CONCORD, N.H. -- New Hampshire lawmakers are scheduled to vote Thursday whether to expand Medicaid under the federal health care overhaul law, but so far no compromise has emerged over a key difference: when to use the federal marketplace to buy private coverage.
An expansion would give Medicaid coverage to an estimated 49,000 poor adults earning up to $15,856 a year.
The Republican-led Senate insists on implementing a private option sooner than Democratic Gov. Maggie Hassan and the Democratic House, who want to give other insurers more time to join Anthem Blue Cross and Blue Shield in the marketplace -- thus providing the competition needed to keep costs in check.
"What separates the two bills now is not philosophy, it's reality," Hassan said Friday. "In reality, the Republican bill simply doesn't work, and we can only seize this opportunity if we have a bill that works. We can't put working people in a situation where their health coverage will be taken away because one party insisted on unrealistic timelines."
Senate Republican Leader Jeb Bradley of Wolfeboro -- a former congressman -- said last week that Republicans believe Congress will address the problems with the Affordable Care Act by giving states more flexibility, making the Senate's aggressive timetable to move adults onto private coverage a possibility.
The House and Senate expansion plans are essentially the same for the first year, but take different approaches after that.
Both start by using federal Medicaid funds to pay for private insurance for eligible adults already on employer-sponsored plans through an existing state program. Others would be enrolled into a new state managed care program. State officials estimate up to 15,000 of the 49,000 people eligible for Medicaid under expansion would remain on their employer's plan.
The House plan proposes waiting to shift the remaining 34,000 people onto private insurance through the marketplace until 2017 -- and only then if three providers are offering insurance plans and the state has more control over the marketplace currently run by the federal government. The Senate proposal shifts people onto private insurance through the marketplace in 2015 regardless if Anthem has a monopoly.
Both expansion plans would require federal waivers and would end if federal financial support fell below promised levels. The Senate would give the government one year to approve its plan to use the marketplace or expansion would end. The Senate last week agreed to start the 365-day clock a few months later than it originally wanted to give officials more time to get the waiver, but still insists on having absolute deadlines for approval that would allow the program to continue.
"Both sides want to find an agreement on this complex issue and the bill advanced out of (the Senate) committee Thursday gets us closer to that point than we have been at any time in the last six months," Senate President Chuck Morse said Friday.
House Speaker Terie Norelli said Friday the House plan also reflects significant compromises.
"We continue to be open to ideas, but they must be workable. It is critical we act now, further delays would be detrimental to the state and to our communities," said Norelli, a Portsmouth Democrat.
The Senate plan also would end automatically after three years when federal funding begins dropping below 100 percent unless the Legislature reauthorized it. Expansion is fully financed by Washington for the first three years, gradually phasing down to 90 percent.
House Republicans unsuccessfully fought to add a cost cap triggering an end of expansion and the provision for lawmakers to reauthorize it.
"If this is no longer affordable, we should no longer do it," argued Republican Rep. Neal Kurk.
Kurk said for people whose coverage would end, "they would revert back to their current situation" of getting charity care at hospital emergency rooms or clinics.