As N.H. nears a Medicaid work requirement, Dems remain skeptical

It took two years and a change in presidential administrations, but a long-sought federal waiver to add a work requirement to New Hampshire’s Medicaid expansion appears within reach.

On Thursday, the federal Centers for Medicare and Medicaid Services, known as CMS, issued a letter to state governors allowing states to apply for work requirement waivers to the Medicaid expansion program.

But as the drafting of the reauthorization bill gets underway, a pivotal question remains: Will New Hampshire Democrats accept a new work requirement to save a program they’ve championed from the start?

Some in the party are not yet sold.

“I’m very concerned,” House Democratic Leader Steve Shurtleff of Penacook said last week. ‘The whole purpose of Medicaid expansion was to make people healthy. And to put up any kind of a roadblock that would keep people from not wanting to apply to receive those benefits, I think, could be dangerous.”

Shurtleff’s remarks are not out of place with his party’s position nationally.

But in New Hampshire, with an all-Republican Legislature and governorship, the political calculus is different. Whether to accept federal funding for Medicaid expansion – an option first extended to states through the Affordable Care Act in 2014 – has been a volatile question since the beginning. Republicans have warned of ballooning future costs to the state, while Democrats have touted the program’s services to low-income people just above the poverty cutoff for traditional Medicaid.

In 2016, a bill to reauthorize the program, which included a work requirement, narrowly passed the Legislature – with Democrats voting in favor of that requirement. But under the Obama administration, CMS denied the waiver request, and the provision stayed dormant.

Last year, with a new administration and a radical shift in health care philosophies, New Hampshire Republicans pressed again, adding to the budget trailer bill a proviso that the Legislature secure a new, different federal work requirement waiver for New Hampshire’s expansion by April 30, 2018, or let the entire program sunset.

Last week’s announcement was the clearest indication yet that New Hampshire’s application, submitted in October, could be finally granted.

Now, Democrats – the primary advocates for reauthorizing a program that holds thin support among Republicans – are keeping cautious on how to proceed.

Shurtleff’s Senate counterpart, Minority Leader Jeff Woodburn, favors pragmatism. Democrats should support a work requirement in theoryand direct their political energies to staving off other potential conditions to care, such as mandatory premiums or co-pays, he said Friday.

“In this debate, Democrats in the Senate understand that we have to bend, we have to work with the majority to get the program renewed,” said Woodburn, of Whitefield. “We have to compromise. Democrats want this program. We’re not playing politics.”

But guiding that support, Woodburn added, is the presumption that any work requirement would adequately exempt people with disabilities.

In its October waiver application, New Hampshire requested it be allowed to require those without disabilities who receive Medicaid expansion services to work 20 hours a week in their first year of the program, a quota that would increase over time. The requirement would not apply to those not considered able-bodied adults under the Social Security Act, as well as those in drug treatment, incapacitated by illness and those providing care to relatives.

The CMS guidelines released last week, meanwhile, established broad outlines for how states could impose work requirements – including by providing exemptions on the basis of disability.

“Democrats obviously respect and value the purpose and the value of work and improvement,” Woodburn said. “So we see this as a very positive thing. But there’s also people in our community that can’t for various reasons. We want to find a way to get them into the workforce or get them into volunteer activity to make their lives meaningful and useful.”

But as the drafting process for the new plan continues, it is still unclear whether New Hampshire’s waiver application will be wholly accepted by CMS under its new guidelines, without reservations. And if it does get through, the exact nature of the requirement could affect Democratic support; while Democrats got behind requirement in theory during the reauthorization effort in 2016, they rejected the later language set out in the 2017 budget trailer bill, HB 517. Skepticism abounds. 

“Conceptually Democrats have previously voted for a work requirement, but the devil will be in the details, especially in light of the new CMS guidance,” said Sen. Dan Feltes, who served on a bipartisan study commission into New Hampshire’s Medicaid expansion program, chaired by Senate Majority Leader Jeb Bradley. 

Rep. Cindy Rosenwald, the deputy House Democratic leader, argued that imposing a work requirement will impose responsibilities on the state as well as the workers – responsibilities that carry extra costs. Some who are able to work don’t have the transportation options to do so; money will need to be provided to accommodate them, Rosenwald said.

“I’d want to have those answers – I’d want to know what it’s going to cost the state,” said Rosenwald, who also served on the study commission. And she expressed doubt that one of the intended benefits of a work requirement – increased health outcomes – will pan out.

Whatever Democrats’ reservations, the process at this point may be by and large out of their hands. While the parties have worked together so far – last year the study commission voted unanimously in favor of shifting the program to a managed care  model – the crafting of the work requirement is presently in the hands of Bradley and Republican leadership, Woodburn said. 

“We’re allowing Sen. Bradley and his team to try and put a deal together, and we understand how difficult it is, and we’re respectful of that,” Woodburn said. 

But the final bill is very likely to include a work requirement. To Shurtleff, that remains a vital concern.

“Other programs I could see having some form of a work requirement, but not the health care,” he said. “This surely isn’t appropriate.”

(Ethan DeWitt can be reached at, or on Twitter at@edewittNH.)
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