With Medicaid under the gun, new study highlights program’s successes in Cheshire County

June 23--Amid fierce national clashes over the future of health care, and a new Republican bill unveiled Thursday, one federal program has proven a particular emotional flash point: Medicaid. Efforts to pare back the program, which provides coverage to low-income adults and children, have drawn alarm from Democrats and some Republican senators representing rural states.

New research points to a reason why. A study out of Georgetown University this month found that those living in rural counties -- particularly children -- have benefited from Medicaid at a higher proportion than urban ones.

And rural counties in states that opted to accept a federal Medicaid expansion under the Affordable Care Act have seen large drops in the uninsured rates for adults, the study found.

New Hampshire is no exception. Between two time periods -- 2008-09 and 2014-15 -- the statewide rate of uninsured adults dropped from 16.1 percent to 11.9 percent, according to the study by the university's Center for Children and Families.

Low-income children were not included in the federal Medicaid expansion under the Affordable Care Act, having long been automatic recipients of Medicaid funds under the Children's Health Insurance Program.

But the rate of uninsured children throughout New Hampshire has nonetheless dropped, from 5.5 percent to 4 percent, the study says.

Since 2015, New Hampshire has received expanded Medicaid funds under the Affordable Care Act, President Barack Obama's signature legislation that passed in 2010. New Hampshire's expansion -- which was modified by a waiver to allow recipients to use the funds on the new insurance markets -- was re-approved in the Statehouse in 2016. The latest approval will "sunset" at the end of 2018, at which point it will need to be approved again.

Since the initial expansion, about 52,000 Granite Staters have received insurance through the program, according to the Kaiser Family Foundation.

Among the Granite State's less populated counties, the changes are starker.

In Cheshire County, the number of uninsured adults dropped from 8,700 to 5,600 over that time period -- a decrease from 18 to 12 percent of county residents, according to the report.

Children have benefited more: In 2008 and 2009, 1,320 Cheshire County children were uninsured; by 2015, that number had dropped to 320, or 2 percent, the study says. Presently, 29 percent of Cheshire County children receive Medicaid funds, according to the report.

Meanwhile, New Hampshire counties with higher populations and bigger cities -- like Hillsborough, Rockingham and Strafford counties -- had lower rates of Medicaid users, the report found.

The study, a nationwide review of data from the Census Bureau's American Community Survey, concluded that those in rural U.S. counties are more likely to use Medicaid due to lower income levels, higher rates of disability and lower workforce participation.

For Tricia Brooks, a senior fellow at the Center and a former New Hampshirite herself, the numbers make sense.

Brooks, who co-founded the N.H. Healthy Kids Corporation, a nonprofit organization created by the state Legislature to develop children's health insurance, said the findings in the Georgetown study align with her own experiences on the ground.

"I think we've known for a very long time that ... there tends to be lower-income people living in rural areas and perhaps a lack of the types of jobs that would come with good employer-based coverage," she said in an interview.

Brooks said the study provides evidence that New Hampshire's Medicaid expansion has benefited low-income workers burdened by that inability to get employer-based coverage.

And she said that Cheshire County -- whose Medicaid rate among children and adults was lower than other counties, such as Belknap, Carroll and Coos -- may have benefited from more available jobs than the northern counties.

Shawn LaFrance, vice president of population health at Cheshire Medical Center/Dartmouth-Hitchcock Keene, said some of the coverage increase in New Hampshire can be attributed to outreach efforts by hospitals, which often go to schools and other areas to reach low-income families and enroll them in the Medicaid program.

One hospital official at Cheshire Medical has taken the task to heart. Family resource counselor Ruth Abbott has built deep connections to people in the community, allowing her to guide low-income families through the often-complex process to sign them up for insurance on the exchanges, LaFrance said.

"She'll meet them at their house; she'll meet them at the school, or the Wendy's, or some place that works for that parent," he said. "She'll proactively help them figure out what's the best choice for them in terms of whether it would be Medicaid, Medicaid expansion, or something in the (insurance) marketplace."

To LaFrance, who was executive director at the Concord-based Foundation for Healthy Communities before joining the hospital in April, Medicaid expansion is an undeniable benefit to overall population health, providing funding for mental health treatment and preventive solutions for addiction, among other health care coverage and other uses.

But the program could be in dire straits. A bill drafted by a committee of U.S. Republican senators and unveiled Thursday would make sweeping cuts to Medicaid, which would gradually fade out the expansion funds starting in 2021.

However, New Hampshire is one of seven states that has a "trigger law," which mandates that its own expansion is voided if the federal arrangement changes, meaning if the Senate law passes, New Hampshire's expansion could come to an end long before 2021.

And a budget that passed the N.H. Legislature Thursday would add a work requirement to Medicaid eligibility in the state, a long-desired provision by Republicans concerned that the present program encourages dependency.

For Greg Moore, state director of the conservative advocacy group Americans for Prosperity, the work requirement fixes what he says is a troubling side effect of the expansion. Though the increased federal funds have helped more in the Granite State be insured, the newcomers are using emergency services at a disproportionate rate, driving up premiums for other insurance customers, Moore said.

In an interview with the Union Leader published June 5, the CEO of Minuteman Health, the second largest insurer in the state, announced that the company is seeking a 30 percent average rate increase for its exchange plans next year, blaming Medicaid expansion as a contributor to the costs. The CEO, Tom Policelli, said that while he supports Medicaid expansion overall, he thinks recipients should be added to federally funded high-risk pools to mitigate the costs.

A spokesman for Minuteman confirmed Thursday that the company's plans have not changed.

Moore, a former communications director at the N.H. Department of Health and Human Services, pointed to the increase as evidence that New Hampshire's Medicaid expansion had been structured poorly.

A work requirement, Moore said in an interview Thursday, would drive more people into paying jobs and off Medicaid entirely, reducing the federal government's financial liability and tamping down some of the rate hikes.

But the rate hikes are a direct result of expanding Medicaid in the first place, Moore argued.

"A lot of the problems we're seeing take place right now were knowable and foreseeable (when Medicaid was expanded) -- the breakdown was entirely predictable," he said.

Political actors on the other side of the spectrum see it differently. U.S. Sen. Maggie Hassan, D-N.H., jumped on the Georgetown study as evidence that Medicaid should continue to be funded.

"In several New Hampshire school districts, particularly in the North Country, the majority of students receive health coverage through Medicaid or CHIP," Hassan said in a statement Wednesday, using an acronym for the children's Medicaid program. "We cannot afford to cut funding for essential programs that are supporting the health and well-being of our next generation."

Ethan DeWitt can be reached at 352-1234, extension 1439, or [email protected]. Follow him on Twitter at @EDeWittKS

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