inside sources print logo
Get up to date New Hampshire news in your inbox

Insurance Commissioner Hits Siren Over Ambulance Rate Bill

Granite Staters could see the cost of a life-saving ambulance ride more than double under a proposed law change that has New Hampshire’s Insurance Department Commissioner worried.

“I’m deeply concerned,” Commissioner D.J. Bettencourt told NHJournal.

Lawmakers are set to hold hearings this week on SB407, a bill that caps the rate for ambulance services at 325 percent of the Medicaid and Medicare reimbursement rate. The bill is meant to address the Medicaid and Medicare payment shortfalls that already have New Hampshire ambulance services scrambling to stay afloat. But Bettencourt said the proposal would actually set a floor for prices, which will increase costs and shift the burden onto insurance companies and individuals.

“There is no way you’re not going to see upward pressure on premiums,” Bettencourt said

Among the proposed changes in SB407 is a provision that requires health insurance companies to pay the full bill set by the local ambulance services, or 325 percent of the current Medicaid and Medicare reimbursement rate, whichever is lower. Bruce Berke, with the National Federation of Independent Business, said all that does is incentivize local services to set their rates right at the arbitrarily high rate of 325 percent of Medicaid and Medicare.

“The bill will increase premiums for New Hampshire employers who are providing health insurance to their employees but are struggling to afford rising premiums driven by increasing health care costs. The bill’s new mandate would establish government rate setting for the very first time in New Hampshire, essentially creating a ‘minimum charge’ mandate,” Berke said.

The problem the bill doesn’t address is that 80 percent of all patients who require ambulance rides in New Hampshire are on Medicaid or Medicare, Bettencourt said. That means the ambulance companies are significantly underpaid for the vast majority of the patients who require services, forcing them to make up the difference with everybody else.

Dave Juvet, senior vice president of public policy with the New Hampshire Business and Industry Association, said that because the state and federal governments aren’t dealing with the real problem, the cost of an ambulance ride for everyone else could go up 350 percent under the plan, he said.

“That’s just astronomical. I remain mystified why the state feels it needs to step in and somehow establish these rates and a one-size-fits-all rate,” Juvet said.

The effect will be increased insurance costs for employers, which could force them to hire fewer workers at worst or depress wages at best. Juvet said the vast majority of people in New Hampshire get their health insurance through their work.

“Somebody pays for the insurance, and in New Hampshire, that’s employers,” Juvet said.

Drew Cline, with the Josiah Bartlett Center for Public Policy, a free-market think tank, said SB407 keeps people in the dark and hikes the rates they will pay for healthcare.

“The fundamental problem with ambulance billing is that consumers are entirely cut out of the pricing system. No consumer knows how much any given ambulance service will cost or who will pay. SB407 tries to address this by setting an arbitrary number as the default market price, and that number is quite high. Instead of solving the underlying problem, this will just raise prices and insurance costs,” Cline said.

Still, says Chris Stawazs with the New Hampshire Ambulance Association, something must be done, or ambulance companies in the Granite State are going to be forced to shut down.

“Ambulance companies are going out of business because of poor reimbursement rates,” said Stawasz, who works for America Medical Response. “These are the most critical people in the world to be paying appropriately.”

Ambulance billing is complicated and involves private insurance companies dealing with ambulance services that are quasi-government agencies in many cities and towns. The billing process involves both the ambulance service and the insurance company essentially using the patient as a middleman, with bills and checks going to a patient who can get stuck with thousands of dollars in charges.

Stawazs claims SB407 keeps the process just between the ambulance service and the insurance company while bringing the rates up enough to cover the costs. But, he acknowledged, some people will have to pay more.

“Some patients will still have to pay out of pocket depending on deductibles,” Stawazs said.

But Bettencourt is concerned that SB407’s net effect is that health insurance will become out of reach for more people. He’s also worried about people who won’t call 911 and delay getting emergency care when seconds matter because they cannot afford the ambulance ride.

“We want people to focus on getting the help they need,” Bettencourt said.

Ruais Goes to Concord Seeking Bail Reform

Less than 24 hours after being sworn in, Manchester Mayor Jay Ruais was already at work on one of his top priorities: reducing crime on his city’s streets by fixing the state’s broken bail system.

Ruais led a bipartisan coalition of Manchester officials to the capitol Wednesday morning, where he laid out what he sees as the brutal math from lax bail rules.

“The reason I made this one of my first official acts is to highlight the importance of this issue to our city,” Ruais said. “In 2023, 813 criminals were arrested, released, and rearrested. Many of these criminals were not just arrested for petty crimes but violent assaults, robberies, and other serious offenses.

“There is nothing, and I mean nothing, that would have a more transformative effect on the city of Manchester than reforming our state’s bail laws,” Ruais added.

Since 2018’s controversial bail reform law, thousands of alleged Manchester criminals charged with violent crimes have been released without bail only to get arrested on new charges. Rep. Ross Berry (R-Manchester) said some of those suspects have been charged with murder.

“Eight is the number of times my constituent was stabbed to death by somebody already out on double-PR bail,” Berry said.

Ruais, a Republican, scored his upset victory over Democrat Kevin Cavanaugh in last year’s election by running on issues like crime, homelessness, and the city’s lack of order. The word is out on the street in Manchester that criminals get a free pass, Ward 3 Alderman Pat Long warned.

“I recall being in a (homeless) encampment in Manchester and overhearing the residents in that encampment talking about no concern with breaking into cars, trespassing. There was no concern (because) they would be back out on the street in a couple of hours,” Long said.

Long is also a Democratic state representative.

The original bail reform bill passed in 2018 was aimed at keeping poor people who are charged with non-violent crimes from getting locked up because they could not afford a $100 or $200 cash bail, according to Sen. Donna Soucy (D-Manchester). Soucy said even in 2018, she and other lawmakers were worried about the unintended consequences.

“This has been an issue for a long time,” Soucy said. “I was in the Senate when we initially enacted bail reform, and although well-intentioned, I think we all recognized this law needs fine-tuning.”

Ruais promised in Tuesday’s inaugural address he would champion bail reform and lobby lawmakers until they got it right.

“The fight for our security will continue today, it will continue tomorrow, and it will continue until everyone in our community feels safe,” Ruais said Tuesday.

Ruais made sure to get to Concord Wednesday, on his first full day on the job, to put friendly pressure on lawmakers as they opened their legislative session for the year. Two proposed bail reform bills, one in the House and one in the Senate, have a good chance to pass this session.

Ruais isn’t saying which proposal he prefers, leaving it up to legislators to do their job in crafting a bill that works and will pass.

On Wednesday, the Senate voted to move its bill, SB-249, to the Senate Finance Committee. Sen. Daryl Abbas (R-Salem) said it is past time for a bail reform bill that protects people.

“We have heard testimony for years in both the House and the Senate that we need bail reform. We have dangerous individuals committing crimes, being released on bail, and then immediately reoffending,” Abbas said. “No one should be denied bail solely because they cannot afford it, and this bill will not change that. This bill requires a judge to determine whether a violent offender poses a threat to the public before being released. Senate Republicans have been fighting for years for common sense bail reform, and we will continue to do so to keep our communities safe.”

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.

Forget Partisanship. This Week’s House Session Is All About Attendance

New Hampshire Republicans tell New Hampshire Journal they believe this week’s House session will hinge on which party’s members best heed the advice of Woody Allen: “Eighty percent of success is just showing up.”

Vital issues like vaccine mandates, bail reform, and abortion are all on the docket as the legislature gets to work on Wednesday.

The question is, will Democrats show up to vote?

Despite moving this week’s House session to the exposition center in the DoubleTree by Hilton in Manchester, many Democrats have expressed concerns about having an in-person session during the Omicron COVID-19 wave.

Democratic leaders like Hampton’s Rep. Renny Cushing and Nashua’s Rep. David Cote did not respond to requests for comment, but many in the rank and file have expressed concerns about the session.

Rep. Jeffrey Salloway, D-Lee, an epidemiologist, told InDepth NH the House session has the potential to be a “super-spreader event.” Rep. Bill Marsh, D-Wolfeboro, a physician, said he will only go to the session while wearing an N95 medical-grade mask.

“I don’t believe we are taking sufficient precautions to keep everybody safe,” Marsh told InDepth.

Cushing, who is dealing with a terminal cancer diagnosis, tried to force the Republican-controlled House to meet remotely, even filing a federal lawsuit. But GOP House Speaker Sherman Packard is going with the in-person session. Meeting in the 30,000 square-foot convention center will allow for people to safely socially distance themselves. Facemasks will be optional, Packard said.

“With hospitalizations at record levels and community transmission still high, the responsible thing to do is to maintain health and safety protocols for our legislators and hold off on returning to the House chamber, at least for now,” he said in a statement about the move.

House Majority Leader Rep. Jason Osborne, R-Auburn, expects his party to be in the building.

“I cannot speak for the other caucus, but I do know with only a couple exceptions Republicans will be present and ready to do the people’s business,” he said.

The House has met at various times during the pandemic at the University of New Hampshire’s Whittemore Center ice arena, outside on an athletic field, and inside a Bedford athletic complex.

During one of last year’s sessions, Democrats staged a walk-out in an attempt to deny Republicans a quorum. Instead of shutting down the session, Packard had the doors locked during the ensuing chaos to keep the quorum and keep out the Democrats who walked out first. The Republican House then easily passed two controversial abortion bans.

Osborne said Democrats are unlikely to make the same mistake twice.

“I am pretty sure House members now realize that a frenzied stampede is neither an appropriate nor effective parliamentary tactic. These are the kind of lessons that need to be relearned from time to time given the high turnover of membership biennially,” Osborne said.

If Democrats fail to show up it could backfire again. For example, Sen. Jeb Bradley, R-Wolfeboro is sponsoring a bill to roll back part of the recently-passed bail reforms. SB 92 would require people charged with serious crimes like murder, kidnapping, and domestic violence to be required to spend up to 72 hours in jail awaiting arraignment.

Bradley’s bill is opposed by Black Lives Matter and the New Hampshire ACLU, as well as the libertarian Americans for Prosperity.

The House is also expected to vote on a measure that would push back the ultrasound provision of the state’s 24-week abortion ban. The ultrasound provision is opposed by Gov. Chris Sununu and Democrats. Sources tell NHJournal to expect a GOP-engineered compromise to clarify the mandate only applies in cases when there’s a legitimate question as to whether the pregnancy has extended beyond the six-month time period.

If Democrats stay home, they would also be helping anti-vaccine extremists who want to ban private businesses from setting their own vaccine policies. A proposed amendment to HB 255 would make it illegal for New Hampshire employers to require employees to get the COVID-19 vaccine.

Republicans are split on this, with the New Hampshire Liberty Alliance opposing the measure along with Democrats.

If any of the votes end up being close, MIA Democrats could come to regret not being in the building.