#

Almost everything Granite Staters are hearing about Medicaid in New Hampshire is wrong.

So say supporters of the Medicaid reforms proposed by Gov. Kelly Ayotte and passed by the GOP-controlled House. To make their case, they point to facts that rarely make it into the current debate about the generosity of New Hampshire’s Medicaid system.

Critics focus on the increase in costs for Medicaid users, such as adjusting the cost-sharing from $1 or $2 per prescription to $4 to reflect the impact of inflation.

What’s overlooked is the fact that New Hampshire has the fifth-highest income limit in the country for eligibility in Medicaid’s Children’s Health Insurance Program (CHIP).

Families earning up to 323 percent of the federal poverty line can qualify for CHIP in New Hampshire, while the national median is 255 percent. Families who earn more than that aren’t eligible for any benefits in 25 other states.

And so, when Democrats label Ayotte’s plan to have some families pay a monthly premium a “Medicaid income tax,” they fail to note those families wouldn’t even be eligible for Medicaid in most other states.

“This is something that’s going to preserve the eligibility for Medicaid, and we have some of the highest eligibility in the country, and I thought it was really important that we preserve that eligibility,” Ayotte told NHJournal.

Another key detail: only about 10 percent of children covered by CHIP are in households earning enough to pay the monthly premiums. And those costs are capped at five percent of the family’s annual income.

The big picture story of Medicaid in New Hampshire is similar to the one told across the U.S. During the COVID crisis, the federal government used its emergency power to impose “continuous eligibility” on the states’ Medicaid benefits. Instead of having eligibility evaluated annually, anyone who qualified for Medicaid once simply stayed on the system, regardless of their personal situation.

An obvious example is a worker whose workplace was locked down during the pandemic and who qualified for Medicaid, only to return to work six months later. Without eligibility evaluations, he stayed on Medicaid.

As one person involved in New Hampshire’s Medicaid debate told NHJournal, “You could literally win the Powerball and keep getting free healthcare.”

During that period, enrollment in New Hampshire Medicaid reached record levels, growing almost 42 percent above March 2020. The spending was massive. While New Hampshire’s overall state spending grew about 40 percent over that period, state spending on Medicaid is now up by 60 percent — one-third faster than overall spending.

To fill the gap, Ayotte is eyeing a savings of up to $30 million from Medicaid by adding some cost sharing to the plan.

Ayotte’s premium proposal would not be universal. What Democrats attack as an “income tax” is actually a floor to ensure the neediest recipients are protected.

For people on Granite Advantage, the premium doesn’t kick in until 100 percent of the federal poverty level of income. That’s $15,650 for an individual, or $32,150 for a family of four. People earning up to 138 percent of the federal poverty rate would continue to qualify for Granite Advantage under Ayotte’s plan. That’s $21,597 for an individual, or $44,367 for a family of four.

Under the Affordable Care Act, any changes to the Granite Advantage program would have to be cleared at the federal level first. Therefore, no changes could be implemented until 2027.

For children covered by CHIP, premiums do not take effect until their family reaches 255 percent of the federal poverty level. A single parent with one child earning $52,875 is at 250 percent of the federal poverty rate and would not pay a premium for CHIP. A family of four earning $80,375 is also at 250 percent.

According to the nonprofit Kaiser Family Foundation, New Hampshire has about 18,000 children covered by CHIP. Of those, between 8,000 and 8,500 are in families who would see premiums introduced to their healthcare plans.

Inside the State House, Democrats argue no cost savings would be necessary if not for GOP-backed tax cuts. They’ve called for a return of the income tax on interest and dividends to increase revenue.

Outside the State House, the activist group NH Medicaid Matters says poorly thought-out plans for federal and state budget cuts in Medicaid would land hardest on the poor and working families. 

“The proposed cost-sharing measures would shift more costs to families and enrollees, imposing additional financial burdens and barriers to care,” the group states. “For a family of three making $68,000 per year, the monthly premium could be over $280 each month, with $4 co-pays per prescription. A single individual on Medicaid expansion making around $15,000 per year could also be subjected to increased costs.”

Ayotte said the proposal she’s backing would make sure there are carveouts for people who fall between the income cracks.

“We’re also going to have a hardship provision to make sure that if there’s a hardship and you’re unable to pay, you still receive coverage,” Ayotte said.

To Share Brewery in Manchester is known for tasty beer served in a fun environment. Its Hugs & Belly Rubs Oatmeal Stout features a drawing of a cartoon dog with a big grin getting plenty of love.

But the New Hampshire Liquor Commission (NHLC) says you will never see it, because an artistic rendition of a dog might make the 7.1 percent ABV stout too appealing to children.

“I’ve been doing this for five years, and this is the first time we’ve been denied,” said Aaron Share, one of the owners of the To Share Brewery in Manchester.

NHJournal has learned the NHLC is implementing strict new rules on what beer makers may put on their labels, and they are doing it based on a questionable interpretation of the agency’s current power, along with a proposed law expanding that power but hasn’t been passed by the legislature.

In fact, it hasn’t even been written.

Information obtained by NHJournal indicates the Liquor Commission has been cracking down on brewers in part using the state law that says it has the power to ban advertising with “any subject matter or illustrations that the commission determines is reasonably likely to induce minors to drink.”

Critics say the rejected art, like Kettlehead Brewing Company’s “Buggin’,” doesn’t come close to meeting that definition.

And so, to reject labels like Kettehead’s “Swoll” brew, the NHLC is also relying on its understanding of changes to the law that have been proposed by progressive state Sen. David Watters (D-Dover). But those changes have yet to be drafted, much less enacted.

Many of the brewers contacted by NHJournal were hesitant to talk about the issue, not wanting to get on the wrong side of a state bureaucracy with the power to kill their business.

CJ White with the New Hampshire Brewers Association declined to comment, saying she hoped to get more information from the commission in the coming days.

Share is mystified by the rejection since the same “smiling dog” label has won approval from the state for years. An email to Share from Liquor Examiner Angel Harris cited pending changes as the reason for the label’s recent rejection.

“In consideration of current legislation and anticipated legislation change on restricting product labels, the product label you have recently requested is not approved,” Harris wrote.

The Hugs and Belly Rubs product was changed this year from an American Stout beer to an Oatmeal Stout, and the only change to the label for this year’s brew is swapping out the word “American” and replacing it with “Oatmeal.”

Other brewers told NHJournal they are having the same experience with previously approved illustrated labels. Some are even getting labels approved by the federal Alcohol Tobacco and Tax Bureau, only to have those same labels rejected by the Liquor Commission.

When reached by NHJournal, Harris declined to comment, referring the matter to Lt. Matthew Culver. Culver also declined to comment and referred the matter to the commission’s public relations firm, Montagne Powers. 

EJ Powers, with Montagne Powers, did not acknowledge the commission had changed the review process, or address the apparent use of pending rule changes, as cited by Harris.

“The Division takes its process seriously and closely reviews approximately 5,400 labels each year – approving 96 percent of them,” Powers said via email.

Share and other brewers said they had not been able to get answers when they reached out to the commission. Instead, they have all been referred to as Montagne Powers as well. 

Some brewers suspect the problem is Watters’ ongoing war against alcohol advertising that he believes targets children. Watters confirmed to NHJournal that his efforts may lead to changes that have yet to be enacted. 

“Some decisions might have been made prematurely,” Watters said.

Watters has filed an LSR — a notice he plans to file a law — that would tighten alcohol advertising standards and make the appeals process more transparent. But, Watters told NHJournal, if the NHLCX is making decisions costing small businesses tens of thousands of dollars, they are doing it based on an LSR that doesn’t even have a complete draft yet.

Asked if he supports the treatment Granite State brewers are receiving, apparently as a result of his political influence, Watters deflected.

“I can’t speak to the way the commission makes decisions,” Watters said.

Watters said the commission will issue a new communication to the beer industry shortly to clarify the guidelines. He wants the state to adhere to common sense rules about labels and advertising. Those rules should allow for illustrated labels, he said.

“I don’t think it’s the case you can’t have a dog on a beer can. Maybe Scooby Doo isn’t so good,” Watters said. 

Share is fighting his label’s rejection, going to the Liquor Commission to request a review and possibly an appeal. His message for other brewers in the Live Free or Die State: “I suggest we all fight this. That’s what we’re doing,” Share said. 

But being a pragmatic businessman, Share also has a Plan B: a plain black label explaining why there is no art.