Expanding Medicaid eligibility under the Affordable Care Act will be at center stage this week as lawmakers begin work on a bill or bills that would best provide health insurance to low-income adults.
The House and Senate will meet at 10 a.m. Thursday to set the ground rules for the next two weeks of hearings and meetings before a vote Nov. 21.
Whether there is one bill or more will depend on how negotiations go among political leaders, health and insurance industry representatives and various activist groups.
The House and Senate leadership and Gov. Maggie Hassan's office have already had countless meetings as they've tried to reach an accord to allow expansion to go forward next year and state health care providers to receive about $2.4 billion in federal money to pay for 58,000 newly eligible residents over the next seven years.
Whether the low-income adults receive health insurance and providers get the money depends on at least two Republicans in the Senate.
That has not changed since the 13 Republicans held firm and rejected Medicaid expansion during the budget-writing process earlier this year.
Former Senate President Peter Bragdon, R-Milford, led the charge against expansion and won approval for a study commission instead.
The commission issued its report last month.
The report essentially said the state should start the program Jan. 1 and use private insurance to cover as many of the newly eligible residents as possible, including expanding a program that pays the premiums of adults with health insurance through their employers.
After the report was approved, current Senate President Chuck Morse, R-Salem, called it a good framework for beginning further discussions, and he announced five goals Republicans wanted achieved to expand Medicaid, including using private insurers to assume the risk of covering the newly eligible population.
Republicans want to see something similar to what the Center for Medicaid Services approved for Arkansas, which will use Medicaid money to pay private insurance premiums for people whose incomes are up to 139 percent of the federal poverty level.
That state's newly eligible population will use the Arkansas health insurance exchange to decide which policy is best for them.
The problem with having a similar program here is that New Hampshire has only one company on the exchange: the state's largest health insurer, Anthem Blue Cross Blue Shield.
Federal rules require that Medicaid recipients have a choice of insurers.
Lawmakers are working with the three private managed care companies the state hired to administer the existing Medicaid program, trying to persuade at least one to offer policies on the state's exchange beginning Jan. 1, 2015.
If that happens or if Harvard Pilgrim decides to weigh in, then New Hampshire can use something like the Arkansas model.
The problem is that the private insurance has to cost the same or less than the current Medicaid program, a scenario that would be difficult to achieve.
Morse has often said, "We want a uniquely New Hampshire solution."
A uniquely New Hampshire solution may be hard to achieve, but the pressure is on with just days remaining before the first day of the special session.
If some combination of factors is agreeable to Hassan, House Democratic Leadership and Senate Republican leadership, then one bill would be introduced next week, and passage would be a foregone conclusion. If not, the next few weeks will be very interesting.
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CASINO GAMBLING: Another big issue not involving health care this summer and fall has been expanded gaming and how the state should regulate it in the future.
The Gaming Regulatory Oversight Authority has listened to experts near and far, and from advocates on both sides of the issue and recently began putting together a regulatory scheme in case lawmakers ever vote to legalize casino gambling.
Perhaps the most noteworthy aspect of the study committee works has been the unveiling of "charitable gambling" which one authority member, Sen. James Rausch, R-Derry, called totally unregulated, although that drew a light rebuke from Paul Kelley, executive director of the Racing and Charitable Gambling Commission. Kelley has pushed lawmakers to tighten up the multi-million dollar industry, but has not been successful.
Perhaps because small charities around the state are eager to have the money generated by the 10 charitable gaming halls around the state, the state's attitude toward gambling is considerably different from the majority of House members. The House has never approved casino gambling, although the Senate has on a number of occasions.
A Granite State Poll released last week shows three in five people favor casino gambling in the state.
According to the poll done by the University of New Hampshire Survey Center, 59 percent favor a casino, while 33 percent oppose it and 8 percent are neutral.
The results have been essentially the same for the last year, according to the center.
With the exception of people who regularly attend church, majorities of all demographic and political groups favor a casino in New Hampshire, the center said.
Young people are more likely to support legalization while older residents, North Country dwellers, and Tea Party supporters, along with frequent churchgoers are more likely to oppose legalization.
The threat of casinos in nearby Massachusetts does little to change minds about expanded gaming in the Granite State.
According to the center, 60 percent favor legalizing casino gambling in the state, 33 percent oppose and 8 percent are neutral when asked about Massachusetts casinos.
The survey center contacted 603 randomly selected New Hampshire adults by landline and cell phone between Oct. 1 and 7, 2013. The margin of error is plus or minus 4.0 percent.
The sponsors of Senate Bill 152, which allowed one "highly regulated, high-end casino" along the state's southern border, said they will introduce a similar bill for the 2014 session and try again.
They worry the Massachusetts casinos will reduce state revenue and shift the costs of problem gamblers to state social service programs.
SB 152 passed the Senate, but died in the House despite the backing of Hassan.
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SCRUBBER QUESTION: The Electric Utility Restructuring Oversight Committee has been trying to decide what to do to lower electric rates for residential and small business customers who continue to buy their power from Public Service of New Hampshire. Large users and many small users are now buying their power from alternative providers.
Two issues are key: whether Public Service should be forced to sell its fossil fuel generating plants, and how to reduce the rate shock from the new $422 million emissions scrubber at the Merrimack Station plant in Bow.
Public Service has resisted calls to sell its fossil fuel plants saying they are needed both for generating capacity on high-use days, and to reduce the New England region's over reliance on natural gas generated power.
The state's largest electric utility also argues state law mandated the scrubber be built in order to meet new mercury emissions standards.
The Public Utilities Commission is in the process of determining how much of the $422 million scrubber costs ratepayers will have to pay, but Public Service asked the state Supreme Court to rule the law mandates customers pay the entire cost of the scrubber. That appeal brought the PUC proceedings to a halt.
Last week the oversight committee received a letter from a former attorney with the state's Air Resources Division, Arthur Cunningham, claiming some of the $422 million for the scrubber was spent on extending the life of the plant and upgrading its generating equipment, something the PUC has to approve before the cost is added to customers' bills.
The committee has asked Cunningham to appear in December to talk about the issue and also wants Public Service to send a representative as well.
The ramifications of who pays for the scrubber will have huge impacts on either Public Service power customers or the utility's stockholders.
But now the crucial decision is whether the Supreme Court takes the case or tells Public Service they have to wait until the PUC makes its determination.
The longer this battle goes on, the more expensive electric rates will be for Public Service's power customers. The company collects a rate of return on its $422 million investment of about 9 percent a year or $38 million which goes automatically into rates.
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PALLIATIVE CARE REPORT: People and health care providers need better information about the treatment of pain and discomfort due to illness or trauma, according to a report from a commission that studied palliative care and quality of life this summer and fall.
The commission hopes to pass legislation in 2014 to expand education for patients and care providers.
"The best method for changing current medical practices is to educate the patient to ask their medical provider for the service," said commission member Mary Scott, APRN.
The commission will propose legislation requiring health care facilities to have a plan and procedure for all patients that includes palliative and hospice care.
A statewide registry is needed for advance directives such as do not resuscitate orders that can be accessed in a medical emergency, the commission found.
The commission also decided the state needs to update its medical proxy laws, which allow someone to act on a person's behalf when they are no longer able to speak or make their wishes known.
Two members of the commission, Reps. Suzanne Smith, D-Hebron, and Frank Kowtowski, R-Hooksett, will sponsor legislation for a privately funded education center for palliative care.
The center will accept donations, seek grants for funding and make New Hampshire a leader in the promotion and understanding of all the possibilities — both therapeutic and palliative — available for all patients and their families, according to the report.