CONCORD — New Hampshire's low-income adults will not be eligible for government-paid health care beginning Jan. 1 after lawmakers Thursday failed to agree on a plan to expand Medicaid eligibility under the Affordable Care Act.
After five hours of debate and parliamentary maneuvering, the House voted 198-141 to approve Special Session House Bill 1 to expand Medicaid, but senators killed it on a 13-11 vote in less than 15 minutes. The Senate tabled Special Session Senate Bill 1 because they lacked the votes to pass it.
Lawmakers have been debating expansion for 10 months and all sides agree the Legislature will grapple with the issue again in January when the 2014 session begins.
Democrats and Republicans agreed on many issues but months of negotiations among Gov. Maggie Hassan's office, and House and Senate leaders failed to close the gap and this week the talks degenerated into partisan bickering.
The unreachable divide centered on one key issue: how long the newly eligible Medicaid population stays on the state's existing managed care Medicaid program.
Senate Republicans proposed a plan to move all new Medicaid recipients to private health insurance purchased through the federal marketplace in one year, while Democrats proposed a two-year transition period.
Both sides agreed to use the existing Health Insurance Premium Payment program for those with insurance from their employers and private insurance to provide coverage to the approximately 49,000 individuals who would become eligible under expansion.
They also agreed to require the jobless to participate in Department of Employment Security training and job search programs, and to establish a separate trust to accept federal money to pay health care providers rather than using the state's general fund as the conduit.
While Democrats characterized the differences between the two sides as minuscule, Republicans said they are significant.
"We are not going to pass something akin to Obamacare that does not protect the taxpayers," said Senate Majority Leader Jeb Bradley, R-Wolfeboro. "Without the reform, without changes to bring personal responsibility, without bringing taxpayer protections into the Medicaid system, we cannot support any compromise put forward."
He criticized Hassan for politicizing the issue in the last two weeks by appearing in several Senate Republicans' districts touting the Democrats' plan and criticizing the Republican proposal.
Hassan in turn blamed Senate Republicans for failing to pass expansion, saying they refused to compromise, costing the state millions of dollars of federal money.
"Our providers are ready for expanded health coverage, our businesses are ready, our people are ready, and I am ready. We will keep working and there will be more votes," Hassan said. "I hope that at some point, a few Senate Republicans will set ideology aside and step forward to do what is right. Until then, it is the people who are hurt, and it is the people whom senators must answer to."
Democrats argued that the state's health insurance marketplace needs robust competition to win federal approval for the private insurance assistance program and that will take at least two years. Currently, Anthem Blue Cross Blue Shield is the only qualified carrier on the exchange. One other carrier is likely to participate in the federal marketplace beginning in 2015, but lacks the required statewide provider network for the Medicaid program.
"What we cannot agree to is a set up for failure," said Senate Minority Leader Sylvia Larsen, D-Concord. "What good is all this compromise if we put out a plan that fails because it cannot meet the deadlines?"
The House passed the Democratic Medicaid expansion bill on a mostly party line vote of 198-146 after more than five hours of debate and votes on five proposed Republican amendments as well as several GOP procedural moves designed to delay the vote.
Four Republicans joined 194 Democrats in favor of the bill, while a single Democrat joined 145 Republican opposed.
Originally 28 Republican amendments were proposed, but most were withdrawn when it became apparent Medicaid expansion was not going to be approved.
Rep. Thomas Sherman, D-Rye, the chief sponsor of the House plan, asked his colleagues to think of themselves as medical professionals, and said, "In our world, delay and denial of care are considered malpractice."
By voting for the bill, he said, "you will positively impact the health of 58,000 patients your constituents, your friends and your co-workers."
House Miniority Leader Gene Chandler, R-Bartlett, however, said, "There are many questions still outstanding on this issue. This is the wrong time and the wrong bill for the State of New Hampshire."
The session began with more than an hour of procedural votes as former House Speaker William O'Brien, R-Mont Vernon, led the charge.
O'Brien maintained that portions of the bill were not "germane" to a House special session rule requiring that all sections of the bill deal with Medicaid expansion.
But House Speaker Terie Norelli, D-Portsmouth, ruled the entire bill was germane, and was upheld on several roll call votes. She ruled O'Brien out of order for continuing to try to make motions, citing a parliamentary rule that he was trying to "obstruct" the business of the House.
O'Brien challenged Norelli's ruling, but Norelli was upheld on another roll call.
Rep. Steve Vaillancourt, R-Manchester, moved to indefinitely postpone the bill, but his motion failed, 159-195.
Rep. John Hikel, R-Goffstown, moved to adjourn the session, but was voted down, 144-211, before the House finally began debating the bill.
The Senate first voted down the Republican proposal from Senate President Chuck Morse, R-Salem, when three Republicans — Sens. Sharon Carson of Londonderry, Russell Prescott of Kingston and Andy Sanborn of Bedford — joined Democrats for a 14-10 vote.
The Senate then voted down party lines 13-11 to kill a Democrat proposal that extends to two years the transition period from the state's Medicaid program to private insurance through the federal marketplace before a 13-11 vote for a Republican proposal to eliminate the transition period and not begin Medicaid expansion until the state obtains all the needed federal waivers, something estimated to take up to 18 months.
But lacking the votes to pass the bill, Senate Republicans tabled it on a party line 13-11 vote. Sanborn said he could not support the bill.
After the Senate session Sen. Lou D'Allesandro, D-Manchester, said the state's citizens deserve more from their Legislature.
"Let's not leave this body without accomplishing something we all want; to take care of the people we represent," D'Allesandro said during the session. "It's what we do in this building — not Republicans, not Democrats — it's what we do to solve problems."
But opponents to expansion in the House said lawmakers could try harder to protect taxpayers.
Rep. Neal Kurk R-Weare, called the bill unaffordable and asked for work on a "reasonable compromise" in the full legislative session beginning in January.
"We can get it right," he said. "Let's do it right in the next session."
One of seven states
New Hampshire is one of seven states that have yet to decide whether to expand Medicaid. To date, 25 states plus Washington, D.C., have decided to expand Medicaid and 18 have rejected expansion.
Under the ACA, Medicaid eligibility would expand to adults 65 years old and under earning 138 percent of the federal poverty level, about $16,000.
The state's health care providers would be paid $2.4 billion over seven years for the health care of the 49,000 state residents expected to be eligible under expansion.
For the first three years of expansion beginning Jan. 1, the federal government will pay 100 percent of the cost for the newly eligible Medicaid recipients and then gradually decrease to 90 percent in 2020.