unfortunately, the Trump administration ignored two years of bipartisan compromise and proposed changes that do just that," said Senate Majority Leader and JLCAR member Dan Feltes, D-Concord.

"We hope for the continued cooperation of our Republican colleagues as we work to ensure the changes we make to our state's health care landscape are state-specific and work for New Hampshire -- not cookie-cutter policies handed down by Washington, D.C."

DHHS officials estimate that the work requirement could affect as many as 15,000 recipients of expanded Medicaid benefits.

Three changes

In approving the state's request for a waiver from traditional Medicaid rules to impose the work requirement, the federal Centers for Medicare and Medicaid Services (CMS) made three changes:

Make-up hours required: The work requirement as submitted was designed so that no one would be kicked off their coverage because of "one difficult month" in which they failed to work the required number of hours.

It was changed to a mandate that the required number of work hours be made up in the next month. For example, if in January an enrollee needed to complete 100 work hours, but only completed 50, in February they would need to complete 150 hours to stay in the program.

No carryover: The CMS changes also alter the rules as originally proposed to prevent any additional hours worked in a one month to carry over to the next month.

Fewer exemptions: The CMS alsochanged how people with disabilities are treated, making it tougher for them to get an exemption from the work requirement.

What happens next is unclear. Feltes says the issue is now in the hands of Gov. Chris Sununu and Commissioner for Health and Human Services Jeff Meyers.

"They can choose to move forward to implement the rule even if we object to it," Feltes said of the JLCAR vote. "It's up to Gov. Sununu and Commissioner Meyers to make a determination about whether or not they want to move forward with the rule despite a unanimous vote in opposition.

"It would be rather unprecedented for them to go forward with the rule after this objection. Instead we should all work together on a bipartisan New Hampshire solution," he said.

Sununu hedges

When asked if he would override the JLCAR vote, Sununu hedged. His written statement in response to that question suggests that he has no problem with the CMS changes.

"New Hampshire's work requirement is a critical component of our state's expanded Medicaid program. It is good policy, it is the law, and it ensures that over 50,000 Granite Staters have healthcare coverage. The Democrat-led legislature needs to do their job and get this done."

State Sen. Cindy Rosenwald, D-Nashua, has introduced legislation to codify the New Hampshire specific rules in state law, apparently in the hope that such a move will strengthen the state's bargaining position with the federal government.

The JLCAR vote puts Meyers in a bind, according to Greg Moore, state director for the conservative policy group Americans for Prosperity. Moore was director of public affairs and government relations at the Department of Human Services from 2003-2007.

"The problem is we have a program that runs out on Dec. 31, and if you don't accept the terms and conditions of the federal waiver, you risk not getting federal reimbursement, which accounts for 90 percent of the program," he said.

The Republican caucus will support the Trump administration changes, despite the JLCAR unanimous vote, according to Sen. Jeb Bradley, R-Wolfeboro and House Minority Leader Dick Hinch, R-Merrimack.

Changes called 'minor'

Bradley and Hinch both described the CMS changes as minor, and said their four JLCAR members were caught off guard by Thursday's vote.

"I think the revision Washington sent back is so little in scope that there is no reason we shouldn't be in full agreement with that," said Hinch. "It's not like the whole deal was turned around. This makes it consistent throughout the states that get the work requirement waiver."

With only a week to reach some resolution, there will be a lot of politicking in the background.

"It's a game of chicken with the federal government," says Moore. "We'll see at this 11th hour who takes action first.

"Will there be an emergency meeting of JLCAR to try to accept the rule? Will the governor and commissioner move forward with the rule even though JLCAR has rejected it? Will the Legislature try on Jan. 2 at its first session to rush a bill through immediately?"

The fate of health insurance for thousands of New Hampshire residents hangs in the balance.

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