The New Hampshire Solution

Although various versions of New Hampshire SB 413 have been circulating for some time, it was not until this month that a deal really seemed to come together: that Medicaid expansion under the ACA would take a stepped approach and that some measure of bi-partisan support for SB 413 would make it real. This has been tremendously interesting to observe.

First, we see the New Hampshire-style decision to expand Medicaid under the ACA as soon as possible under the Bridge to Marketplace Premium Assistance Program. Essentially buying in to ACA Medicaid expansion as outlined in the ACA (extending eligibility to adults with incomes up to 138% of the federal poverty level) but sunsetting the expansion on either June 30, 2015 or December 31, 2015 while the state seeks the federal waiver necessary to establish a premium assistance program.

Second, we see the outlines of a Marketplace Premium Assistance Program designed to drive this same population to insurance coverage in the Federally Facilitated Exchange between January 1, 2016 and December 31, 2016.

Finally, we see the requirement that any continuation of the ACA Medicaid Expansion after December 31, 2016 would require further legislative authorization.

I have been reluctant to conglomerate all the of the Medicaid privatization proposals together, because they are, in fact, quite diverse. I think of Medicaid Premium Assistance Plans as an umbrella term, as a result, with the Arkansas Option as a description of a privatized approach, in general, but with mechanics peculiar to Arkansas. These mechanics are well described in Sidney Watson’s recent paper on Medicaid, Marketplaces, and Premium Assistance: What is at Stake in Arkansas?

What interests me about the New Hampshire solution is its act now and sunset later approach.  This is an approach that may have purchase in other states.  Rather than let the ACA Medicaid expansion 100% FMAP slip away, other states may seize the opportunity while also, like New Hampshire, reserving the opportunity to conduct an experiment of privatized expansion that would likely inform the ongoing debate likely to take place around December 31, 2016.

Lawrence Jacobs and Timothy Callaghan have a recent paper on Why States Expand Medicaid: Party, Resources, and History that considers whether the past is prologue on Medicaid expansion, as I have argued elsewhere. They test whether certain political contexts promote Medicaid expansion (they do) and whether something they call “State Medicaid Policy Path and Medicaid Implementation” matters (it does).  The former is no real surprise; political dominance creates a self-reinforcing position on Medicaid expansion.  But the latter is most intriguing.  Jacobs and Callaghan note  that a state’s Medicaid policy path may evolve over time, as voting and activism constituencies grow, producing politically engaged beneficiaries as a by-product of wider access.

When I talk about Medicaid expansion, I sometimes talk about building a constituency for Medicaid (often alluding to the same transformative voting patterns for seniors before and after the establishment of Social Security, during its early precarious years). I have argued, in my forthcoming paper, The Medicaid Gamble, that this constituency building function of Medicaid may have been the biggest gamble of all. I would suggest that, if it can be done, it may begin in a state like New Hampshire with the New Hampshire Solution.

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