Garry Rayno's State House Dome: All Medicaid expansion, all the time in Concord
With no agreement on how best to expand Medicaid eligibility and insure about 50,000 Granite Staters, the House and Senate last week unveiled separate plans on how to do the job.
At the special session Thursday, all sides praised the bipartisan Medicaid expansion commission and its recommendations to use private insurance where possible and the new managed care Medicaid program to provide health insurance for low-income adults.
The House plan mirrored the commission's recommendation, mostly put together by Rep. Thomas Sherman, D-Rye, who is the prime sponsor of the bill.
The Senate plan is different in that it would require all the newly eligible recipients to use private health insurance purchased through the state health insurance marketplace beginning in 2015.
Senate President Chuck Morse, R-Salem, praised the commission's work, saying it offered important ideas. But he said the recommendation would not move the state ahead far enough because it depended too heavily on the Medicaid program.
Simply expanding Medicaid "is not something the Senate can support," Morse said, although he praised Gov. Maggie Hassan and the House leadership for being open to alternative ideas.
The two plans reflect different political philosophies. The Democratic-controlled House would rely on government-provided insurance to cover the majority of people who would be covered under expansion, while the Republican-controlled Senate would rely on private insurers to provide health insurance to the newly eligible.
The first year of expansion would be identical in both plans, but the next two years would be different.
Relying on private insurance, Morse said, would produce better outcomes for low-income adults, more support for health-care providers and greater protection for taxpayers.
But House Speaker Terie Norelli, D-Portsmouth, said some of what the Senate proposes would be unworkable and would not satisfy the federal requirement that private insurance not cost any more than Medicaid.
There are other key differences.
The Senate plan sets a deadline of one year for the state to win a necessary federal waiver to allow all the newly eligible recipients to be transferred to private insurance. If the deadline was not met, the program would come to a halt.
Norelli said more time is needed to develop and seek the waiver, which in the end the state may not receive.
The timeline and the decision of who should be on private insurance are the chief sticking points. The Senate wants everyone who is newly eligible to be on private insurance within a year, while the House wants to limit private insurance to only those people whose incomes fall between 100 and 138 percent of the poverty level. The House also does not want to start transferring people for at least three years, and then only if there are three insurance carriers in the marketplace. Currently, there is one carrier, Anthem Blue Cross Blue Shield.
There are political problems for both Morse and Norelli. The strictly partisan 183-141 vote to introduce the House bill means Democrats will have to pass something without any Republican support.
The Senate may not have enough Republican votes to pass the plan crafted by Morse and Senate Majority Leader Jeb Bradley, R-Wolfeboro. There is at least one Republican who is not playing ball, and there may be one or two more.
Morse may need, and certainly wants, bipartisan support for a Senate plan. A plan that appears too much like the one outlined by Republican senators last week will have problems with the more liberal Democrats in the House, not to mention Democrats in the Senate. Morse has already said the House plan is dead on arrival in the Senate.
That means there is going to have to be compromise regarding the timeline and who will be required to be on private insurance.
There is room for compromise, but it will not be done in public before the two committees. It will be done on the upper floors of the State House by people shuffling back and forth between offices.
When the bargaining becomes intense as the Nov. 21 deadline nears, the key will be who blinks first and who has the most to lose.
In this case, both the House and Senate have plenty to lose, and conventional wisdom says some agreement will emerge before the deadline, largely because the major health care providers in this state - the hospital organizations - want something done.
They would be very pleased with more of the newly eligible on private insurance because of the better reimbursement rates, but they want something done because right now most of those who would be covered are receiving medical services without paying for them. Something is far better than nothing, even if Medicaid pays 54 cents on the dollar.
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BARGAINING CHIPS: Both the Senate and House included provisions in their plans that are best described as bargaining chips that can be traded, including repealing the prohibition on the state having its own exchange, a law passed by the previous legislature.
That provision brought a rise out of House Republicans although it was a day late.
Norelli and Sherman said the change is for technical reasons. They said the state needs its own version to properly recognize those who are Medicaid eligible but have insurance through their employer. Under both plans, those recipients would remain on their employer's insurance, but Medicaid would pay the premiums.
"We were led to believe the bill would mirror the Medicaid Expansion Commission's recommendation," said House Minority Leader Gene Chandler, R-Bartlett. "Now that we've read the bill, we keep identifying things in it that were never part of the commission's report."
Norelli said repealing the prohibition as well as the legislative oversight committee would "take the shackles off."
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- Both the House and Senate will hold public hearings on their separate proposals for expanding Medicaid eligibility on Tuesday.
- The House Finance Committee will hold a public hearing on Special Session House Bill 1 beginning at 10 a.m. in Representatives Hall.
- The Senate Committee on Special Session Legislation holds a public hearing on Special Session Senate Bill 1 beginning at 1 p.m. in Room 100 of the State House.
- House Finance holds a work session on its bill Wednesday at 10 a.m. in Rooms 210-211 of the Legislative Office Building for all committee members.
- The Senate and House committees meet again Thursday at 1 p.m. to decide on what recommendations to make on the bills. House Finance meets in Rooms 210-211 and the Senate Special Session Committee meets in Room 100.
The two committees need to make recommendations by the end of the day Thursday in order to print the proposals in the House and Senate calendars so they can be voted on Nov. 21 when both chambers are back in session.
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NEW POET LAUREATE: An Acworth poet and educator is poised to be the state's next Poet Laureate, a post held by such luminaries of the literary world as Don Hall, Jane Kenyon, Maxine Kumin and Richard Eberhart.
Alice B. Fogel has published three books of poetry and another book about navigating the genre for the reluctant reader.
She teaches writing at Keene State College and works with learning disabled students at Landmark College in Putney, Vt. She has also taught at Colby-Sawyer College in New London.
Fogel grew up in in Croton-on-Hudson, N.Y and moved to Portsmouth in 1983. She soon enrolled in the University of New Hampshire's master of fine arts in the writing program. She received her bachelor's degree in English literature from Antioch College in Ohio.
Fogel, her husband and their three children have lived in Acworth since 1997.
The state's Poet Laureate position has been vacant since March 31 of this year when former laureate W.E. "Walter" Butts of Manchester died.
Hassan nominated Fogel to the position last week and the Executive Council is expected to vote on her confirmation Nov. 20.
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ROADS AND BRIDGES: The state of the highway system will be the topic of an informational meeting Nov. 20 between 7 and 8 p.m. at Manchester Aldermanic Chambers.
Hosted by Sen. Lou D'Allesandro, D-Manchester, key lawmakers will discuss the condition of the state's roads and bridges and what needs to be done to bring the transportation infrastructure up to snuff.
Along with D'Allesandro, attending the meeting will be Sen. Jim Rausch, R-Derry, who is chair of the Senate Transportation Committee; Rep. David Campbell, D-Nashua, who chairs the House Public Works and Highways Committee; Rep. John Graham, R-Bedford, long-time public works committee member, and Rep. Pat Long, D-Manchester.
State officials are in the two-year process of revising the state's 10-year highway improvement plan. Lawmakers will have to approve the new plan during the 2014 session.
The program will be broadcast live on MCTV.
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DEBT FOR RETIREMENT: Adhering to the old New Hampshire adage "No New Taxes" former Senate Minority Leader Bob Preston of Hampton approached the current Hampton area senator Nancy Stiles with an idea he considered years ago. A "Granite State" credit card would pay the retirement system for each card issued and a percentage of every transaction.
Research indicates one organization with 25,000 active card holders generated about $500,000 annually.
State government has 13,000 employees and the retirement system has 85,000 retired or active members plus their spouses and family members, according to Stiles and Preston.
They shared the idea with the Senate leadership, Hassan and D'Allesandro, the Senate Finance Committee vice chairman.
"The success or failure of the affinity care program is up to the state employees, retirese, municipal and school district workers throughout the state to apply for affinity cards knowing that all income would be to their benefit for the now under-funded pension fund," Stiles and Preston said.
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CORRECTION: In last week's column, attorney Arthur Cunningham was incorrectly identified. He argued several cases decided by the Air Resources Division, but was not an attorney with the division.