Because of our hard work on expanding coverage to the uninsured in New Hampshire, I was asked to serve on the Medicaid Expansion Study Commission and I wanted to share some updates from this.  The Commission was set up to give the State more time to study expansion so that the Legislature can possibly come back for a special session this fall so that we can take full advantage of federal funds.  So far we have met three times and have been given background information on the Medicaid program, what it costs and who it serves, and options for expansion.  In NH, Medicaid is a 50-50 partnership between the federal and state governments.  Under expansion, the newly covered population would be 100% financed by the federal government for 3 years and then would titrate down to 90% by 2021 and the state would be responsible for 10% into the future. 

Yesterday, the commission reviewed financial numbers to see what the impact on the State’s budget would be and the numbers look quite good.  If NH simply expands Medicaid to all people who make less than 138% of the federal poverty line or roughly $15,500 per year, the per person per year cost over the next seven years is about $236.  However, we have several options to tinker with our existing Medicaid program to make it even more cost effective. 

Currently, NH Medicaid has a small program called the Health Insurance Premium Payment where the State currently pays for premiums for low-income individuals so that they can maintain private insurance.  They can only do this if it is more cost effective to pay for the premium than to offer them Medicaid and for the 175 individuals in the program currently it works very well.  Under expansion, the State could expand this to an estimated nearly 10,000 individuals that would result in significant savings.  This coupled with a few other changes which involve how the State pays for healthcare for people who are incarcerated and expanding the marketplace (also known as the Health Insurance Exchange) the State will actually see net savings of $45.7 million dollars over the next 7 years.   

In addition, physicians, hospitals, and community mental health centers will see uncompensated care decrease by at least $82 million dollars in the next biennium.  We have always known the human argument for expanding coverage and now it is plain to see that the numbers add up as well! 

If you choose, you can now follow the work of the commission here: ( 

If you have input or ideas please feel free to contact me at or post a comment below.




I think I can guarantee you that the cost will be more than $236,and that as the cost rises the feds will renege on their 90%, and that savings will never be any $47 million, and that any savings will immediately be spent by Concord and then some. Pessimistic, yes, but born of experience.

Please see my submission to the Concord Monitor "My Turn" section earlier this month regarding medicaid expansion. Uncompensated care may go down but the level of compensation is for many of us BELOW the cost of providing the care. Our local hospital REQUIRES that we ALL participate in Medicaid (yes, even the private NON-HOSPITAL physicians) as part of privileging so that they can get their cut while leaving the private physicians to hemorhage....with NO provisions for compensation of these newly sanctioned underinsured and uninsured. The only way this works is not to pay the providers. Simple as that. I am seeing a growing divide in the medical community between employed docs and private docs where our interests in policy are diverging.

I want to thank both Dr Bowen and Dr DeGregorio for their thoughtful comments and would like to continue the dialogue. As for the savings predictions, the Lewin Group reports used fairly conservative assumptions to craft their model and DHHS projections are based on the Lewin Analysis that you can see here (along with all of the Commission's proceedings) As for the concern that the federal government won't fulfill their commitment, since it's inception in 1965, the feds have always come through with their piece without fail. That is a track record of over 40 years that I believe we can trust. As for the concern about Medicaid reimbursement rates, the Commission is very interested in expanding the HIPP program as I discussed in my original post so that individuals will be able to keep their private insurance with premium support. This is a cost effective tool that will help keep people in the private market and most importantly will help patients but will also help physicians in both employed and private practices.

Dr. Harker, you seem so hopeful in your embrace of the new world order of medicine and trust of centralized government that for a moment even I felt a little better! Detroit has been solvent for over 40 years and take a look now. Gas is pushing $4/gallon when recent past performance wouldn't predict it. Federal support for the 40% contribution on special eduction costs is never really met or realized according to some folks I speak with in education. What I am saying is that past performance is no guarantee of future performance especially when the math is formidable. Also, all this talk of federal money and state money seeming to fall like mana from Heaven....that money is US. Dems want the policies because they care (sic) and republicans will ulitmately give in...but on the cheap. Viola! Providers get !@#$%^&. The "private market place" can make and sell, for the sake of comparison, really nice cars. It also brought us the Yugo. I would like to see the payment to physicians schedule of these HIPP plans. My bet is that they will be such poor plans (that we are subsidizing) that they will essentially be guilded lilies. You can slap a sexy new name on a piece of junk and what you have is a piece of junk with a sexy name. Think Medicaid for kids when they re-badged it as Healthy Kids Gold. It will be interesting but I fear not encouraging as we watch this sausage of legislation evolve.

In 1965 we were told that Medicare would cost $9 billion a year by 1990. In 1990 Medicare came in at $63 billion. In 1935 Franklin Roosevelt told us that 1% was the most we'd ever have to pay into Social Security. Today, every day in my practice I see people younger than I on SS disability for trivial maladies, and people on Medicare in their forties. If you decline to go on Medicare when you come of age, you lose your Social Security. This week a reporter visited three Obamaphone offices where, despite telling them she did not qualify, she ended up with a phone each time. At the third office she showed up WHILE TALKING ON HER CELL PHONE and was still given a phone. There is simply no way this expansion will not cost far more than advertised, and will not become clotted with undeserving people because it's a great way to buy votes. Supporters of Big Gov't programs always say that their opponents want old people to starve to death on cat food. Recall the Democrat ads showing a man, who by a strange coincidence looked just like Paul Ryan, pushing an old lady in a wheelchair off a cliff. Not only has it never been true that if government doesn't do it it won't get done; it has most often been the case that if you have government do it it still won't get done.