#

In an attempt to reach a compromise with reluctant House Republicans, the Senate Finance Committee Tuesday added a seven-year sunset clause to the proposed reauthorization of Medicaid Expansion.

“From where I sit, seven years is pretty darn good,” said Senate President Jeb Bradley (R-Wolfeboro).

The committee added the seven-year sunset as it moved SB263 to become part of the biennial budget and a major part of the GOP majority’s Family First platform.

“We have allocated resources to support key areas such as education, our economy, health care, infrastructure, and public safety, all while delivering more financial support to our communities. Further, the Senate Finance Committee accomplished all this while reducing spending by three-quarters of a billion dollars less than the budget was brought to us,” Bradley said.

The budget includes $169 million for education, $30 million for the Housing Champions program, an additional $10 million for local homelessness programs, and a $134 million increase to the Medicaid reimbursement rate. Senate Finance Chair Sen. James Gray (R-Rochester) said that was all being done without adding to the tax burden.

“Throughout the budget process, we have remained mindful of the diverse needs of our state, listening to the concerns of our constituents and working diligently to address them. This budget reflects our efforts to serve New Hampshire families without harming the financial stability of our Granite State,” Gray said.

Bradley is the main GOP driver behind SB263, the bill to continue New Hampshire’s Granite Advantage Medicaid program. It provides medical insurance for about 60,000 low-income residents and is scheduled to end next year without another reauthorization.

The bipartisan bill, already passed by the Senate, would have created a permanent Medicaid program as part of the Affordable Care Act. Though it is supported by New Hampshire’s medical and business communities, the bill ran into opposition from the slim GOP majority in the House.

House leadership under Speaker Sherman Packard (R-Londonderry) tried to limit the expansion to five or six years when SB263 went to the chamber earlier this month.

With the measure now heading to the House Finance Committee later this week, pressure was on to reach a compromise that could get to Gov. Chris Sununu’s desk. Sen. Cindy Rosenwald (D-Nashua) agreed to Bradley’s amendment limiting the expansion to seven years, saying it could always be changed next year.

“If the House retains the bill, we can override the seven-year sunset next year,” Rosenwald said.

Bradley said the seven-year extension allows the state to seek the best deal with managed care companies to administer the insurance. Any shorter time frame could add about 10 to 15 percent to the costs, he said. The bill also includes a clause to revive a commission that will investigate the future of the expanded Medicaid program.

“The seven-year sunset, I believe, is an acceptable compromise,” Bradley said.

Sen. Regina Birdsell (R-Hampstead) said the budget protects families while strengthening the state’s economy.

“By extending our innovative Granite Advantage Health Care Program for seven years and increasing Medicaid reimbursement rates by $134 million, this budget will not only safeguard the health and well-being of New Hampshire’s most vulnerable populations but also provide financial stability to our state’s health care sector,” Birdsell said.

Steve Ahnen, president of the New Hampshire Hospital Association, praised the compromise.

“We are pleased with the agreement on reauthorization of Medicaid expansion for the next seven years as part of the state budget for fiscal years 2024 and 2025 currently in Senate Finance,” Ahnen said. “This agreement will provide much-needed stability for the program that will serve our patients, providers, and the state well. The Granite Advantage Health Care Program has successfully helped to ensure our patients are able to receive the right care, at the right time, in the right place, and this compromise agreement will continue to help people access the care they need, when and where they need it. We appreciate the bipartisan leadership in both the Senate and House in reaching this important compromise.”

Under the Affordable Care Act, 90 percent of Granite Advantage is paid for by the federal government, with the remaining 10 percent getting funded by an insurance premium tax and other sources. In 2022, Granite Advantage cost a total of $558 million, but the federal government covered $502 million.

Expanding Medicaid to low-income residents has created savings for hospitals and led to more people being healthier and able to enter the workforce. It is also driving the costs of private insurance down by cutting the amount of money hospitals lose providing uncompensated care.

According to the New Hampshire Hospital Association, Granite Advantage has led to a 63 percent decrease in the number of uninsured people going to emergency rooms. There has also been a 57 percent drop in uninsured people being admitted to hospitals and another 41 percent reduction in the number of outpatient visits by uninsured people.

In 2014, hospitals reported $174 million in uncompensated care costs before Granite Advantage went into effect. In 2021, that figure dropped to $69 million, according to the NHHA.

Granite Advantage has also helped close to 30,000 people have been able to access mental health care. Another 9,000 have been able to seek treatment for substance use disorders.

As the bipartisan bill to reauthorize New Hampshire’s Medicaid expansion program, Granite Advantage, moves through the legislature, backers are making a conservative case for the expansion.

Senate President Jeb Bradley (R-Wolfeboro) is one of the bill’s prime sponsors. He says expanding Medicaid has lowered healthcare costs, improved healthcare for Granite Staters, and helped get more people into the workforce.

“The program has worked as intended,” Bradley said.

The Granite Advantage bill, SB 263, won unanimous support in the Senate last month. It’s scheduled for an executive session discussion on Wednesday before the House Health, Human Services and Elderly Affairs Committee. If approved, the bill will then head to the full House for a vote.

Granite Advantage was last reauthorized in 2018 and is set to expire at the end of the year without SB 263’s passage. Enrollment in the program was around 94,000 residents at the start of the year, though the national COVID-19 emergency inflated those numbers. Those figures are expected to return to around 60,000 residents in the coming months.

SB 263 would reauthorize the program and remove the requirement that the legislature pass legislation to reauthorize it every few years, instead relying on a study commission to send an annual report to the legislature reporting on the effectiveness of the program. Even if SB 263 were to pass, the legislature could sunset this program at any time by a vote of the legislature.

According to Bradley, providing coverage through Granite Advantage is taking a bite out of healthcare costs. The program is driving down the cost of uncompensated care hospitals are required to provide to people without insurance. That protects people with private insurance from being stuck picking up the tab when someone without insurance goes to an emergency room for treatment, he said.

“[Uncompensated care] is a hidden tax on any individual or any business with private insurance,” Bradley said.

According to the New Hampshire Hospital Association, Granite Advantage has led to a 63 percent decrease in the number of uninsured people going to emergency rooms. There has also been a 57 percent drop in uninsured people being admitted to hospitals and another 41 percent reduction in the number of outpatient visits by the uninsured.

In 2014, hospitals reported $174 million in uncompensated care costs before Granite Advantage went into effect. In 2021, that figure dropped to $69 million, according to the NHHA.

Sen. Lou D’Allesandro (D-Manchester) said permanently expanding Granite Advantage makes sense beyond the numbers.

“I just feel it’s the right thing to do,” D’Allesandro said. “We take care of a lot of people.

And, he pointed out, the bill does not use any money from the state’s General Fund.

The bill’s costs are 90 percent covered by the federal government. In 2022, Granite Advantage cost $558 million, but the federal government covered $502 million. According to Bradley, the remaining $56 million was paid through healthcare taxes and fees, with money from the state liquor fund also available to cover costs.

New Hampshire Business and Industry Association (BIA) President and CEO Michael Skelton said abandoning Medicaid expansion would hurt both the state’s economy and the people who make New Hampshire’s growing economy possible.

“We benefit from an overall healthier population,” Skelton said. “Hospitals and other caregivers avoid catastrophic loss of revenue, and employers and employees across the state will benefit from individuals being healthy enough to work.”

In addition to the BIA, numerous other NH-based business organizations including the NH Retail Association and several chambers of commerce have advocated for the reauthorization of Medicaid expansion.

Granite Staters are paying too much for healthcare, have too few options, and don’t want to be stuck with government-run plans that are part of the Affordable Care Act.

That was the view of several panelists who participated in a radio roundtable on the Pulse of New Hampshire Friday, led by host Jack Heath. 

Heath said the politics of healthcare have become too fraught with Republicans and Democrats dug in. “Republicans would prefer private healthcare options, but they run away from the issue,” Heath said.

Americans for Prosperity New Hampshire head Greg Moore is also a former director at the N.H. Department of Health and Human Services. He said that in poll after poll, New Hampshire residents say they want better choices.

“People don’t like high costs, and they don’t like government-run healthcare,” Moore said. “There are other options, like giving everyone an HSA (health savings account).” 

There are ways to create more competition in the healthcare marketplace that will help drive down costs; he said. Moore favors options like changing the tax code to give individuals the same healthcare tax benefits that businesses currently enjoy.

The Main Street Freedom Alliance radio roundtable on health care hosted by Jack Heath on April 14, 2023.

And it’s not just individuals who are sick of the costs and regulations. Christie Elliot Peters, co-owner of Elliot Controls, an Amherst HVAC company that specializes in automated building controls, said her employees would love to be able to sign up for the company health plan rather than the Affordable Care Act Granite Advantage plan. But the plans her small business is able to secure can price out some workers. She said the costs have been going up almost every year for decades.

“When I trace back, the jumps we have had in rates result from legislation that was supposed to fix the problems or because of the Affordable Care Act,” Peters said.

State Sen. Keith Murphy (R-Bedford) owns Murphy’s Tap Room with locations in Manchester and Bedford. He told Heath he spends hundreds of hours every year trying to get the best plans to offer his 65 employees, But he said the plans are so expensive many of his younger workers opt out.

“When you’re 23, you’re immortal, you think,” Murphy said.

D.J. Bettencourt, deputy commissioner at New Hampshire’s Insurance Department, said Washington regulations that favor individual plans over small businesses are hurting the economy, especially in the Granite State. With New Hampshire companies struggling to hire workers, a good healthcare plan can be the difference between getting and keeping qualified employees.

“The government is trying to improve the individual market and not helping the small business market,” Bettencourt said.

He said New Hampshire’s economy relies on small business owners like Peters and Murphy. “We are a small business state; they are the engine of our economy,” he said.

Bettencourt noted between the aging New Hampshire population and the large swath of people signed up for Granite Advantage; insurance carriers see less reason to offer their plans in New Hampshire given the small pool of potential customers. 

“Layer on government regulations with that smaller pool, it’s even less attractive for (insurance) companies.”

That leaves people and businesses with fewer, more expensive options.

State Rep. Jess Edwards (R-Auburn) told the roundtable people want more choice in their healthcare options, but the government simply cannot get out of the way. Part of the problem is the unwillingness of Democrats to revisit the Affordable Care Act. 

“Democrats would not support plans to let people out of [the ACA] and get on plans offered by small businesses,” Edwards said.

Republicans also seem unable to address the problem in a meaningful way on their side of the aisle. Bettencourt noted the GOP had a trifecta in 2017 — control of the U.S. House, Senate, and White House — and could still not pass legislation to give people more choices.

“They were like the dog that caught the car,” Bettencourt said.

Moore said Democrats are bent on pushing for more government involvement in the healthcare market as part of the ultimate push for universal healthcare.

“Democrats want to increase the number of people on government insurance,” Moore said. “We need a third way.”

Listen to the entire discussion here.

The end of the federal COVID Public Health Emergency is coming, and that could result in tens of thousands of New Hampshire residents without health insurance. 

When the pandemic hit, some Americans were left without jobs and health insurance. The COVID Public Health Emergency allowed people who lost their insurance to sign up for their state Medicaid plan. But that help is coming to an end soon.

The Granite State is ready, though, with organizations preparing people to sign up for coverage in the Affordable Care Act Marketplace.

“I believe New Hampshire is way ahead of most other states,” said Keith Ballingall, president of Market Health Connect. “The state right now contains different partners to make sure we’re all working together.”

Market Health Connect is one of several companies working in the state to get people signed up for health insurance ahead of the ending of the Public Health Emergency.

President Joe Biden recently extended the so-called Public Health Emergency until the middle of January, creating a perfect storm for Ballingall and his team at MHC. The end of the emergency coincides with the open sign-up period for the marketplace, meaning thousands more people will be looking for coverage.

Keith Ballingall, president of Health Market Connect

New Hampshire residents who are on Medicaid through the Public Health Emergency are now getting pink letters informing them they will lose their coverage when the emergency officially ends. Ballingall and his team are reaching out to those people now to get them ready to sign up for a new plan.

Ballingall said about 50,000 people are already anticipated to be looking for health care during the open sign-up period, and another 50,000 to 60,000 will be looking because they got pink letters from the state.

“When the Public Health Emergency ends we will have a 60-day window to help,” Ballingall said.

MHC has people, called navigators, positioned throughout the state serving specialized populations, he said. New Hampshire attracts people from all over the world, and there are dozens of languages spoken in the Granite State.

“I think we’re doing a very good job having a very diverse team ourselves,” he said.

The health care navigator program is community-driven, he said, with the navigators living in their regions, understanding the people there, and able to provide real on-the-ground help.

Donna Toomey, one of MHC’s healthcare navigators, is based in the Lakes Region and reaches out to people wherever she can find them.

“I have been doing this work for over 20 years,” Toomey said. “I am very rooted in my community.”

Toomey goes to public meetings and holds open hours at town halls and tax collector offices. She talks with local police and firefighters, goes to schools and attends wellness fairs and old home days, and even meets people at homeless shelters to connect with people who will need help in the coming weeks.

Navigators like Toomey can make sure people will still be able to go to the doctor and get care even if they get a pink letter.

“We’re starting applications for the Marketplace now if people are going to lose their coverage when the emergency ends. That way they won’t lose coverage,” Toomey said.

Ballingall said navigators at MHC can work with people now and do all the necessary paperwork so that they are prepared for the end of the Public Health Emergency, no matter how many people will need assistance.

“At some point, it’s going to go back to the traditional rolls, and we’ve got to find someplace for them to go,” Ballingall said.

Many people who got a pink letter will go to a new plan on the Marketplace, though some may remain signed up for state Medicaid, he said.

The challenge is to reach so many people before the end of the Public Health Emergency. Toomey said the state has made the process as easy as possible, and applications can be done in 15 minutes. The key is to be ready before the January rush.

“I think the name of the game is sooner rather than later,” Toomey said.

People who have received a pink letter can start the process by connecting with a navigator at MHC through the website, www.hmcnh.com.

People with anxiety and depression are disproportionately prescribed painkillers. That’s what new research from the Dartmouth-Hitchcock Medical Center suggests, adding a complex layer to the opioid epidemic ravaging the United States and encouraging calls from New Hampshire’s congressional delegation to not move forward with the repeal of the Affordable Care Act.

The findings, which appear in the July issue of the Journal of the American Board of Family Medicine, show that nearly 19 percent of the 38.6 million American adults with mental health disorders use prescription opioids compared to only 5 percent of those without a disorder. Adults with depression and anxiety receive 51 percent of the 115 million opioid prescriptions distributed each year in the U.S., the study found.

“Because of the vulnerable nature of patients with mental illness, such as their susceptibility for opioid dependency and abuse, this finding warrants urgent attention to determine if the risks associated with such prescribing are balanced with therapeutic benefits,” said Brian Sites, an anesthesiologist at Dartmouth-Hitchcock and one of the co-authors of the study.

Image Credit: Dartmouth-Hitchcock

Opioid prescribing in the U.S. quadrupled between 1999 and 2015, and during that time more than 183,000 people died from overdoses related to prescription opioids, according to the Centers for Disease Control and Prevention.

Sites also notes that because pain is subjective, “the presence of mental illness may influence the complex dynamic between patient, provider, and health system that results in the decision to write an opioid prescription.”

The study does not give a specific reason why people with mental disorders are more frequently prescribed opiates. The study encourages more research on this population to understand opiate addiction.

Those patients may have some form of physical pain, but their mental condition may cause them to feel that pain more acutely or be less able to cope with it, leading to increased requests for something to dull the pain. As a result, doctors trying to be empathetic to their patients’ complaints may tend to overprescribe opioid painkillers, Stiles said.

Research also shows that patients are more likely to take opioids when there aren’t specialists nearby. A study published earlier this year found that the number of seniors in rural America who take at least three prescribed psychotropic drugs ― including opioids and antidepressants ― tripled over a nine-year period. The study found that many of these prescriptions were given without a proper diagnosis.

Being able to identify a subset of the population that could be more likely to use opioids could help providers and policymakers address opioid use. It “suggests that there may be additional patient- and provider-related factors specific to those with mental illness that increase the likelihood of receiving prescription opioids,” the authors wrote.

U.S. Rep. Annie Kuster, D-N.H., was present for a press conference about the study on Monday. She said repealing Obamacare could be disastrous for New Hampshire’s opioid epidemic.

“This is critically important in New Hampshire, as we have gone from second in the nation in deaths from the opioid crisis and heroin to first for fentanyl,” she said. “That’s not what we want to be known as first in the nation for.”

The U.S. Congress is currently in a heated healthcare battle. The Senate is working on legislation to repeal the healthcare law, but a vote on the bill has been delayed due to opposition from Republicans. New Hampshire Democratic Sens. Jeanne Shaheen and Maggie Hassan have both stated their opposition to the healthcare overhaul and have sent many press releases condemning “Trumpcare.”

“This new study is yet another reminder that, to combat the devastating opioid crisis, we must make mental health treatment affordable and accessible,” Shaheen said in a statement.

Hassan said she opposes proposed cuts to Medicaid that would affect coverage of mental health and substance abuse services.

“As we work to combat the horrific substance misuse crisis that is devastating our communities and taking a major toll on our economy in New Hampshire, this study highlights how dangerous Trumpcare, which includes massive cuts to Medicaid, would be for our state,” Hassan said in a statement. “We need a comprehensive, holistic approach to combating this epidemic that addresses the underlying causes of addiction, including mental health issues.”

To address the overprescription problem within the mental health community, Sites has suggested physicians need more access to alternative medicine besides opioids, including acupuncture, massage therapy, physical therapy, and non-opioid pharmaceuticals.

Follow Kyle on Twitter.

Sign up for NH Journal’s must-read morning political newsletter.

For 2018, the company was seeking to increase premiums by about 30 percent but is working to organize as a new insurance provider, Minuteman Insurance. It would remain in the ACA exchange but would not be subject to the co-op rules.

“Offering our members a quality, more affordable coverage option has been Minuteman’s mission from day one,” said Minuteman Health CEO Tom Policelli. “We want to continue that mission in 2018 and beyond through the new company we are currently working to organize. Forming Minuteman Insurance Company will allow us to address numerous federal restrictions and work to make our coverage available to more people.”

Nationally, insurers are pulling out of some markets or are seeking to charge higher premiums. Republicans are hoping to repeal President Barack Obama’s health care law, and the Senate is pushing a bill that would leave 22 million more Americans uninsured over the next decade, according to a Monday analysis from the Congressional Budget Office. It would also cut the federal deficit by $321 billion, driven by reductions in Medicaid and smaller subsidies to help people buy insurance.

Minuteman Health is the second co-op to drop out of the New Hampshire market. Community Health Options pulled out for 2017 to focus on Maine, and recently announced it made a surplus after two years of losses. With Minuteman Health exiting, individual and small group customers in New Hampshire will have three options in next year’s exchange: Anthem, Harvard Pilgrim, and Ambetter.

With the American Health Care Act moving to the U.S. Senate, some New Hampshire Republicans are cheering as the bill makes its way through the legislative process. Yet, for some Trump supporters in the Granite State, especially in the North Country, they might not be too happy with its current version.

Despite still having some concerns about the AHCA, Gov. Chris Sununu said on Thursday that he was glad the bill passed the Republican-led U.S. House of Representatives.

“Failure to reform our health care system is not an option,” he said. “It is critical that we keep this conversation moving forward. My concerns with the AHCA remain firm and I expect that the United States Senate will take those concerns into consideration as they work to improve our nation’s health care system.”

Before the House passed the bill on Thursday afternoon, Sununu and 15 other governors sent a letter to House Speaker Paul Ryan reiterating their support for the Obamacare replacement and asked for states to have more flexibility when it comes to Medicaid.

It’s a similar letter Sununu signed on to earlier this year when the U.S. House tried to repeal and replace the Affordable Care Act the first time. In a Friday interview with the Concord Monitor, he applauded the passage of AHCA, but said he still had issues with the current version.

“I love the idea that Congress is taking action, the president is taking action,” he said. “They’re listening to the American people and they’re moving the ball forward. In it’s current form, I still have a lot of concerns, there’s no doubt. But we are moving it forward, and more important than anything is the need to reform the health care system right now that has failed the American people.”

It’s a different tone than he had in March, when he said the first version of the bill didn’t give states flexibility and would hurt New Hampshire’s expanded Medicaid program, which had bipartisan support.

“The bill that’s been proposed in Congress gives us concerns on a lot of different levels, to be very blunt about it,” Sununu said at a March press conference. “What I’m seeing in Washington gives me a lot of pause for concern to be sure, not just on the Medicaid expansion front, because that would drastically affect New Hampshire, but just on the mandates that are coming out of it.”

As expected, all of New Hampshire’s Democratic congressional delegation is opposed to the GOP-led plan. U.S. Reps. Carol Shea-Porter and Annie Kuster voted against the bill. Critics slammed the bill for potentially making millions lose health care and making it harder for people with some pre-existing conditions to find affordable insurance.

Some Granite State health care providers say more than 100,000 low-income New Hampshire residents could be at risk of losing health coverage under the AHCA plan. New Hampshire Hospital Association President Steve Ahnen said his organization was “deeply disappointed” that the U.S. House passed the health care bill.

“This bill is a significant step backwards on the commitment to ensure coverage and we cannot support it,” he said. “We will continue to work with Congress as this bill moves over to the Senate to ensure that any final legislation to repeal and replace the Affordable Care Act improves our health care system in a thoughtful and responsible way, rather than dismantling coverage for our most vulnerable residents.”

President Donald Trump campaigned aggressively on repealing Obamacare and lowering premiums. However, according to recent analysis, it appears premiums would significantly increase for older Granite Staters.

The Henry J. Kaiser Family Foundation, a nonprofit focused on health care, compared premium costs under the ACA and AHCA. For New Hampshire residents aged 60 or older who make $30,000, they could see their premium costs increase by 173 percent under AHCA. However, the same analysis also says younger residents in New Hampshire would pay less under the AHCA plan.

Many critics point out that the Trump-approved health care bill would negatively impact the people who voted for him. This holds up when using Coos County as an example.

Coos County overwhelmingly voted for Trump over Democrat Hillary Clinton by 52 to 43 percent, respectively. There is a large number of residents who are aged 65 and older in the North Country and the average household income is about $42,000, according to U.S. Census Bureau data. Those residents could fare worse under the AHCA plan than under the ACA.

In a Granite State Poll released Monday by the University of New Hampshire Survey Center, Trump’s approval rating in the state has remained steady at 43 percent. It’s the same rating he had in February. Republicans also still overwhelming approve of the president at 83 percent. Survey results from the North Country showed a statistically insignificant change.

It will be interesting to see over the next few months if residents in the North Country, especially those who voted for Trump, change their support. Nationally, it seems his base is sticking with him so far. Now, the U.S. Senate will now take over the AHCA bill and reports suggest the chamber will overhaul the legislation, making it different from the House version. The health care debate in Washington is far from over, leaving how it will ultimately impact New Hampshire a mystery for now.

Follow Kyle on Twitter.

Sign up for NH Journal’s must-read morning political newsletter.

To politicians who paint the picture of couples poring over a household budget and bills at their kitchen table: save the sympathy. Set an example.

The disappointing congressional budget process of Fiscal 2017 needs to be wrapped up quickly, with a federal government partial “shutdown” looming this Friday.

Comparing Congress to a procrastinating college student near spring semester’s end would disparage the student. Spring Break’s a week. Members of Congress just returned Monday from a two-week recess they gave themselves.

For two decades, the budget process has repeatedly broken down. Both major parties have relied on stopgap measures and omnibus bills to keep the federal government’s doors open. This way of conducting the country’s business is resulting in poor policy that produces large and growing deficits, adds to the nation’s debt, and leaves little time for serious long-term planning.

Doing better for Fiscal 2018 means at least approving all twelve appropriations bills for Fiscal 2018 — which begins October 1 — in a timely, orderly fashion. A crowded press conference with party leadership, and the chairs and ranking members of the House and Senate Committees on the Budget, committing to a calendar would be an optic that communicates an expectation to the full Congress and public.

Presidential administration officials have recently reiterated advocacy for increased defense spending, initial funding for a Mexican border wall, and altering or eliminating Affordable Care Act subsidy appropriations. Whether intentional or incidental in their complication of resolving the imminent operations shortfall, the executive branch has been enabled by a chaotic Congress.

Constituents aren’t explicitly asking for everything for nothing. But they have changed their minds some since the pre-election fall. The nonpartisan Pew Research Center has observed an 11-point swing toward a 48-45% preference for a bigger government, more services—for the first time in eight years, and almost across the board. When asked if they were making up the federal budget this year, a majority said they’d increase spending on six of 15 causes (in order of popularity: veterans benefits, education, rebuilding highways and bridges, Medicare, and health care). The 67% for increased federal spending on education are either overlooking the “local control” impulse or simply favor funding schools over federalism. Another six causes garnered plurality support for increased federal funding (descending: scientific research, military defense, environmental protection, anti-terrorism in the U.S., Social Security, assistance to the needy in the U.S.). At 48% for increased scientific research and another 38% for “Keep spending the same” in the survey conducted prior to last weekend’s March for Science, there’s an apparent appetite for maintaining to expanding exploration and innovation at parity with entitlement programs.

Americans surveyed by Pew said they’d keep spending the same for assistance to the unemployed, assistance to the needy around the world, and for the State Department and embassies. So there’s not a consensus or even inclination in favor of reducing spending on any sector. And the narrow two-percent margin for decrease as compared to increase for foreign aid (the plurality still for keeping spending the same) would undoubtedly disappear if respondents knew the actual spend data; Americans have historically overestimated U.S. foreign aid tenfold. We can’t afford it all amidst the nearly $20 trillion debt and reasonably expected revenues via Title 26 (the Internal Revenue Code) with its present enforcement mechanisms.

There are also people who want tax cuts. There are no people who want to keep paying hundreds of billions of dollars on debt service—i.e., on interest.

To the extent that foreign affairs are particularly unpredictable, a more predictable budgetary process in the Capitol would at least serve to “control what we can control.” Let’s get through this week, and then we can ask our congressional delegation to help lead on consistency.

The American Health Care Act (AHCA) was pulled Friday minutes before a vote was to take place on the bill in the U.S. House of Representatives, which essentially means Obamacare is here to stay.

House Republicans were shy of the votes needed to get the legislation passed, and defections from the conservative House Freedom Caucus, whose members didn’t think the “repeal and replace” bill went far enough, put it out of reach for President Donald Trump and House Speaker Paul Ryan.

After pulling the vote, Trump said that the “best thing we can do, politically speaking, is let Obamacare explode. It’s exploding right now. Almost all states have big problems.”

With no new health care plan in the foreseeable future, there are a couple of bills that New Hampshire lawmakers are expected to revisit that would make changes to Granite Staters’ health care.

Under AHCA, the Congressional Budget Office estimated that 14 million fewer people would be insured in the first year if it passed. Although it was unknown how many New Hampshire residents could have lost coverage under the plan, about 91,000 people had individual plans on the health exchanges as of February, according to state estimates. Also, 52,000 low-income people in New Hampshire who have insurance through Medicaid expansion were at risk.

It didn’t take long for the Granite State’s all-Democratic congressional delegation to praise the withdrawal of the AHCA, citing how much harm it would do to the state’s residents.

“It’s time for them to admit that while the Affordable Care Act is not perfect, it has made New Hampshire and the country healthier and is worth improving, rather than repealing,” U.S. Sen. Jeanne Shaheen said to WMUR.

U.S. Sen. Maggie Hassan also applauded the defeat of the bill.

“The failure of Trumpcare is good news for people across New Hampshire and America who would have faced higher costs for less care,” she said.

They also all said that Republicans and Democrats should work together to make improvements to former President Barack Obama’s Affordable Care Act (ACA).

“It’s time to have a serious discussion about improvements that can help our health care system work better for everyone,” U.S. Rep. Carol Shea-Porter said. “There’s so much more work to do if we can put partisanship aside and work for the good of our constituents. Let’s get to work.”

Since it appears Congress isn’t going to change health care, it’s now up to the states to make changes within the scope of the ACA, and that’s what the New Hampshire Legislature will do. Leaders of each state party also seem ready to tackle Medicaid expansion with bipartisanship, yet there appears to be some disagreement over when it should get done.

Gov. Chris Sununu said he had issues with the AHCA and he wanted flexibility under the law to allow states the power to implement the policy in ways that made sense to each state. He previously supported a block grant system for Medicaid, which would have capped the federal share, letting the states decide how to spend the dollars on care.

“The bill that’s been proposed in Congress gives us concerns on a lot of different levels,” Sununu said last week. “Expanded Medicaid is part of that discussion. There’s no doubt expanded Medicaid has provided [drug] recovery, treatment options for a lot of folks that otherwise may not have had that option available.”

New Hampshire was one of 31 states that expanded Medicaid under Obamacare. Former Democratic Gov. Maggie Hassan signed the plan into law in 2014 after working with Republican legislators to approve it in two-year increments. She signed the latest expansion bill in 2016. New Hampshire has more than 187,000 individuals enrolled in either traditional or expanded Medicaid, according to state health officials.

Now that block grants aren’t on the table anymore, New Hampshire lawmakers will figure out if they want to extend the program past 2018. The Senate tabled a bill last week, without debate, that would make Medicaid expansion permanent. Senate leadership said they wanted to see what happened with the AHCA before they debated Medicaid expansion in the state.

Senate Minority Leader Jeff Woodburn told NH1 News that “what we designed in a bipartisan fashion clearly has worked. Democrats are ready to move immediately.”

Senate Majority Leader Jeb Bradley said lawmakers shouldn’t rush into anything, especially since the New Hampshire Protection Health Program doesn’t expire until the end of next year.

“Even though the legislation in Washington was pulled and there’s no changes right now to federal guidelines for Medicaid Expansion, I think before we think about reauthorizing the current program, we need to make sure that’s exactly what’s going to happen in Washington that three or four or five months from now, they’re not coming back with a new health care bill,” Bradley told NH1 News. “If December comes and there are no changes to the ACA, that will guide us in what we’re going to do in terms of Medicaid Expansion next year. To me that’s the prudent way to do it. It’s what we did in 2016. We waited for the implementation to go forward in [2015]…So I continue to think doing it now is premature.”

Sununu has also previously indicated that he doesn’t want to continue kicking the can down the road with Medicaid expansion by renewing it every two years. He said he wants to find a long-term solution.

The right-leaning public policy group, Federalism in Action, released a 2016 study discussing the issue of long term care in New Hampshire and the challenges it will face in the future.

“New Hampshire is an apt harbinger of the country’s long-term care challenges. The state’s age 85 plus population will nearly quadruple in the next three and a half decades,” the report stated. “If its Medicaid long-term care expenditures for the elderly keep pace they’ll increase from $282 million per year to $1,047 million, more than one billion dollars every year. Sustainability at that level is highly dubious.”

It’s not immediately clear if New Hampshire lawmakers plan on taking the Medicaid expansion bill off the table in 2017 or will debate in 2018.

The N.H. Senate also tabled Senate Bill 149 last week that would allow out-of-state health insurance companies to operate in the Granite State without providing the benefits required under state law. It was tabled most likely to see what the federal government was going to do.

Significant questions still remain over what Obamacare would have in store for people with health insurance on the exchanges. Health experts are also curious about how the insurance industry will react in 2018. Will they stay or leave? What will rates be like? Minuteman Health in New Hampshire said it plans to be on the exchange in 2018, but no other health insurer has yet to say it would remain in the state.

Follow Kyle on Twitter.

Sign up for NH Journal’s must-read morning political newsletter.

When it comes to Medicaid expansion in New Hampshire, Gov. Chris Sununu is in a tight spot. It’s not just him, actually. A lot of Republican governors across the country are having a difficult time figuring out how to balance the “repeal and replace” rhetoric on Obamacare within their party, while also seeking to protect certain provisions of the health care law, like Medicaid, that help the residents of their states.

It’s a balancing act that Sununu, the first GOP governor in the Granite State in 12 years, waded into last week. He said in its current form, he’s not “signing on” to the House Republicans’ American Health Care Act due to his concerns over Medicaid funding and coverage.

“The bill that’s been proposed in Congress gives us concerns on a lot of different levels,” Sununu said on Tuesday. “Expanded Medicaid is part of that discussion. There’s no doubt expanded Medicaid has provided [drug] recovery, treatment options for a lot of folks that otherwise may not have had that option available.”

The Congressional Budget Office estimates that $880 million less in federal money would be spent on Medicaid over the next decade. The Republican plan phases out the program by 2020 with states receiving funding for existing expansion recipients as long as they maintain continuous Medicaid coverage.

The Medicaid provisions in the Republican’s bill are reigniting a longstanding debate between conservatives and moderates of the party. Conservatives are critical of the program’s cost and performance, while moderates are worried that cuts to the program will result in a loss of funds in their state’s budget, leaving patients without help.

Sununu falls into the latter category. He has previously indicated his support for Medicaid expansion, yet doesn’t want to make the program permanent. He’s waiting to see how the Medicaid battle plays out in Congress before taking any action in the state.

New Hampshire was one of 31 states that expanded Medicaid under former President Barack Obama’s Affordable Care Act. Former Democratic Gov. Maggie Hassan, now a U.S. senator for the state, signed the plan into law in 2014 after working with Republican legislators to approve it in two-year increments. She signed the latest expansion bill in 2016, with the program scheduled to expire at the end of 2018. New Hampshire has more than 187,000 individuals enrolled in either traditional or expanded Medicaid, according to state health officials.

During Sununu’s 2016 gubernatorial bid, he said extending the state’s Medicaid program until 2018 was “probably a good step forward,” but lawmakers shouldn’t keep doing it every two years.

“I like the idea that we’re moving forward without any tax payer burden, any tax burden on the taxpayers back,” he told NH1 News in February 2016. “We have essentially a public-private partnership helping to fund it as we move forward, and those are very positive steps. What I would like to see is a long term strategy for this state, not simply taking it in two- or four- year chunks.”

Democrats attempted to paint him as opposing Medicaid expansion because of his 2014 Executive Council vote against a $292 million state contract to implement Medicaid expansion. However, the item was added to the agenda at the last minute and he tried unsuccessfully for a two-week delay to fully understand the contract. He said the council shouldn’t vote on something that hasn’t been read thoroughly.

Yet, throughout the campaign, he was ambiguous about his plans for the future of Medicaid in New Hampshire. He didn’t indicate if he was supportive of extending past 2018 or would support an outright repeal of the program.

Those in New Hampshire who were concerned about Medicaid’s future were also not consoled by a letter Sununu sent to Congressional GOP leadership in January. With Republican President Donald Trump in the White House and GOP majorities in the U.S. House and Senate, it appeared that the repeal of Obamacare was imminent.

As a result, Sununu sent a letter to U.S. House Majority Leader Kevin McCarthy, urging Congress to give states as much flexibility as possible to design their own health care systems.

“We urge Congress to untie the hands of the States,” he wrote in the letter. “Let us have the flexibility to design a New Hampshire system for New Hampshire citizens.”

However, his letter left out any mention or comment on Medicaid expansion.

It wasn’t until February that Sununu became more clear on what he thinks about the program. He said “there’s no doubt that it’s [Medicaid expansion] been helpful.”

“It was a price tag of somewhere between $400 and $500 million,” he told NHPR. “We’ve been able to do it to date without a single New Hampshire taxpayer dollar. No state taxes go into it.”

Later that month, he expanded on what he wanted to see from Medicaid in the GOP’s health care plan.

“When we hear the term block grants coming out of Washington, especially with healthcare, the opportunities are tremendous for us,” he said at a meeting of the Concord Chamber of Commerce. “We spend tens of millions of dollars on the state level on things we simply don’t need. So give us a block grant.”

When Republicans initially rolled out their health care plan, block grants weren’t included. The House plan focused on paying states a fixed per-capita amount to cover their population based on their average expenses, but a Republican amendment to the bill allowed the option for states to choose a Medicaid block grant in lieu of the capped reimbursement model.

Under current health care laws, when an eligible person enrolls in Medicaid there are matching federal funds to ensure that they get care. The block grant proposal caps that federal share, letting states decide how to spend the dollars on care. However, many health care professionals say capping Medicaid funding in block grants could hurt access to quality health care for the poor, children, and elderly by cutting the amount of federal dollars available.

It’s not immediately clear if Sununu approves of the most recent, updated version of the American Health Care Act, but Sununu said he would work with Trump to to ensure that the bill gives states the opportunity to create “flexible” and “nimble” health care program.

Democrats in the state, including Hassan, believe block grants would fail to sustain the expanded Medicaid program. It’s a position that’s shared with many advocacy groups, including AARP, which released a “fact sheet” last week about how changing Medicaid to a block grant or per capita cap could hurt New Hampshire residents.

“The House bill will impact health care seriously, but what it would do to Medicaid expansion … it would in fact repeal it,” Hassan said at a press conference last week. “That [block grants] will make health insurance out of reach for thousands of Granite Staters, and it hurts the ability of those on the front lines to save lives and fight this [opioid] epidemic.”

New Hampshire has one of the highest drug overdose death rates in the country. Nearly 500 people died from drug overdoses in 2016 and approximately 6,000 Medicaid expansion recipients have accessed treatment, state health officials said.

Sununu, and other state Republican leaders, believe block grants will allow them to allocate the money to places that need it most, such as towns hardest hit by the opioid crisis. Yet, some policy experts argue that block grants will severely strain state budgets and leave states vulnerable when they have to deal with unexpected issues, like drug outbreaks that raise the average cost of treating individual patients.

Sununu said he has spoken with Trump and Vice President Mike Pence about the importance of Medicaid with treatment and recovery for the opioid crisis, and how that requirement should continue under the GOP plan.

The N.H. Senate tabled a bill Thursday, without debate, that would make Medicaid expansion permanent. The senators said they wanted to wait to see what will happen at the national level before they tackle it in the state.

As conservatives and moderates battle it out on Medicaid provisions in the GOP health care bill, it appears New Hampshire, and Sununu, will wait for the dust to settle.

Follow Kyle on Twitter.

Sign up for NH Journal’s must-read morning political newsletter.