New Hampshire Democrats are not the only politicians gaining power following the November elections who are threatening to fight the Trump administration's push for tough Medicaid work requirements. Newly elected Democratic governors in Wisconsin and Michigan also have expressed dissatisfaction with Medicaid work requirement waivers pushed through by their Republican predecessors and approved by the CMS.
Incoming Democratic Gov. Tony Evers of Wisconsin has said he's considering ending the state's waiver. But on Wednesday, the state's GOP-controlled Legislature, during a lame-duck session, passed a bill that would block him from doing so.
On Friday, the CMS approved New Hampshire's five-year Granite Advantage Health Care Program waiver, replacing the previous waiver, which sunsets this month. Under a bill passed in June, the state is transitioning the nearly 52,000 expansion enrollees from managed-care coverage through the Affordable Care Act exchange to new Medicaid managed-care plans. Those contracts start next July. The change required new CMS waiver approval.
"The community engagement and work requirement will help bring more people into the workforce, empowering individuals with the dignity of work, self-reliability and access to high-quality healthcare," Sununu said in a written statement Friday.
The state's first waiver, approved last May, has some of the toughest provisions of any of the five so-called community engagement demonstrations approved by the CMS so far. It applies to low-income, nondisabled adults from ages 19 to 64 who are eligible for the program, including parents of children ages 6 and older.
The waiver requires beneficiaries to report at least 100 hours per month of work, job training, education or volunteer activities, compared to 80 hours in other states. The work requirement starts 75 calendar days after the program launches.
Beneficiaries will face suspension from Medicaid the month after failing to report the required level of community-engagement activities, rather than losing coverage only after repeated months of failure to comply, as in other states.
The state's waiver proposal would have allowed beneficiaries to "cure" a shortage of hours in one month by making those hours up in subsequent months. That's considered important because many low-wage workers have part-time and seasonal jobs with varying hours.
In the CMS' biggest revision of the state's request, the agency will not allow such cures over more than one month starting in May 2020, according to an analysis by the Center on Budget and Policy Priorities, which opposes work requirements.
"I am unhappy with the Trump administration's changes," said Democratic Rep. Steve Shurtleff, the new speaker of the House. "If someone did more work in the spring and summer than in the winter, their average would come up. Now it will be watched over a shorter period of time, and that could drop people off the program."
The CMS, Sununu's office and the New Hampshire Department of Health and Human Services did not respond to requests for comment.
In a waiver change that particularly displeases providers, expansion enrollees will not be eligible for Medicaid's standard 90-day retroactive coverage from the time they first receive care to the time they officially enroll in Medicaid.
"We will continue to review the waiver's work and community engagement requirements to ensure that they do not become barriers to Medicaid beneficiaries accessing the kind of primary, preventive healthcare services that Medicaid expansion was designed to provide," said Steve Ahnen, CEO of the New Hampshire Hospital Association.
While the new CMS waiver approval allows the work requirement to start as soon as Jan. 1, it's likely to begin later than that. The state Legislature won't finalize the rules for the program until late this month. Beneficiary notification efforts are still in process. And contracts for the new Medicaid managed-care plans won't be finalized until well into 2019.
Shurtleff said Democratic lawmakers also want the state to provide more funding to train Medicaid expansion enrollees for employment. The previous GOP-controlled Legislature provided limited funding to help enrollees participate in work activities, and that was only for people receiving Temporary Assistance for Needy Families. And no funding was provided for the state's additional administrative and staffing needs to run the work program.
Beyond that, New Hampshire policymakers and advocates are closely watching the status of federal lawsuits challenging CMS approval of similar Medicaid work requirement waivers in Kentucky and Arkansas. A federal judge blocked the Kentucky waiver in June, and is now hearing a challenge to Arkansas' program, which already has resulted in more than 12,000 losing coverage.
"We don't want New Hampshire to be the next state to make this mistake of undermining healthcare for people who need it," said Dawn McKinney, policy director for New Hampshire Legal Assistance, which opposes the work requirement. "We hope our Legislature will look at what happened in Arkansas and decide to change course."
There is particular concern about the impact of possible coverage losses on addiction treatment in New Hampshire, which has been rocked by a high rate of opioid addiction and overdose deaths. It's estimated that 11,000 Medicaid beneficiaries have received treatment for substance use disorders under the expansion program.
In its new approval letter Friday, the CMS downplayed concerns expressed by public commenters about coverage losses, saying far more people would lose benefits if the demonstration were not approved. That's because New Hampshire state law established the work requirement as part of the expansion program, and because the state is not obligated to cover the expansion population, the agency argued.
If the waiver wasn't approved, the Legislature and the governor "could then respond by seeking to scale back or even end coverage for the ACA expansion population," the CMS wrote. "Thus, the ACA adult expansion could be eliminated if the state is unable to implement the demonstration project."
Expansion supporters scoffed at that reasoning. "I don't think that's a good argument for CMS to rationalize approving work requirements," said McKinney, who declined to say whether her agency is considering filing a lawsuit challenging the New Hampshire waiver program. "Ending the program is not a genuine threat in our state."
