N.H. commission looks to Iowa and Arkansas for guidance on Medicaid

  • Senate majority leader Jeb Bradley is seen during a New Hampshire Senate session at the State House in downtown Concord on Thursday, Jan. 19, 2017. Elizabeth Frantz / Monitor file

Monitor staff
Published: 10/16/2017 12:23:00 AM

With some New Hampshire health care premiums projected to spike more than 50 percent, policymakers tasked with stabilizing the state’s individual insurance market are facing a steep climb.

But weeks into the creation of a study commission of legislators and stakeholders, one idea is gaining broad support. If the Department of Health and Human Services can identify high-risk and high-cost patients and move them off the individual market and into more stable state-run insurance programs, policymakers say, those remaining on that exchange could see their costs stabilize.

Now, members of a study commission exploring mechanisms for that change are looking to two states – Iowa and Arkansas – for guidance.

The key, some lawmakers say, lies with an unwieldy-sounding designation: “medically frail.” Under New Hampshire’s Medicaid expansion program, those eligible for the Medicaid expansion can enroll in the individual insurance market with subsidies from the state’s Premium Assistance Program, which draws from expansion funds. But if consumers qualify as medically frail, meaning they have a physical, mental or emotional impairment that affects everyday living, they’re eligible to either join the traditional Medicaid program or an “Alternative Benefit Plan” that covers a list of basic services defined by the Affordable Care Act.

Crucially, the list of qualifications for the medically frail designation include substance use disorders and mental health conditions.

Getting more people designated in that category and onto traditional Medicaid will help reduce the rise in premiums in the long term while providing adequate care to all recipients, some legislators say.

“From what I understand, Arkansas and Iowa have been more comprehensive in trying to identify the medically frail and have them in a managed-care product, which is what I think we need to do in New Hampshire,” said Senate Majority Leader Jeb Bradley, chairman of the study group, the Commission to Evaluate the Effectiveness and Future of the Premium Assistance Program. “That in and of itself is not cost-saving, but it will reduce the impact on the individual market.”

New Hampshire has its own medically frail designation system, required for all states that expanded Medicaid under the ACA. But the system is wholly voluntary: Patients must actively apply when they enroll for a plan under the Premium Assistance Program – and they must determine that they meet the criteria.

And there’s evidence that the program is underused. At a Sept. 27 commission hearing, Lisa Guertin, president of Anthem BlueCross BlueShield New Hampshire, pointed to an analysis by her company that found 36 percent of Anthem’s customers who receive Medicaid expansion subsidies have conditions that would likely qualify them to be medically frail. But according to DHHS, only 11 percent of the 50,000 Granite Staters receiving expansion support have applied for the designation.

That’s where Iowa comes in. The Hawkeye State’s medically frail screening system allows physicians and providers to actively refer patients they believe qualify. In that case, the provider fills out the form for the patient; if eligible to move onto the program, the patient needs only to decide whether to accept it.

Meeting at the New Hampshire State House, commission members have pointed to that system as robust and efficient. Health care experts in Iowa, though, caution that it’s difficult to draw a clear lesson on the approach’s effectiveness.

To start, according to Peter Damiano, director of the University of Iowa Public Policy Center, there’s an uncomfortable reality: Iowa’s insurance system under the Affordable Care Act has largely collapsed, with many insurers pulling out of the individual market. The state transitioned to a managed-care system in 2016, which has helped to stabilize premiums, but which makes a direct comparison to New Hampshire ineffective.

Meanwhile, Aaron Todd, chief strategy officer at the Iowa Primary Care Association who helped craft Iowa’s health care plan, said the system was never designed with the exact aim of keeping high-cost patients off the individual market.

Todd explained that because all Medicaid expansion patients are eligible for managed care anyway, their designation as medically frail does not have a direct effect on premiums.

“It really doesn’t have a major reference in the marketplace, although I see how you could potentially make that connection,” he said. “But that’s now how it is in Iowa.”

However, Todd said the state’s referral system has helped those who do experience hardship to transition into appropriate plans.

“In this case, Iowa has made the process very simple,” he said.

Arkansas, meanwhile, approached its medically frail screening process differently. The state implemented a 12-part mandatory survey for anyone enrolling under Medicaid expansion; a software algorithm would then sort applicants into their proper designations based on a weighted score. The program included a cap: No more than 10 percent would be allowed by the algorithm to qualify as medically frail.

A 2015 study by the Kaiser Health Foundation, a nonprofit health care research organization, found that Arkansas’s system appeared to be working well, finding that the cap did not create a restrictive burden and that health care stakeholders were satisfied with the system.

But if Arkansas was once a useful case model, the example is now dated. A spokeswoman for the state’s Department of Human Services said that the state did away with the algorithm in November 2016. Now the process is simple: applicants answer four questions, spokeswoman Amy Webb said. She didn’t explain why the state made the change.

For Rebecca Farley David, vice president for policy and advocacy at the National Council for Behavioral Health, precisely how the screening process is implemented is not as important as whether states are focused on it. David and the council have advocated the screening as a means to help poorer populations with acute behavioral health problems and substance use disorders.

“We would recommend that the screening process be as easy as possible to reach them and figure out who they are,” David said. “You wouldn’t want to impose a lot of administrative burden on getting this designation.”

But despite the interest, whether New Hampshire can get the proper green light in Washington to implement a more robust screening process is unclear. DHHS Commissioner Jeffrey Meyers, speaking at the Sept. 27 commission meeting, said his department had applied for a waiver to the Centers for Medicare and Medicaid Services under the Obama administration, only for the application to be rejected.

At that time, Arkansas was a test case for CMS over whether to issue that specific waiver, Meyers said.

Bradley said whether and how to strengthen New Hampshire’s present screening process is not likely to be at the top of the agenda for the commission, which is deliberating whether to recommend a managed-care model in time for its Dec. 1 report. Instead, he said, designing such a system might be delegated to DHHS if the governor decides to move in that direction.

And he said any effort to boost the medically frail designation would have to be part of a broader strategy.

“When we’re talking about (projected) 50 percent rate increases, I think we’re going to have to employ many tools, and it’s just not going to be one thing that’s going to help the individual market,” he said.

(Ethan DeWitt can be reached at edewitt@cmonitor.com, or on Twitter at

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