Jonathan P. Baird

This piece appeared in the Concord Monitor on April 6, 2014 under the title “Impressive Political Maturity from Medicaid Expansion Activists”. Jon

The passage of the bill which expands Medicaid coverage to low-income citizens in New Hampshire is a historic accomplishment. Governor Maggie Hassan signed the bill on March 27 and the program becomes available for most people on July 1.

The Medicaid expansion will cover 50,000 poor New Hampshire residents who previously had no insurance coverage. Up til now, Medicaid had gaps in coverage for adults because eligibility was restricted to specific categories. If you were a single parent with dependent children, an adult with disabilities or a poor elderly person, you possibly could qualify. Now all adults earning up to 138 percent of the federal poverty limit should be able to qualify. That translates into coverage for a single adult who is earning up to $15,856. The income limit rises based on family size.

There are many costs to being uninsured. Without insurance, people needing care often avoid it. Because people wait on getting medical care, chronic medical problems become acute, Medical bills become a disincentive to going to the doctor. In the worst cases, medical debt leads to bankruptcy, major depression and suicidal ideation. Medical providers have needed to raise rates on insured people to deal with the large numbers of uninsured so there is a big economic ripple effect. The Medicaid expansion will help to break this vicious cycle since those previously uninsured will now be paying through Medicaid.

Advocates deserve much credit for building a winning coalition around the Medicaid expansion. The political maturity of this effort was impressive. The coalition included, among others, business leaders, health care providers, seniors’ organizations and a wide array of advocates reflecting different interest groups.

Instead of posturing and making impossibly purist demands, advocates used creativity in adjusting a plan specific to New Hampshire. Under the bi-partisan bill, low-wage workers will be able to use federal Medicaid dollars to buy private health insurance. This is a bit unorthodox and requires a waiver from the federal government but it allowed moderate Republicans to jump on board.

Since the New Hampshire Senate is controlled by Republicans, getting the majority in the Senate to support the Medicaid expansion was no easy task. This is particularly true because many on the right have built their 2014 political platform on opposition to Obamacare. The Medicaid expansion is an essential element of Obamacare.

I do think there is much to learn from the success of advocates in this effort. As a long-time progressive and a reader particularly of the progressive and left-wing blogosphere, I am used to seeing the glass half empty perspective. Obamacare is not single payer national health insurance. So many gnash their teeth and bemoan that.

From my past experience, many of the bemoaners are removed from the legislative process. It is easy to rail from the sidelines when you are not in the game. In my earlier life when I previously worked as a legal aid lobbyist, I was always impressed by the persistence and determination of my typically more conservative opponents. Many of the business lobbyists practically seemed to live at the legislature 24/7. That was in stark contrast to progressives who were often MIA. I used to think my side could learn from the conservative forces who did not give up and go cry in their beer. You could always count on the conservatives to be there even when they were losing.

I think you can see the Medicaid expansion from the glass half full perspective. True, everyone is not covered but this is the biggest advance I have seen in many a moon. I think the reform sets the stage for further advances toward universal coverage.

I am hopeful that the New Hampshire example can influence other states to follow our lead. When the U.S. Supreme Court ruled in June 2012 and affirmed the constitutionality of the Affordable Care Act, the Court gave states an option of expanding Medicaid. With New Hampshire as the newest addition, 26 states have now signed on with the expansion.

However, that leaves 24 other states who have not opted for the Medicaid expansion. Six of the states, including Maine, are currently considering it. The New Hampshire example may offer a way forward for those states on the fence or currently balking.

An irony of the Medicaid expansion is that the states who are refusing expansion would benefit the most from it. The states include all the southern states as well as some heartland and Rocky Mountain states. We are talking five million poor uninsured adults who will lack coverage because their state did not opt for Medicaid expansion.

There is a gap in coverage between current Medicaid eligibility and the lower limit of those Obamacare recipients who would get subsidized insurance through the federal marketplace. Just to be more specific, of the five million people who live in states that have not opted to expand Medicaid, about 20% of that group reside in Texas, 16% in Florida, 8% in Georgia, and 7% in North Carolina.

A recent Gallup poll shows that the Southern states are where residents are struggling the most to afford health care. I guess the other side of Southern hospitality toward strangers is meanness toward your own citizens. You can be sure that the governors and legislators in the south who are blocking this advance have fine medical insurance coverage for themselves.

The Medicaid expansion will inject hundreds of millions of dollars in federal funds into New Hampshire’s economy. The federal Medicaid money will allow low wage workers to spend money on other critical needs like housing, food and utilities. This should be a direct benefit for local businesses.

As more states like New Hampshire enact the Medicaid expansion, I think it will put more pressure on the states who had initially opted out to reverse course. Their citizens will see the benefit and will want it for themselves. The course of change is usually not a straight shot . It is more circuitous and Medicaid expansion is no exception.