Jonathan P. Baird

When the New Hampshire Legislature passed the Medicaid expansion in 2014, there was one noteworthy wrinkle. The very creative Medicaid expansion plan had a sunset provision which meant it must be reauthorized by our new Legislature.That reauthorization, as part of the general budget discussion, is under review by legislators now.

Let’s be clear about what the Medicaid expansion has done. It uses available federal funds to offer health coverage to lower-income adults up to 138 percent of the federal poverty level. So far it has attracted 36,404 new recipients to the Medicaid rolls in New Hampshire. It is expected an additional 25,000 will enroll over the next six years, assuming the Medicaid expansion is reauthorized.

Overwhelmingly, the new enrollees are from low income working families. These are exactly the people who had been uninsured prior to the legislation because they could not afford the cost of health insurance. That lack of affordability is the major reason why so many do not have insurance.

New Hampshire must now consider whether the program will continue or whether it will throw thousands off the insurance they have newly obtained. Early program results have been promising. The New Hampshire Hospital Association just released a study showing that in 2014 there was a 17% reduction in the number of emergency room patients without insurance compared to 2013.

Failure to reauthorize would be the kiss of death for health insurance for these many thousands of newly insured. It is hard to estimate the damage if the Medicaid expansion goes away but I think it would be huge.

Realistically, there is no likelihood a Republican-led legislature would be crafting any alternative health insurance plan in 2015-2016 to insure low and moderate income New Hampshire citizens. Based on the available evidence, snow is more likely in July.

One oddity of the national debate around Medicaid expansion has been the emergence of the perspective that it is fine to be uninsured. Former Texas Governor Rick Perry has best articulated this position. With 22% of its residents uninsured, Texas holds the brutal distinction of having the highest rate of uninsured people in the country. In February, Republican presidential candidate Perry, on a campaign swing in New Hampshire, was quoted, saying:

“Texas has been criticized for having a large number of uninsured. But that’s what Texans wanted. They did not want a large government program forcing everyone to purchase insurance.”

I could be wrong but I do not believe any other major politician has spoken up for the alleged value of being uninsured. Perry is the first to brag about it like it is a golden badge to wear proudly. In Texas, Perry and his brand of extreme conservatives have denied 1.5 million low income people the chance to be insured. This is the estimated number of low income people in Texas who would benefit from a Medicaid expansion.

Only in the United States is there a serious debate about the value of insurance coverage for protecting health. That debate has been long settled in all other advanced industrial countries. All recognize the importance of being insured. Not to recognize that is almost the equivalent of being a flat earther.

So how is it that some have come to devalue having health insurance? Cynically, I think many of those who do the devaluing have plenty of money and they have good health insurance. Like Rick Perry, they advocate no health insurance for others.

I expect these liberty lovers who tout the freedom to be uninsured have never had a personal health crisis where they faced the future with no insurance or inadequate insurance. If they had had that kind of personal experience and they still believed in this “freedom”, you would have to wonder if there was a screw loose.

I had my own personal wake-up call and increased awareness about the importance of health insurance when I was 42. After going on a long, freezing winter hike, I came home and realized there was a slight swelling under my left arm. The next day I went over to New London Hospital to see my primary care physician. I do remember the look on his face when he examined me. He was as white as a sheet and he said I needed to see a surgeon for a biopsy.

I arranged for that, had it done at New London Hospital and then waited two weeks for the results. The verdict: malignant melanoma. Probably like many relatively young patients, I went through shock and disbelief. I was healthy. How could that person in the medical records be me?

Then I had to figure out what to do next. It was not that easy. Different doctors suggested different treatment. I went to see a radiation oncologist at Dartmouth Hitchcock Medical Center. He suggested radiation. Then I went to Brigham and Women’s Hospital in Boston to see a surgical oncologist. He suggested surgery. It was hard not to notice that doctors were businessmen who wanted business.

I did my own research and decided on surgery as the most effective treatment. I had been very impressed by the surgical oncologist I saw.

Meanwhile, the medical bills started cascading in. They were extremely confusing and I had insurance. It was honestly hard to tell how much you owed. I felt like I needed an interpreter to understand the bills. I was left with the impression that a cash register starts ringing the second you enter medical facilities and it keeps going while you are there.

I did end up having surgery which was successful. (I am still here.) The insurer required a Massachusetts pay rate when my insurance was New Hampshire-based. Even after my insurer paid, I still owed a sizable balance. I talked to my oncologist and asked him if he would accept the New Hampshire pay rate as payment in full. He very graciously agreed and waived the cost difference between state plans. Still, there were a raft of other bills that flooded in. It took me a while to resolve everything.

I had insurance and I can only imagine the outcome if I had no insurance. I probably would not have been able to see that fine oncologist. I am not sure I would have ever gotten out from under the avalanche of medical bills. It would have meant a financial burial.

There is a significant body of social science research about the costs of being uninsured. Maybe it is stating the obvious but when people lack health insurance, they are much less likely to go to the doctor when they have a medical issue because they cannot afford the treatment. They must pay out of pocket and that is a big disincentive. Medical expenses compete against other necessities requiring payment.

Lack of health insurance has led to thousands of avoidable deaths, poorly managed conditions, and undetected or untreated cancers. Lacking insurance is generally recognized as the sixth leading cause of death for people ages 25 to 64 behind cancer, heart disease, injuries, suicides and cerebrovascular disease.

I have not touched on the financial benefits to our state of having the Medicaid expansion. It has brought hundreds of millions of dollars into the New Hampshire economy. For the enrollees, they can spend their money on other needs. They do not have to worry about paying medical bills that were previously unaffordable. More generally, for the state and for local government, there is a significant cost-saving. These folks will not be downshifting medical costs onto city and town welfare.

Legislators need to find a way to get the reauthorization done. Even if only looked at from an economic angle, there is too much money on the table to pass up. By any rational cost benefit analysis, the cost to the state is very small compared to the benefits gained.

I do think the narrative of this story is very American. It is about inclusion and consideration for the health and well-being of more New Hampshire citizens.