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Are State House Dems Plotting to Blow Up the Budget?

Guy Fawkes Day could be coming early to Concord as a contingent of House Democrats is reportedly scheming to blow up the proposed budget in a fight over Medicaid expansion.

Multiple sources tell NHJournal Democrats are toying with some radical plans, including the possibility of using a potential future majority in the evenly-split House to “vacate the speaker’s chair,” giving Speaker Sherman Packard (R-Londonderry) the boot.

Another idea: Strip Medicaid expansion from the House budget by voting on it as a standalone bill, then leave the House GOP to attempt to pass a budget — and fail — without Democratic votes. But since the Medicaid expansion bill has already been retained in committee, the Democrats would have to override the committee process and vote to bring it to the House floor.

The conspiracy talk comes at a time of heightened tension in the budget negotiations between legislators and Gov. Chris Sununu, with one source saying no one knows what is going to happen next.

“If they do any of this, it is total Armageddon,” one GOP House member told NHJournal.

Senate President Jeb Bradley (R-Wolfeboro) shares a similar view, calling the talk he has heard from the Democratic side of the aisle “Washington-style politics at its worst.”

As for a possible Democratic attempt to pull Medicaid expansion out of budget for its own vote, “I think it’s a very dangerous game,” Bradley said during a podcast interview with NHJournal. “It puts at risk the budget and Medicaid expansion at risk.”

Bradley took the lead in the Senate, spearheading SB 263, the Medicaid expansion bill, which extends the state’s Granite Advantage health insurance program. While low-income families qualify for traditional Medicaid, the Granite Advantage program makes Medicaid available to working families who earn too much for Medicaid but don’t have access to affordable health insurance through their employers. And 90 percent of the funding comes from federal dollars.

“My responsibility as I see it is to get the job done for the 50,000 to 60,000 people now depending on Medicaid expansion,” Bradley said. “To say nothing of the providers, the hospitals, the business community, all of the people that have gotten behind this coalition effort for the last nine years.

“Our responsibility, as adults, is to get the job done.”

The original proposal would have permanently expanded health coverage, while some House GOP members wanted to see just a two-year expansion. Bradley has agreed to a compromise plan that extends the benefit for seven years. That is complicated by the fact the budget, HB2, includes a two-year extension to Medicaid.

Packard is seen as a key opponent to the permanent expansion. Now, sources tell NHJournal some Democrats plan to yank Medicaid expansion away from the House Finance Committee and hold a floor vote on a permanent expansion. At the same time, those Democrats are also gearing up to push Packard out of the speaker’s chair.

House Clerk Paul Smith said motions to vacate the speaker’s chair are rare and typically unsuccessful. Any vote to remove Packard would require “50 percent plus one” of the entire body — not just those present. There are 196 Democrats in the House. With several vacancies, the current House membership is 396, meaning Democrats need 199 votes.

House Finance Committee member Rep. Peter Leishman (D-Peterborough) has heard the rumblings about Medicaid expansion, but he said the House conspirators are all talk. He noted that the Finance Committee voted Thursday to retain the bill, locking it into the committee.

“If the bill’s not reported out, they can’t take it away from the Finance Committee,” Leishman added.

But other House sources said an obscure and rarely-used move could allow Democrats to override the committee’s vote to retain. Smith said it would be a highly unusual move.

“Does it usually happen that the House withdraws a bill from committee? No, not usually,” Smith said.

House Majority Leader Jason Osborne (R-Auburn) conceded that, given the tight margins in the House and attendance issues, it’s very possible Democrats could again find themselves with a majority on the floor. If they do and choose to abandon the norms and traditions of the House, they could wreak havoc.

“But the real result would be total Republican unity,” Osborne added. “These things Democrats are talking about would completely unify my caucus.”

In fact, Deputy Speaker Steve Smith now says House leadership is on board with Bradley’s proposed Medicaid expansion deal.

“We’ve heard from the business community, the health care community, and people across New Hampshire about the importance of reauthorizing Medicaid expansion,” Smith said in a statement. “We all agree that the program needs to be reauthorized, and we’ve had a productive conversation about the appropriate length of time for a sunset provision.

“A seven-year extension of the Granite Advantage Healthcare Program makes logical and fiscal sense. New Hampshire gets the financial benefit of a full contract period, a continued drop in uncompensated care costs – which is a hidden tax, and it stabilizes the market allowing for more competition to help further drive down health care costs in our state. House Republican leadership fully supports the budget compromise of seven years. Let’s get it done,” Smith said.

Regardless of how the Medicaid vote goes, former House Speaker Rep. Steve Shurtleff (D-Penacook) said an attempt to force a vote, or worse, depose Packard, is a mistake.

“What we don’t need right now is this kind of gamesmanship,” Shurtleff said. “There’s no need for these kinds of fights.”

Too many people in the state rely on the budget passing, Shurtleff added, and delaying that makes those people the victims in an unnecessary political fight. “The budget is too important to too many people,” he said.

Then there is the question of motive. Given how relatively apolitical the current budget is — no anti-CRT legislation or late-term abortion bans — why would Democrats contemplate such high-risk actions against it? Particular a budget with hefty pay raises for state workers, who tend to be political allies of the Democratic Party?

Several House Republicans told NHJournal they believe the real target is Sununu. If the governor is tied in an ugly budget battle or trying to corral House chaos, it might stop — or at least slow — his presidential plans.

“Or maybe the Democrats are just [expletives],” one GOP House member said.

Blowing up the budget would hurt state employees, people who need affordable housing, families who need childcare, Granite State communities that need water infrastructure repairs, and every homeowner who needs property tax relief, Bradley said.

“I would just say that is the worst possible case scenario because everything could wind up in the tank,” Bradley said.

Even Democratic stalwart Sen. Lou D’Allesandro (D-Manchester), who voted against the budget last week, wants the spending plan to pass. D’Allesandro and Sen. Cindy Rosenwald (D-Nashua) voted against HB2 in the Senate Finance Committee, saying they want improvements to the final bill before they support it.

“There’s an opportunity to add a couple of things to the budget,” D’Allesandro said.

D’Allesandro wants to see more money for state employee pensions, more money for affordable housing, and no money for northern border security. He said that as long as the bill remains intact and the House remains sane, there will be another opportunity to vote on the budget after more negotiations. That includes negotiating more time for Medicaid expansion.

The specter of a messy fight over Packard’s speakership is a non-starter for D’Allesandro. Packard is doing a solid job leading a closely divided House, he said.

“Sherman Packard was my student when he was in high school. I think the world of Sherman; he’s a fine man.”

Likewise, Leishman does not think Packard should be pushed out.

“I think Sherm’s done a good job trying to hold things together,” Leishman said.

Senate Pushed Seven-Year Sunset for Medicaid Expansion

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.

Medicaid Expansion Bill Gains Steam in State House

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.

Medicaid Expansion Gets Bipartisan Push from Senate Committee

The bipartisan effort to make New Hampshire’s Medicaid expansion permanent got a push Wednesday as the Senate Health and Human Services Committee heard from people like Manchester’s Michelle Lawrence, who said the law allows her to get vital cancer care. 

Lawrence, who is suffering from a rare form of cancer, told lawmakers she was finally able to focus on her health once she received care through New Hampshire’s Granite Advantage plan.

“For the first time in my cancer journey, the primary focus in my care has not been on insurance and insurance costs,” Lawrence said. “I’m not getting up in the middle of the night having to think about delaying care or paying rent.”

Senate President Jeb Bradley (R-Wolfeboro) joined Nashua Democrat Sen. Cindy Rosenwald in urging the committee to approve SB 263, the bipartisan bill that would make Medicaid expansion permanent.

“I think our law is a good common-sense law and should remain in place,” Bradley said.

Making Medicaid permanent is part of Gov. Chris Sununu’s budget plan. Ben Vihstadt, Sununu’s communications director, said Sununu is ready to make sure the bill gets to his desk.

“Gov. Sununu worked with legislators in 2018 to deliver a five-year reauthorization of Medicaid Expansion in a fiscally responsible manner and supports this permanent step. He looks forward to working with the legislature this session to get this bill across the finish line,” Vihstadt said.

Granite Advantage, which currently provides health care to 94,000 residents, was last reauthorized in 2018 and is set to expire at the end of June. The current proposal will make the program permanent, meaning it will not have to come back for reauthorization if approved.

New Hampshire first expanded Medicaid in 2014 under President Barack Obama’s Affordable Care Act. Henry Lippman, New Hampshire’s Medicaid director, said the program is expected to decrease to about 64,000 enrollees by the end of the year as the COVID-19 emergency authorization is expected to be phased out.

Extending Medicaid to low-income Granite Staters has been economically beneficial to the state’s hospital system, according to Steve Ahnen, president of the New Hampshire Hospital Association. Uncompensated care for hospitals dropped to $69 million in 2021, down from $173 million in 2014.

Uncompensated care costs all Granite Staters, Ahnen argued, and the bills are generally passed on through higher premiums to those with insurance. Bradley said the program has cut this hidden tax while also bringing down the cost of insurance for everyone else. 

Business & Industry Association President and CEO Michael Skelton said keeping Medicaid expansion in place is good for businesses and people. Access to healthcare means employees won’t lose time to serious medical problems, and businesses that are already short-staffed will be able to4 remain open.

“A healthy population contributes to worker availability,” Skelton said.

And without Granite Advantage, New Hampshire could lose up to $500 million a year in federal funding while having to shoulder the costs of uncompensated care alone.

“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.”

Robert Dunn, director of public policy for the Roman Catholic Diocese of Manchester, made a moral argument for Medicaid expansion, saying the expanded coverage has likely saved lives. Speaking on behalf of Bishop Peter Libasci he urged the committee to support the permanent expansion.

“I think we can say it’s a pro-life measure,” Dunn said. 

Though the bill had bipartisan support in the Senate committee, there is resistance in the House of Representatives, sources say. And the influential Americans for Prosperity – NH opposes the move. State Director Greg Moore said the plan incentivizes people to earn less income in order to qualify for health care.

“This regressive policy works to keep people in poverty instead of lifting them out of – it is the opposite of the Live Free or Die way of life,” Moore said. 

But Moore’s position did not carry the day. The committee voted unanimously to approve the bill, sending it to the full Senate for a vote.