Failure of Republican ‘repeal-and-replace’ bills keeps Medicaid expansion alive

The Affordable Care Act, which allows states to expand their Medicaid programs to include those up to 138 percent of the poverty level, was on the Capitol Hill chopping block earlier this year, but when Republican efforts to repeal and replace the law failed, the program survived.

Now, as the result of a major change to health care policy implemented three weeks ago by the Trump administration, some states are moving to implement work requirements that would affect some Medicaid expansion participants.


With attention in Congress now focused on immigration and a budget — and with a Trump administration infrastructure plan on the horizon – another GOP try for a broad repeal-and-replace plan seems unlikely before the mid-term election.

“What I’m hearing is that the focus in the short term will be on tweaks and changes to a lot of the problem areas in the health care system,” said Greg Moore, state director of the conservative issues group Americans for Prosperity and a former public affairs director at the New Hampshire Department of Health and Human Services. “But as far as comprehensive change relative to a lot of the significant components of Obamacare, that is probably unlikely at the federal level in 2018.”

That’s good news for Affordable Care Act supporters. U.S. Sens. Jeanne Shaheen and Maggie Hassan and U.S. Reps. Carol Shea-Porter and Ann Kuster, all Democrats, strongly support Obamacare and strongly opposed the Republican repeal-and-replace bills. They charged that those bills would have drastically cut Medicaid overall and the expansion program in particular.

Shaheen called an early Senate GOP repeal-and-replace bill potentially “devastating to the health of Granite Staters.” She called the most recent Republican bill, which was pulled from the Senate agenda in September, “unconscionable.”

Hassan in September said the Graham-Cassidy bill, which was before the Senate at that time, was “every bit as dangerous as the ‘Trumpcare’ plans we saw this summer, if not worse.”

Moore said, however, that rather than push another sweeping bill, “the real changes on health care will take place at the state level. That’s where we’ll see more flexibility offered by the federal government within their waiver authority to allow states to adjust programming, whether it’s Medicaid, Medicare or the marketplace.”


A prime example was a decision by the U.S. Department of Health and Human Services’ Center for Medicare and Medicaid Services (CMS) two weeks ago to allow states to impose work requirements for some Medicaid recipients.

At the New Hampshire State House, state Senate Majority Leader Jeb Bradley, R-Wolfeboro, said lawmakers are working on a plan to reauthorize the state’s Medicaid expansion program with a work requirement as a key component. He said they are moving forward under the assumption that Congress will leave the current health care system, including Medicaid, largely intact through this year and probably well into 2019.

Paying for the state share

Bradley said that when New Hampshire implemented Medicaid expansion for the first time in 2014, the federal government paid 100 percent of the cost of the program. When it was reauthorized in 2016, the federal share dropped to 95 percent, leaving New Hampshire with current a state annual cost of $35 million to $40 million, while the federal government, he said, is contributing nearly $500 million.

Next year, Bradley said, the federal share will drop to 93 percent, and the following year, to 90 percent. But Bradley said he and other lawmakers working on a reauthorization plan intend to save state and federal government millions of dollars by switching from the current premium assistance model to a managed care model.

“We should be able to show significant savings to the feds in this program by moving to a managed care product,” Bradley said. “We’ll focus on preventative care and minimize the use of emergency rooms and provide incentives for wellness. That will be more cost effective.”

He said the change will directly address a CMS finding in August that the state’s method for funding its share of Medicaid expansion through insurance premium tax payments and “voluntary provider contributions” by the state’s hospitals did not comply with federal law. No state tax dollars were used, and Bradley said that while work on identifying new funding sources is still underway, no taxpayer dollars will be used in the new reauthorization plan.

“These are the details that we’re working through right now, and I think it will be resolved fairly soon,” Bradley said. He said he has no specific timetable for unveiling the legislation, but he said the bill must be introduced, have a public hearing, win approval by the Senate and be passed to the House by late March.

“I think there is consensus at the State House to reauthorize Medicaid expansion,” Bradley said. “But I also think we would lose that consensus that was built in 2016 if we raise New Hampshire taxes or implement fees.”

Work requirement

New Hampshire was among 10 states that applied to CMS during the Obama administration for waivers to allow work requirements for some Medicaid expansion recipients. Those requests were denied because CMS officials said a work requirement was not consistent with the objectives of the Medicaid program.

The Trump administration reversed that position on Jan. 11, finding, “Productive work and community engagement may improve health outcomes.”

Gov. Chris Sununu praised the decision.

“Work requirements offer opportunities to lift individuals out of poverty, empower them with the dignity of work and self-reliability while also allowing states to control the costs of their Medicaid programs,” he said. “They also assist people to gain the skills necessary for long-term independence and success.”

Hassan, as governor, signed into law the Medicaid expansion reauthorization bill that included the work requirement. While not enthusiastic about the requirement, she accepted it as part of a compromise with the Republican-controlled state Legislature in order to continue the expansion program.

Does Hassan support a work requirement now?

“The vast majority of people on Medicaid expansion are working,” Hassan spokesman Aaron Jacobs said Friday. “We would need to see the details of the Legislature’s plan to reauthorize Medicaid expansion, but it’s critical that any plan does not punish people who are family caregivers, who are ill, or who have substance use disorders.”

“We know that some people are prevented from working because of chronic health conditions, and with high-quality health care, they may be able to return to the workforce,” Jacobs said.

Bradley said the goal of the work requirement is “to make sure that able-bodied adults are not just receiving a benefit without some work or community engagement – a job, pursuing education, or caring for an ill relative or volunteering. There are different avenues to fulfill the work requirement, or community engagement requirement, that CMS allowed.”

He said that the CMS decision adopted an approach taken by officials in Kentucky and, as a result, will require changes to New Hampshire’s pending waiver application.

“They will not be huge changes, but we will have to conform to Kentucky or run the risk that it doesn’t get approved,” he said. “I hope that people on both sides of the political spectrum will support this. We want to help people, but we also want people to help themselves.”

“Just to be able to get a benefit without having some responsibility, I think that runs counter to our live-free-or-die spirit.”

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