"I want to utilize the federal money to support the people most in need. I don't want a New Hampshire (-funded) plan," Stiles said.
New Hampshire's Medicaid program now covers low-income children, parents with nondisabled children under 18, pregnant women, senior citizens and people with disabilities. The expansion would add anyone under age 65 who earns up to 138 percent of federal poverty guidelines, which is about $15,000 for a single adult.
New Hampshire could refuse or postpone a decision, but states can benefit from choosing to expand Medicaid now. The U.S. government will pick up the entire cost in the first three years and 90 percent over the long haul.
Under the overhaul law, new insurance marketplaces also will offer individuals and their families a choice of private health plans resembling what workers at major companies already get. The government will help many middle-class households pay their premiums, while low-income people will be referred to safety net programs they might qualify for. Enrollment starts Oct. 1 with coverage taking effect Jan. 1. After that, virtually everyone in the country will be required by law to have health insurance or face fines.
Stiles and lawmakers in several other states are looking at possibly funneling some adults who would qualify for Medicaid into the marketplace instead and paying for private coverage with Medicaid funding.
Adults with incomes of less than 100 percent of the poverty limit — 22,300 in New Hampshire — aren't eligible for the marketplace under the law.
Arkansas has proposed an alternative where the state would accept the money allocated for Medicaid expansion but use it to buy private insurance. U.S. Health and Human Services Secretary Kathleen Sebelius has endorsed the private option concept but stopped short of giving the state final approval. The state will have to submit a waiver showing how the plan won't cost more than Medicaid while providing the same services.
Iowa also is proposing an alternative where people earning up to 100 percent of poverty would go on a state-run health plan and people earning 101 to 138 percent of the poverty limit would get private health plans through the marketplace bought with federal money.
But New Hampshire's Republican leaders remain wary of the federal government's promise to keep up its funding commitment — an estimated $2.5 billion over the first seven years. In its ruling last year, the U.S. Supreme Court made Medicaid expansion optional, meaning states can expand and later end coverage to the adults. Some states have included provisions in their laws expanding Medicaid that end the program if government funding falls below promised levels. The federal government has assured New Hampshire it can withdraw from covering the adults at any time without penalty.
But Senate Republican Leader Jeb Bradley of Wolfeboro questions whether New Hampshire lawmakers would have the moral will to end the program if the federal government shifts more of the cost onto states.
"We are depending on a promise. We are the 'Live Free or Die' people," said Bradley, using the state motto to describe New Hampshire's commitment to keep its word. "A promise is a promise is a promise. But that isn't the case in Washington. It's a dangerous gamble."