Health care debate just starting in N.H.

By Paul Briand
The future of certain pieces of the federal Affordable Care Act, as they apply to the Granite State, will be decided not only by the next governor but by the next iteration of the New Hampshire House and Senate as well.

In particular, the health care exchanges and Medicaid expansion will be determined largely by the political decisions that voters make in November.

Certainly, the political future of the law itself -- upheld as constitutional last week by a 5-4 vote of the U.S. Supreme Court -- will be determined by the national election: Whether President Barack Obama returns to office or is replaced by Republican Mitt Romney, whether there is a Democratic- or Republican-controlled House, whether there is a Democratic- or Republican-controlled Senate.

A variety of combinations -- Obama as president but a fully GOP-controlled Congress, or Romney as president with a Republican House and Democratic Senate -- are possible on the national level.

So too are there political combinations that could have ramifications on how certain aspects of the health care law are implemented here.

A Democratic governor with a Republican House and Republican Senate could swing health care exchanges and Medicaid one way. A Republican governor and Republican Legislature could swing the two another way. And a Democratic governor with a Democratic Legislature could swing them yet another way.

In general, a strong Democratic influence in the state will seek to take full advantage of aspects of the health care law. A strong Republican influence will attempt to limit the health care law as much as possible.

As it is, the current GOP-controlled Legislature already sought to blunt the creation of health care exchanges, essentially retail markets that the law created for consumers to shop for affordable health insurance options.

It passed and Gov. John Lynch reluctantly signed HB 1297, which prohibits the state from establishing these exchanges. Lynch knew he wouldn’t win a veto fight on the issue, so he signed it knowing that the law mandates if states don’t create the exchanges the federal government will step in and create the exchanges for them.

The state -- through its Department of Insurance and through its insurance commissioner -- will potentially have a lot to say on the creation of these exchanges. The reality is that a commissioner appointed by a Democratic governor will take a more pro-active, cooperative approach for consumers on these exchanges than a commissioner appointed by a Republican governor who wants nothing to do with the law.

Exchanges are supposed to be in place by Jan. 1, 2014.

Also at issue is the future of Medicaid in this state. Medicaid is a state program with federal backing that provides health coverage for the poor, and the Affordable Care Act seeks to expand the eligibility so that more low-income Americans can get health care.

According to ProPublica, nearly 16 million Americans could be added to the Medicaid rolls by 2019 under an expansion in the Affordable Care Act. In New Hampshire that could mean the addition of 55,918 individuals who are not covered today.

But the Supreme Court, as part of its decision last week, ruled that states can opt out of this provision without risk of losing federal support for Medicaid.

Again, a Democratic control over the issue will play very differently from Republican control over the issue. Democrats will want as much eligibility as possible; Republicans will want to limit eligibility.

The debate over the future of the health care law will color the race between Obama and Romney. Certainly it will color the U.S. House races in the state -- Republican Frank Guinta in the 1st Congressional District and Republican Charlie Bass in the 2nd CD, both of whom favor repeal of the law.

But the debate will also color the race for the governor’s seat and for every seat in the N.H. House and Senate.