Medicaid can’t continue expanding forever

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As legislators consider more proposals to expand Medicaid eligibility or services to specific populations, they ought to consider that Medicaid is both like and unlike the universe.

Like the universe, Medicaid is expanding faster than it should be. Unlike the universe, there’s no scientific possibility of Medicaid expanding forever. (Maybe the universe can’t either.)

Two bills moving through the Legislature this session are based on increasingly questionable assumptions about federal spending commitments. House Bill 282 would end the five-year waiting period for Medicaid eligibility for “lawfully residing” children and pregnant immigrants. House Bill 565 would extend Medicaid benefits for new mothers from two months after birth to a full year. 

These expansions come as New Hampshire enjoys a temporary, pandemic-related increase in its Federal Medical Assistance Percentage (FMAP), which is the share of Medicaid spending the federal government covers. For the duration of the federally declared COVID-19 emergency, 56.2% of New Hampshire Medicaid spending is covered by the federal government. When the emergency declaration ends on May 11, New Hampshire’s FMAP rate reverts to its normal level of 50%. 

(Incidentally, the additional 6.2 percentage points of additional federal funding during the pandemic emergency was given on the condition that the state not conduct eligibility determinations. That waiver of eligibility requirements will end when the emergency ends, which will affect an estimated 72,500 current enrollees. The pandemic enrollment increase has been so costly to the state that it has pumped additional federal funds into the Medicaid program.)

Legislators tend to assume that the default 50% rate will continue indefinitely. But the federal budget situation could prompt reductions in the federal contribution, something the Congressional Budget Office (CBO) recently suggested. 

The CBO this month projected that the federal deficit will nearly double from $1.4 trillion to $2.7 trillion in the next decade, and the federal debt held by the public would reach a record 118% of Gross Domestic Product. 

This record debt is driven by historically high federal spending, which is projected to increase from 23.7% of GDP to 24.9% of GDP by 2033. Federal spending has exceeded 24% of GDP only during World War II, the 2008 financial crisis, and the COVID pandemic. The CBO projects it to reach this level again within the next decade simply due to regular budget outlays. 

Federal revenues, meanwhile, are projected to remain around 18% of GDP through 2033. 

That unsustainable course will put pressure on Congress to cut costs or raise taxes or both. Anticipating this, the CBO in December offered suggestions for reducing the federal deficit. In the area of health care spending, the CBO suggested that Congress “establish caps on federal spending for Medicaid” and “reduce federal Medicaid matching rates.” 

Such actions are not out of the question. As the Congressional Research Service puts it, “Medicaid was designed to provide coverage to groups with a wide range of health care needs that historically were excluded from the private health insurance market.” But the program has grown over the years to cover people who could find coverage in the private market. 

By routinely expanding Medicaid benefits and eligibility, lawmakers have grown the program’s outlays from $206.2 billion at the turn of this century to $748 billion in federal fiscal year 2021. Medicaid accounts for 17% of U.S. health care expenditures. 

These expansions are unsustainable for both the state and federal governments. Eventually, some level of financial discipline, however small or limited, will have to be imposed. Clawing back Medicaid spending is politically easier than touching Social Security or Medicare. That is especially true after Medicaid has grown to cover people who could find alternative insurance coverage. Given those realities, current levels of federal Medicaid spending cannot be taken for granted.

Any discussion of expanding Medicaid coverage or eligibility should start with the understanding that current spending levels are unsustainable, and increasing those levels just accelerates the date of reckoning.

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Temporary licenses offer life support for N.H. health care system as permanent fix proves elusive

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On Feb. 1, amid a critical shortage of health care personnel in New Hampshire, the licenses of 22,328 medical workers were set to expire. That’s 26% of health care workers licensed to practice in the state. 

In January, the state’s Office of Professional Licensure and Certification (OPLC) prevented that disaster by issuing an emergency rule to extend the licenses — for four more months. 

When that rule expires on May 31, all of those licenses will expire with it. 

Unless the Legislature acts before then, Granite Staters will lose access to tens of thousands of medical professionals, including 951 mental health counselors, 1,064 social workers, 1,114 psychologists, 2,104 Advanced Practice Registered Nurses, and 14,920 physicians. 

Many of those, such as psychologists, are offering services remotely. Others, including a lot of physicians, were licensed under bulk applications and might have few New Hampshire patients. Others, such as nurses, fill staff positions in New Hampshire.

All of them were granted temporary emergency licenses during the pandemic. Those licenses were extended through January, then again through May. Legislators so far have refused to pass a law to make these licenses permanent, or to grant permanent recognition of out-of-state health care licenses. 

A health care system in crisis mode

Nearly two years after the first COVID case was documented in New Hampshire, health care in the state is being triaged through a rolling series of emergency professional license extensions. 

“We get calls all day saying, ‘We need you to approve this license right away,’” Lindsey Courtney, executive director of the OPLC said. 

“It’s mostly hospitals or residential or long-term-care facilities. And often it’s because they’re bringing in travelers. They’ll call a staffing agency and they’ll be told, ‘I can get you five people, but they have to be licensed tomorrow.’”

Because obtaining a permanent state license can take months, quickly licensing those new hires is done under a stop-gap fix the Legislature passed last year. It lets the OPLC offer temporary, 120-day licenses to health care workers.

“I would say that’s how the bulk of the traveling nurses get licensed,” Courtney said. “They don’t even seek a permanent license because they’re going to be here less than four months. If they had to seek a regular license, I’m not sure where we’d be.”

In seven health care fields, more than a third of licensed practitioners hold emergency licenses, a review of state licensing data shows. In two fields, the percentage is close to two thirds.

Percentage of licensed health care practitioners who hold an emergency license: 

Licensed Alcohol and Drug Counselors    36%

Advanced Practice Registered Nurse        39%

Licensed Independent Clinical Social Workers     44%

Licensed Clinical Mental Health Counselor           45%

Marriage and Family Therapists         47%

Psychologists        63%

Physicians             65%

Courtney has pressed legislators to provide a permanent fix by simply letting her office recognize out-of-state health care licenses. 

It’s hardly a new idea. The Journal of the American Medical Association published a brief arguing for medical license reciprocity in 1899. But every time it is proposed in New Hampshire, licensing boards object. 

Dominance of state licensing boards

Professional licensing in New Hampshire is conducted by 54 different state licensing boards. Thirty-five of those regulate health care occupations. 

In theory, giving current practitioners the ability to license new entrants into their field raises quality. In reality, it reduces the number of practitioners and gives established license holders the power to restrict competition.

For health care occupations, that is bad for patients, said Morris Kleiner, the AFL-CIO chair in labor policy at the Humphrey School of Public Affairs at the University of Minnesota, and an expert on occupational licensing.

If New Hampshire doesn’t make these licenses permanent, it could harm Granite Staters by suddenly and sharply reducing access to care, he said.

“Not having the licenses, or revoking them, reduces the supply of labor and reduces access of patients to these important, healing occupations,” he said.

Senate Bill 277, sponsored by Sen. Erin Hennessey, R-Littleton, would offer another temporary fix by extending the 22,328 emergency health care licenses, set to expire May 31, for another two years. That would stretch these “emergency” licenses out for four years in total. 

At a Jan. 11 Senate hearing on the bill, the OPLC offered an amendment to have the licenses made permanent. The Board of Psychologists opposed the amendment, saying it would amount to “rubber-stamping the approval of an out-of-state license” and therefore diminish the quality of care offered to patients in New Hampshire. 

Currently, 1,114 psychologists hold a temporary emergency license to practice in New Hampshire. They far outnumber the 645 psychologists who hold a permanent license. If these emergency licenses were to be made permanent, it would increase the number of permanently licensed psychologists by 73%. 

During the state of emergency, New Hampshire granted licenses in bulk to Massachusetts health care providers who accepted Medicare and Medicaid. This ensured that New Hampshire patients could see their caregivers remotely. In some cases, a large health care facility made a bulk application on behalf of its employees who might have New Hampshire patients. Bulk submissions can cover a lot of providers who don’t regularly see New Hampshire patients, or who don’t intend to move to the state. (Many of the emergency-licensed physicians fall into this category.)

About 35% of the emergency licenses for psychologists were part of a bulk submission. The rest of the applications came from individuals. That represents “a significant increase in the number of people who were actually practicing,” Courtney said. “Those were probably people conducting a lot of telehealth services with patients, probably a lot of cross-border care.”

“Mental health is continuing to operate in a largely telehealth platform,” she added.

Another bill, Senate Bill 330, sponsored by Sen. Bob Giuda, R-Warren, would authorize the OPLC to license practitioners who work in other states in which the requirements for licensure are substantially similar to those in New Hampshire. 

Both bills have bipartisan support in the Senate. But hostility to SB 330 from some licensing boards and licensed professionals suggests that a permanent fix to the problem is unlikely this year. 

It’s an uphill battle, given the political strength of licensing boards, Professor Kleiner said.

“The only state that has extended the temporary licenses and made them permanent is your neighbor in Massachusetts,” he said. “Most other states have let the temporary licenses expire, and that’s unfortunate given the spike in the number of COVID cases we’ve seen.”

An outdated system

State licensing boards typically meet monthly and approve license applications at their meetings. Though modern technology allows instant online application submissions, New Hampshire’s licensing system operates on a 19th century schedule of in-person meetings and infrequent reviews. Getting an application approved through the regular process can take months.

“Vermont’s doing it in 24 hours, and we’re competing for the same licensed person,” Courtney said. “You have to keep up with the times, and people are not going to wait around 60 days.”

Vermont a few years ago overhauled its professional licensure process to make it easier and faster to get a state license. (The reform was funded by a federal grant received in 2018.) 

The Green Mountain state processes all applications online and offers fast-track recognition for professionals who hold out-of-state licenses in many occupations. Under Vermont law, three years of experience practicing a regulated occupation in another state is considered sufficient experience to qualify for licensure.

“Colorado and Vermont are among the most efficient in the country at getting licenses processed,” Professor Kleiner said. “Vermont’s very efficient.”

Arizona passed a universal license reciprocity law in 2019. Since then, 4,000 people have used it to obtain state licenses. 

Such comprehensive reforms have never gotten far in New Hampshire. Some state boards have made improvements, for example by passing rules to allow the OPLC to process license applications between meetings. Others, including the boards for psychologists and licensed alcohol and drug counselors, haven’t. 

“We have a psychologist who lapsed his license,” Courtney said. “He’s been practicing for 30 years. He also practices in another state. It took him a month. If he had had patients, that would’ve been problematic because he would’ve had to choose between cutting them off or committing a violation.”

No serious complaints

Licensing boards often object to automatic reciprocity by arguing that it would jeopardize public health and safety. The record of the last two years suggests otherwise. 

The governor’s emergency order recognizing out-of-state health care licenses in New Hampshire took effect on March 23, 2020. Since then, 22,328 emergency licenses have been issued. Yet the state has received only two complaints about emergency license holders, Sen. Hennessey testified during the Jan. 11 meeting of the Senate Finance Committee. 

Neither of those complaints was serious enough to go to a hearing, Courtney said.

The number of practitioners operating under an emergency license varies by field. They include a single acupuncturist, six midwives, nine optometrists, 25 dietitians, and 92 licensed alcohol and drug counselors. In fields with significant shortages, the numbers can be substantial. Emergency licensees include 1,064 licensed clinical social workers, 2,104 Advance Practice Registered Nurses, and 14,920 physicians.

Far from creating a public health problem, these emergency licensees likely saved numerous lives by providing services that would not have been offered otherwise. Hospitals and nursing homes in particular have relied on emergency licenses to stay staffed during the last two years. 

Even with these additional health care workers, some facilities have had to close rooms and limit services. Were it not for the thousands of additional staff made available through emergency licensure, these closures would have been much worse. 

Despite the stressful conditions and difficult working environment that has prevailed for two years, only a few complaints have been made against emergency licensees, and none was serious enough to bring to a hearing. The tiny number of complaints is powerful evidence that the safety concerns regarding large-scale license reciprocity are unfounded, according to Courtney.

“I think we’ve shown that the world doesn’t end and the sky doesn’t fall when we remove some barriers for licensure,” she said. 

 

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State laws have limited the supply of new hospital beds for decades

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New Hampshire is scrambling to find enough staffed hospital beds to handle the current surge in COVID-19 patients. Suddenly, politicians on the left and the right are deeply concerned about the low number of hospital beds in the state. Which is kind of maddening because they’re the ones who created the shortage in the first place.

For decades, state laws have severely restricted the state’s hospital capacity. They still do. 

Before 2016, New Hampshire was one of many states with a Certificate of Need (CON) law that essentially required businesses to prove that a large medical equipment or facility investment was needed before it could be approved by the state. That law suppressed investment in new facilities and services. 

In 2016, the CON law was repealed, but it was replaced with laws that created additional restrictions on hospital capacity. Senate Bill 481, passed that year, added three major requirements into state law that restrict hospital competition. 

  1. RSA 151:2-g mandates that every hospital “shall operate an emergency department offering emergency services to all individuals regardless of ability to pay 24 hours every day, 7 days a week.” This law prohibits the creation of any competing hospital services that don’t also include a 24/7 emergency room. Conveniently, this law “shall not apply to any hospital licensed and operating prior to July 1, 2016, which does not operate an emergency department.” Incumbent hospitals are protected from this anti-competitive law. 
  2. RSA 151:4-a prohibits the establishment of any “ambulatory surgical center, emergency medical care center, hospital, birthing center, drop-in or walk-in care center, dialysis center, or special health care service” within 15 miles of an existing critical access hospital if the new facility “will have a material adverse impact” on the incumbent hospital. That is, if it would hurt the hospital’s business, it is prohibited from state licensure. A 15-mile radius might sound small, but it equals 706.9 square miles. 
  3. RSA 151:2-f mandates that every hospital, infirmary, “outpatient rehabilitation clinic, ambulatory surgical center, hospice, emergency medical care center, drop-in or walk-in care center, dialysis center, birthing center, or other entity where health care associated with illness, injury, deformity, infirmity, or other physical disability is provided” accept all forms of payment. This law mandates that medical facilities accept Medicare, Medicaid and private insurance — which means that it bans any facility designed to cut costs by accepting only cash payment. This inflates the cost of services and eliminates competition. 

In addition, RSA 151:2 VI (a.) imposes a moratorium on new beds for nursing and rehab facilities. It states that “there shall be no increase in licensed capacity of, any nursing home, skilled nursing facility, intermediate care facility, or rehabilitation facility, including rehabilitation hospitals and facilities offering comprehensive rehabilitation services.”

State laws ensure that it is much easier for incumbent hospitals and other medical facilities to expand than for new competitors to enter the New Hampshire market. The results are exactly what one would expect. 

Since 1980, New Hampshire’s population has increased by 49.6%. But in that time, only one new acute care hospital, Parkland Medical Center in Derry, has been built, Greg Moore, state director of Americans for Prosperity-NH has pointed out.

The current COVID-induced crunch on hospital capacity has many causes. The media have reported, accurately, that a surge in patients combined with a staffing shortage has put severe strain on the system. 

But that system entered the COVID-19 pandemic with a capacity already artificially constrained by anti-competitive state laws. Going forward, politicians who insist that New Hampshire needs to improve its hospital bed capacity can start by removing unnecessary barriers that make it extremely difficult for new competitors to enter the New Hampshire market. 

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96.5% of NH COVID infections, 93.5% of deaths are among unvaccinated, but state doesn’t publicize the data

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New Hampshire’s official COVID-19 statistics continue to show the efficacy of vaccines in fighting infection, hospitalization and death from the ongoing pandemic. But this information is not included on the state’s COVID-19 dashboard, nor in the daily or weekly COVID press releases, hindering the state’s vaccine promotion efforts. 

New Hampshire recorded its first breakthrough infection (a COVID-19 infection in a fully vaccinated patient) on January 20th of this year, the state Department of Health and Human Services reports. Since that date, only a small fraction of the state’s COVID-19 infections, hospitalizations, and deaths have occurred among fully vaccinated persons, according to data released to the Josiah Bartlett Center from the state Department of Health and Human Services. 

From Jan. 20-Sept. 24, 2021:

  • Only 3.5% of total COVID-19 infections (1,976 of 57,203) have occurred among fully vaccinated individuals;
  • Only 6.4% of initial hospitalizations (37 of 579) have occurred among fully vaccinated individuals;*
  • Only 6.5% of deaths from COVID-19 (28 of 430) have occurred among fully vaccinated individuals.

(*The state records COVID hospitalizations for those who were hospitalized upon the initial report of their infection. If someone is hospitalized after the initial report of infection, that would not be included in the hospitalization statistics. The state has always reported COVID hospitalizations this way.) 

While state data show that 96.5% of New Hampshire’s COVID-19 infections, 93.6% of initial hospitalizations and 93.5% of deaths have occurred among unvaccinated individuals since January 20th, these statistics are created manually within the department and thus are not part of the daily or weekly information released to the public. 

Making these statistics a regular part of the state’s vaccination message might help reduce vaccine hesitancy, polling suggests. 

And higher vaccination rates would improve the state’s economic prospects while accelerating the end of the pandemic. 

New Hampshire ranks 10th in the nation in the percentage of residents who are fully vaccinated (61%), according to the latest tracking data from Becker’s Hospital Review. Yet that percentage is well below all other New England states. The top five most vaccinated states are the five other New England states. 

Vaccine hesitancy has slowed the state’s vaccination efforts. According to a University of New Hampshire poll released Sept. 21, the top two reasons unvaccinated Granite Staters gave for not wanting the vaccine were: 1. They don’t trust it will be safe; and 2. They don’t believe it’s effective. 

Both of those fears run contrary to large amounts of publicly available data.

Regarding vaccine safety, the state could put more resources into promoting research that has shown the vaccines to be safe. A Harvard study of nearly 2 million Israelis, for example, found that not only were vaccine complications extremely rare, but conditions commonly associated with the vaccines — such as inflammation of the heart muscle — occurred more frequently in unvaccinated individuals who were infected with COVID than in individuals who received the vaccine. 

Regarding vaccine effectiveness, the state should make the vaccination statistics listed above part of its daily COVID reporting, as well as part of any public information campaign. 

Data highlighting the effectiveness of the vaccines should be put atop the state’s COVID-19 dashboard and should be made the focus of every press release and briefing.

People are getting a lot of bad information from unreliable sources. The state needs a more rigorous effort to counter misinformation with its own reliable data. 

State officials are aware that the vaccination data would help combat myths about the vaccines, but the statistics were not built into the initial reporting system, and a general manpower shortage has delayed the state’s effort to add them, according to a spokesman for the state Department of Health and Human Services.

“We’re working on it, but it boils down to capacity,” HHS Director of Communications Jake Leon wrote in an email. “As you might imagine, we’re as busy as we’ve ever been but do not have as much access to temp staffing with the National Guard standing down.”

The public health reasons for publishing accurate information about the safety and efficacy of vaccines are obvious. There also are economic reasons. 

COVID-19’s negative economic impact is widely known, and that impact continues to push down economic forecasts. The National Association for Business Economics this week cut its economic growth forecast, largely due to fears over the prolonged presence of COVID-19. 

For those who want to see New Hampshire’s economy reach its maximum potential, a high vaccination rate for COVID-19 is vital. It’s hard to engage in free and open commerce when a potentially fatal communicable disease continues to suppress direct human interaction, reduce labor force participation and otherwise disrupt overall economic activity.  

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The unvaccinated account for 98% of N.H. COVID deaths since Feb. 1, state data show

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Since the beginning of February, unvaccinated individuals have accounted for 99% of New Hampshire’s COVID-19 cases and 98% of deaths, according to state data. The numbers indicate how extremely effective vaccines have been at fighting COVID-19 in the state.

From February 1 through June 23, the state recorded 33,703 COVID-19 cases, according to the state’s Joint Information Center, part of its Emergency Operations Center. Of those, only 349 involved people who had been fully vaccinated. That’s 1.03% of the total.

During the same period, 236 people have died from COVID-19. Only five of those were fully vaccinated. That’s 2.1% of the total.

Only 15 fully vaccinated individuals have been hospitalized for COVID-19 in New Hampshire,  according to the Joint Information Center.

Because of the way the state tracks hospitalizations, an exact percentage breakdown for hospitalized patients is not possible. The state records whether a patient was hospitalized at the time the case was reported to the state, but not whether hospitalization was required later. However, the state does track how many vaccinated people have required hospitalization for COVID-19 at any point. That number has totaled only 15. 

The Joint Information Center sets February 1 as the approximate date by which Granite Staters began to become fully vaccinated. 

A University of New Hampshire poll released Thursday reports that 25% of Granite Staters say they probably or definitely will not get the vaccine. 

Among that group, 56% say they don’t believe it will be effective at stopping them from getting COVID. 

The state data show that, contrary to this view, the vaccines are highly effective at reducing the risk of infection, serious illness and death from the coronavirus. 

The state figures also are similar to national data released last week. An Associated Press analysis of COVID-19 data from May found that 99.2% of COVID-19 deaths in the United States were among unvaccinated people. 

The difference between the 99% and 98% rates for New Hampshire cases and deaths, respectively, is not statistically significant, Beth Daly, chief of the state Bureau of Infectious Disease Control, said. (Dr. Daly’s comment was received after press time and was added to this story after publication.)

“The numbers are not really statistically different because you are comparing a small number (236) to a larger one (33,703).

“This is an issue of small numbers when you compare a denominator of tens of thousands to a denominator of just a few hundred. The confidence interval of 5 divided by 236 is from <1% to 5%, so the 1% observed in the calculation of 349 divided by 33,703 is not statistically nor meaningfully different from the proportion of deaths.

“To say it another way,  the proportion of vaccine breakthrough infections is statistically the same/no different from the proportion of vaccine breakthrough deaths. They are also not substantively different.”

 

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The COVID-19 emergency is over in New Hampshire

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When Gov. Chris Sununu announced the end of the statewide mask mandate on April 15, the seven-day rolling average of positive COVID-19 cases was 411.6, the number of positive cases in the state was 3,763, and 130 people were hospitalized with COVID-19. 

By June 8, the number of known COVID-19 cases had declined by 91% from April 15, hospitalizations had declined by 78%, and the seven-day average of new cases had declined by 88%. 

Only 28 people were hospitalized on June 8, and only 322 known cases existed in the state.

Going back to the height of the pandemic in New Hampshire, the drop is even more dramatic. 

  • The number of new infections has dropped by 97.5% from its December 3 peak.
  • The seven-day rolling average of infections has dropped by 94% from its December 8 peak.
  • Hospitalizations have dropped by 92% from their January 1 peak. 
  • The seven-day rolling average of COVID-19 deaths has dropped by 88% from the peak, which was reached on both December 26 and January 7. 

Vaccinations have changed the state of the pandemic in New Hampshire, dramatically reducing the number of hosts for the virus to infect, and providing protection to the most vulnerable populations. 

Nearly 60% of the state’s population has received at least one vaccine dose and 50.7% have been fully vaccinated, according to the state’s COVID-19 dashboard.

By any measure, the COVID-19 public health emergency in New Hampshire is over. 

Gone with it are the justifications for a state of emergency.   

When Gov. Sununu declared a state of emergency on March 13, 2020, his executive order stipulated the following concern (among others), that “if COVID-19 spreads in New Hampshire at a rate comparable to the rate of spread in other countries, the number of persons requiring medical care may exceed locally available resources, and controlling outbreaks minimizes the risk to the public, maintains the health and safety of the people of New Hampshire, and limits the spread of infection in our communities and within the healthcare delivery system.”

The declaration stated that “under RSA 4:47, III, the Governor has ‘power to make, amend, suspend and rescind necessary orders, rules and regulations’ to carry out emergency management functions in the event of a disaster beyond local control.”

State law does give the governor those powers — when there is a state of emergency. 

RSA 21-P:35 VIII defines “state of emergency” as “that condition, situation, or set of circumstances deemed to be so extremely hazardous or dangerous to life or property that it is necessary and essential to invoke, require, or utilize extraordinary measures, actions, and procedures to lessen or mitigate possible harm.”

Though COVID-19 still exists in the state, its presence no longer presents a situation so extremely dangerous that “it is necessary and essential” to invoke “extraordinary measures” to mitigate the harm. 

Further vaccinations will continue to reduce infections, hospitalizations and deaths. 

When a state of emergency ends, all of the emergency orders end with it. Many of those orders nullified regulations that were never needed and that interfered with both medical and business innovations. Rules limiting pharmacists’ scope of practice, preventing hospitals from hiring unlicensed helpers, preventing telemedicine and the practice of medicine by retired physicians, and preventing businesses from adapting by offering sidewalk dining or alcoholic beverages to go are just a few of the regulations lifted by emergency orders.

Because these and other allowances would disappear as soon as the emergency ends, the governor might have an interest in keeping the state of emergency in place a little longer until pending legislation making such emergency orders permanent is adopted. For example, a bill is pending that would let restaurants continue outdoor dining in common areas such as public sidewalks. If the emergency is lifted before that passes, restaurants would have to close those popular outdoor seating areas immediately. 

But the threat that prompted the emergency declaration last year clearly is gone, and prolonged extensions of the state of emergency no longer can be justified.

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Free beer & no masks: How better vaccine incentives can help shorten the pandemic

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In late April, New Hampshire was No. 1 in the nation in the percentage of distributed vaccines administered. Nearing mid-May, the state has dropped to 24th (80%). 

As those who were most eager to get vaccinated have done so, the number of people signing up for their first dose has fallen sharply. Though Becker’s Hospital Review reports that 59% of the population has received at least one dose as of May 14, only 35% has been fully vaccinated. 

This slowdown in vaccine demand creates a public health concern because it threatens to prolong the spread of the pandemic.

The state has been encouraging people to get vaccinated for months. It has initiated a public awareness campaign with the message that getting vaccinated protects you and others. This has been the standard public messaging for COVID-19 vaccination campaigns. But recent research suggests that it’s not very effective at convincing those who remain reluctant to get vaccinated.

A recent YouGov poll found that 63% of Americans who do not plan to get vaccinated think it’s safe to gather indoors with other unvaccinated people without wearing a mask. A campaign that focuses on telling people they and their loved ones will be safer if vaccinated won’t resonate with unvaccinated people who already think they’re safe.  

Shift to incentives and a positive message

A better vaccination campaign would offer a combination of fun incentives and positive messages. 

A UCLA study found that people respond to cash and lifestyle incentives. Offering between $25-$100 raised people’s willingness to get the vaccine by between 13-19%. Cash was more effective with Democrats than Republicans.

Telling people that they won’t have to wear a mask after they get vaccinated also was effective at changing minds. For all respondents, the percentage who said they were more likely to get a vaccine rose by 13 points, from 50% to 63%. For Republicans, the gain was 18 points, from 35% to 53%.

That’s one reason the CDC’s newly announced guidance that vaccinated people don’t have to wear masks is so important. Requiring people to continue masking in public after vaccination undermines the government’s message that vaccination will make them safer and bring a return to pre-pandemic life. 

This confusing messaging is prevalent in New Hampshire. Dover, which has a public mask mandate, tells residents that they must continue masking after getting vaccinated. 

Its guidance reads: 

“WILL I BE ABLE TO STOP WEARING A MASK AND SOCIAL DISTANCING IF I GET THE VACCINE?

“No.”

Portsmouth and Nashua are among the New Hampshire municipalities that continue to mandate mask-wearing in public, including outdoors, which undercuts the state’s vaccine messaging. 

Instead of communicating the depressing, negative message that vaccination offers no escape from mask mandates and other government controls, government ought to be sending a message of hope and joy while offering people fun incentives to get the shot.  

Yes, the caveat is that businesses, local governments and other organizations might continue to require masks indoors for the time being. But governments aren’t effectively communicating that this should be a temporary, transitional practice rather than a permanent one.

A few jurisdictions, however, have tried creative, incentive-based initiatives to encourage vaccination, and the results are encouraging.

An Erie County, N.Y., program that offered free local craft beer and a pint glass to those who showed up to get vaccinated at a local brewery resulted in more vaccinations in one day than all of the county’s first-dose clinics for the previous week, The Buffalo News reported. 

New Jersey is partnering with the Brewers Guild of New Jersey to provide a free beer for anyone who gets vaccinated in May. 

Ohio is giving away $1 million each to five newly vaccinated people via a lottery, plus college scholarships to five students. 

Alabama is holding a mass vaccination event at the Talladega Superspeedway and letting people do two laps around the speedway (behind a pace car) after getting their shots. 

There is good evidence that unvaccinated people respond more to incentives such as free cash and beer — and the lifting of mask requirements — than to New Hampshire’s current messaging. The state could produce better results by changing its vaccine marketing as soon as possible to do the following:

  1. Partner with willing craft breweries, wineries, distilleries, restaurants, etc. to offer freebies in exchange for getting a vaccine. Businesses hard hit by the pandemic — such as movie theaters and restaurants — might make good partners. The state is receiving another $1.5 billion in federal COVID relief funds. Using some of that money to boost the state’s vaccination rate by partnering with local businesses to offer beer, coffee, doughnuts or movie tickets to reluctant residents would be a cost-effective investment in speeding the end of the pandemic. 
  1. Start communicating to people that mask-wearing and other restrictions, at least in public spaces and especially outdoors, can end when enough people get vaccinated. The confusing messaging on masking is suppressing interest in vaccination. A clear, positive message, effectively communicated, can help to reverse that. 

The state has both a public-health and an economic interest in bringing the vaccination rate up to the highest possible level. Giveaways and better messaging won’t convince everyone to get a vaccine, but there is evidence that they can produce a large enough change on the margins to make a significant difference. Available evidence suggests that this would be more effective than the standard messaging being used by New Hampshire and most other states. 

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Vaccinations killed the mask mandate, and now show the way forward

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Gov. Chris Sununu lifted the state’s mask mandate on April 16, and much hand-wringing ensued. And scolding. And partisan attacks. 

New Hampshire Public Radio noted, with apparent worry, that the hospitalization rate was higher than it was when the mandate was issued last November. 

State Democratic Party Chairman Ray Buckley tweeted, “When Republicans get elected, people die.”

A University of New Hampshire poll released April 21 found that 43% of Granite Staters supported lifting the mandate, while 48% opposed. 

But the data support the governor’s decision. 

If a statewide mask mandate had been justified to preserve hospital capacity and limit deaths through the winter, that justification receded with the rest of the second wave. The numbers just don’t support the continuation of an emergency order commanding people to wear masks when outside and in public spaces.

Keep in mind that the state mandate was of its highest utility primarily in outdoor public spaces (where infection risk is extremely low) and in indoor places of public accommodation where business owners were not already requiring masks (which was a small minority of businesses).

On November 19, when the governor issued the mandate, new cases had been rising for three months, and rising sharply for several weeks. Confirmed hospitalizations were rapidly approaching their spring peak. Signs were that the expected second wave was on its way. 

By April 15, when Sununu announced that the mandate would not be extended, the second wave — never as severe as feared — had long since subsided. 

There were 108 hospitalizations on November 19 when the mandate was issued. There were 132 on April 15, when the governor announced the mandate wold be lifted. There were 112 on April 23, a week after the mandate was lifted. 

Throughout the pandemic, the state prepared to manage 1,000 hospitalized COVID-19 patients. We never approached that number. The highest daily count was 334 on January 1. 

There is no shortage of hospital beds or ICU beds in the state. 

Deaths, the most important metric, have plummeted since January. 

Deaths peaked at a seven-day average of 11.7 on December 26. They hit a seven-day average of 11.6 on January 7. Since then, they have fallen dramatically. 

The seven-day average was two on March 5 and has been below that ever since. It stood at 1.1 on April 15. It was at 1 on April 18, the last day for which the state has posted data.

Switching from masks to vaccines

Without a vaccine, COVID-19 cases were a more important metric. With a vaccine, deaths is the most important metric, with hospitalizations second. Vaccination dramatically reduces both of those outcomes, as New Hampshire’s data show. As vaccinations have risen, deaths have plummeted and hospitalizations have fallen sharply. 

Remember “flatten the curve?” The point of state interventions all along has been to preserve hospital capacity and prevent mass deaths. It was never to prevent all hospitalizations and all deaths, impossible tasks.

Before a vaccine was available, the state had only very crude tools with which to try to accomplish its goals. Mask mandates, travel restrictions and business closures were the tools at hand, and states used them. 

The vaccine is a far more powerful tool for achieving the same ends. That’s why the governor has shifted the focus away from crude restrictions on behaviors to the encouragement of widespread vaccination. 

Ending the mandate doesn’t immediately end masking. Businesses and municipalities may continue to maintain their own policies as we move toward ever higher vaccination rates. What it does is encourage vaccination in two important ways. 

  1. It shows people the connection between vaccination and the end of emergency restrictions such as mask mandates.
  2. It demonstrates faith in individuals to make their own decisions, which builds good will and trust, the shortage of which has made fighting COVID-19 more challenging than it should have been.

The focus on vaccination, with top priority given to the elderly, already has paid tremendous dividends. New Hampshire was the first New England state to make half of its population eligible for the vaccine. It now leads the nation in the percentage of adults who have received a first dose, at more than 70%.  

The results are so remarkable that on April 23, Andy Slavitt, White House senior advisor for COVID response, tweeted high praise for New Hampshire: 

8 states have now vaccinated more than 60% of adults with a first shot.

New Hampshire  (>70%!)

CT

Mass

NM

Maine

NJ

VT

Hawaii

All of them have turned the corner on the number of cases & hospitalizations.

Well done. Let’s all get there.

We will get there, but not by giving people a disincentive to vaccinate, which is what prolonged mask mandates do. We will get there by encouraging vaccination and showing how it paves the path back to normalcy.

As Derek Thompson of The Atlantic wrote this week,” as more and more of the population is vaccinated, governments need to give Americans an off-ramp to the post-pandemic world.”

Showing people that they can trade masks for vaccines does this. 

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N.H. 1st New England state to make vaccine available for half, then later 2/3, of residents

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On Monday, March 29, New Hampshire became the first New England state to make at least half its population eligible for a COVID vaccine, according to an estimate by the Josiah Bartlett Center for Public Policy. Two days later, on the last day of March, it became the first New England state to make at least two-thirds of its population vaccine eligible.

In March, New Hampshire and Connecticut quickly accelerated their vaccine eligibility, trading places for the most rapid expansion. Connecticut made approximately 45.7% of its population eligible on March 19 when it allowed sign-ups for people aged 45 and older. New Hampshire opened registration for residents aged 40 and older 10 days later, then opened registrations for ages 30 and older on March 31. 

Since state vaccination programs began, they typically have been ranked by the percentage of their population that has been fully vaccinated. Another method is to measure the percentage for whom a vaccine is available. Both measures have problems, and both offer useful insights into a state’s vaccine rollout. 

The biggest problem with judging a state by the percentage of its population fully vaccinated is that state governments don’t mandate vaccination; their responsibility is to make vaccines available. 

Another problem is that a sizable, though declining, level of vaccine reluctance persists, particularly in more rural and Republican-leaning states, some data suggest. 

Measuring a state government’s success by the percentage of the population that got the vaccine is to give credit or lay blame in part for factors that are beyond the state bureaucracy’s control.

Judging states by the percentage of the population that has access to a vaccine could be a better measure of the state government’s distribution program. However, this measure also is affected by public behavior and demographics. 

If large portions of the earliest eligible groups decline vaccination because they are skeptical or fearful of the vaccine, that can make more doses available more quickly for later groups. If a state’s population is heavily skewed toward one end of the age spectrum, that will also affect the percentage eligible. 

New Hampshire’s median age is 42.9, almost two years higher than Connecticut’s (41). That gives New Hampshire an edge over Connecticut on this metric. But Maine’s median age is 44.7. Vermont’s is the same as New Hampshire’s (42.9). Rhode Island and Massachusetts are the youngest New England states, with median ages of 39.9 and 39.5, respectively. 

Another potential complication is that declaring eligibility is not the same as making the vaccine available. States can open sign-ups, but those are good only if the system is granting quick and easy access to appointments where vaccines are available.

Ultimately, states are responsible for creating a functioning distribution system that provides residents with the opportunity to obtain a vaccine. Once that system is functioning efficiently and effectively, states can encourage vaccination, but they do not conscript people into the vaccination program. 

That being the case, looking at the percentage of the population that has access to the vaccine can be a useful way of assessing a state’s competence in getting doses to people who want them. At this core task, New Hampshire has done extremely well. Sign-ups have proven relatively easy, wait times are not long, and vaccines are readily available for those who want them.

Though no state’s distribution system has been flawless, New Hampshire’s has managed to avoid major failures while providing relatively easy and effective access for eligible groups. 

By basing eligibility primarily on age, followed by vulnerability, the state has prioritized high-risk individuals while maintaining an uncomplicated sign-up system. 

Connecticut designed and maintained a similar priority system, based primarily on age and vulnerability. Both states have stuck with these systems amid criticism from some that race, ethnicity and income should be weighed more heavily. 

At the close of the first quarter of 2021, Connecticut and New Hampshire led New England in making vaccines rapidly available for most of the population. Other New England states have lagged weeks behind.

Connecticut’s vaccine eligibility remained at age 45 and older until April 1, when it became the first New England state to offer vaccines to all residents ages 16 and older.

New Hampshire ended March with vaccine appointments available to anyone 30 or older, with its schedule set to open vaccine sign-ups for ages 16+ on April 2, just one day after Connecticut.

Every other New England state is scheduled to expand eligibility to ages 16+ more than two weeks later, on April 19. 

Using U.S. Census data, the Josiah Bartlett Center for Public Policy estimated the percentage of each New England state’s population that was eligible for a COVID vaccine on March 31, the end of the first quarter of 2021. Based on the age groups that were being offered vaccines on that date, New Hampshire was in the lead, with 67% of its population eligible, followed by Connecticut at 45.7%, Vermont at 42%, Maine and Rhode Island at 25%, and Massachusetts at 23%.

In addition to prioritized age groups, states have made first responders and other “essential” workers eligible for vaccines. We used only age groups to estimate the vaccine-eligible percentage of the population because we did not have good data for dividing these workers by age.

Adding essential workers without adjusting for age would boost each state’s figures by a few percentage points, but adding those numbers without knowing the workers’ ages would double count many, if not most, of them, particularly in Connecticut and New Hampshire. 

Discrepancy between eligibility and vaccination rates

Becker’s Hospital Review ranks states by the percentage of the population that’s been fully vaccinated. On March 31, the New England states ranked by that metric were:

Rhode Island 20.7%

Connecticut 20.5%

Maine 19.31%

Massachusetts 18.5%

Vermont 18.4%

New Hampshire 17.1%

Why would New Hampshire rank first in New England in eligibility but last in vaccinations?

A likely reason is that a relatively high percentage of the population has reported being reluctant to get the vaccine. 

The most recent U.S. Census Bureau Household Pulse survey for late March found that 57.5% of Granite Staters who have not yet been vaccinated say they will do so. That is the 15th highest rate in the country. Yet it puts New Hampshire below every other New England state.

Looking into the survey’s data tables shows that 15% of Granite Staters said they definitely or probably would not get the vaccine. That is below the national average of 17.2%, but it’s the highest percentage in New England. Rhode Island is next at 14.3%, followed by Maine at 13.2%, Connecticut at 10%, and Massachusetts and Vermont tied at 7.4%.

Although New Hampshire has rapidly expanded eligibility, making the vaccine available to more than two-thirds of the population by the end of March, a relatively high portion of the state’s population, relative to the rest of New England, is reluctant to be vaccinated.

The importance of persuasion

And that brings us to a point the Josiah Bartlett Center made last year about the importance of building trust for public health measures. Regarding business closures and mask mandates, we cautioned that mandates and restrictions can backfire if they cut against public opinion. They can cause resistance, making it harder, rather than easier, to achieve public health goals. The first step in pursuing public health goals during a pandemic is to explain to the public why changes in behavior are needed.

In a democratic republic, persuasion is the primary political currency. Where people pride themselves in being free to live their own lives on their own terms, government dictates can backfire, causing resistance and making it harder to achieve desired goals. This is true in public health as in all other areas of public policy.

New Hampshire has done its job on the distribution end, making the vaccines widely available and easy to obtain. To get the vaccination numbers up, the state next should devote additional resources to persuading Granite Staters to get vaccinated. 

Mass vaccination is the path out of the pandemic. Though the state has made this point, the federal government’s conflicting messages have caused confusion and delay. A more energetic and high-profile state campaign to encourage vaccination would help bring up our vaccination rates and move us more rapidly back to normal, or as close to normal as we can get.

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Why are we still debating school openings?

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President Biden on March 2 announced a goal of administering at least one vaccine to every educator in the United States by the end of the month. The head of the American Federation of Teachers praised the announcement, saying, “vaccinations are a key ingredient to reopening schools safely.”

But that’s not true. 

A vast and growing body of scientific data show that schools are not major sources of COVID-19 transmission and that neither students nor teachers are at high risk of contracting the coronavirus in school buildings. 

We listed many of these studies when we wrote about this issue in January. In February, the Centers for Disease Control and Prevention issued guidance for safely reopening schools. That guidance listed three essential elements of safe reopening. Teacher vaccination was not on the list. It was included in a second list of suggestions for “additional layers” of prevention.

The New York Times summarized the CDC guidance this way: 

“With proper mitigation, such as masking, physical distancing and hygiene, elementary schools can operate in person at any level of community virus transmission, the guidelines state.

“The document says that middle and high schools can safely operate in person at all but the highest level of transmission, which is defined in two ways: when 10 percent or more of the coronavirus tests in a community come back positive over a seven-day period; or when there are 100 or more virus cases per 100,000 people in the community over seven days.

“Middle and high schools may open at any level of community spread if they conduct weekly coronavirus testing of students and staff members.”

The reason vaccination is not on the list of essential reopening elements is because 1) transmission in schools has proven to be very low, and 2) teachers as a group are not at high risk of infection. 

Aa we pointed out in January:

  • A British Medical Journal study of occupational risk by sector found that workers in the education sector had much lower risk of COVID-19 exposure than health care, medical support, and social care workers, and slightly lower risk than transportation workers. It should be noted that British public schools have mostly been open, unlike American public schools.
  • An occupational risk tool designed by the Vancouver School of Economics put Canada’s education sector in the medium risk category for COVID-19 exposure.

The evidence is so overwhelmingly in favor of school reopening that epidemiologists, infectious disease experts, doctors, and medical professors have been pointedly and urgently insisting that schools should reopen. 

They’ve even begun to publicly criticize teachers’ unions and politicians for ignoring the science in an effort to keep schools closed. 

Benjamin Linas, a professor of epidemiology at Boston University School of Medicine, wrote in Vox in February that he’s “losing patience with our teachers’ unions.”

Frustrated by the politicization of school openings, he wrote that “if educators and their unions don’t embrace the established science, they risk continuing to widen gaps in educational attainment — and losing the support of their many long-time allies, like me.”

On the same day President Biden announced that he would push for teacher vaccinations, The New York Times published quotes from a survey it conducted of 175 health experts regarding school openings.

“Over all, they said that data suggests that with precautions, particularly masks, the risk of in-school transmission is low for both children and adults,” the Times reported.

Among the quotes:

“We need to rely on science and not emotions to make these decisions. Expert guidance can get our children back to school safely. Keeping them out of school will result in irreparable harm to their education, particularly for minority children and those from lower socioeconomic backgrounds.”

— Archana Chatterjee, Dean, Chicago Medical School

“I wish that school reopening wasn’t subject to such politicization and fear, and that decisions could be made based on data and facts. Data would suggest that children, particularly younger children, can safely go to school, and that neither the children nor the teachers are at particularly higher risk.”

— Anne Blaschke, Associate Professor of Pediatrics and Pediatric Infectious Diseases, University of Utah

“This issue has been politicized, and the unions have inappropriately focused on fear and misinformation. San Francisco public schools could have been successfully reopened in August had the district, unions and others come together to support children.”

— Kim Newell Green, Pediatrician; Associate Clinical Professor, University of California, San Francisco

In Canada, the UK, Michigan, Southern California, Northern California, Colorado, and the United States as a whole, doctors have urged governments to reopen schools. The World Health Organization declared back in December that “schools can reopen safely.”

Yet it’s March and many students remain stuck in remote instruction for at least a portion of their school week.

All of New Hampshire’s neighboring states have moved teachers up the priority list for vaccinations, and there is some mild political pressure from the far left for Gov. Chris Sununu to do the same. This week, he refused, and stuck to his program to prioritize vaccines for the elderly and most vulnerable. 

Sununu’s position is quite obviously the correct one, as it’s the only one focused on protecting the most vulnerable residents first, and the only one backed by the overwhelming consensus of medical science. 

No major health organization has concluded that school personnel or students must be vaccinated before schools can open safely. No study has found that school personnel or students are at high risk of infection in schools. No study has found high rates of COVID-19 transmission in schools. 

The CDC recommendation that teachers be put into Phase 1b is not backed by any research showing teachers to be at high risk, and it contradicts the CDC’s February guidance that teacher vaccinations are not an essential element of reopening. The placement in Phase 1b is not based on risk, but purely on the classification of all educational personnel as “essential workers.” 

Of course, it goes without saying that educational personnel who are age 65 or older, or who qualify for vaccination because of underlying health conditions, are vaccine eligible already based on their risk.

There is overwhelming agreement in the medical community that schools can reopen safely with basic mitigation protocols in place, and that vaccinations for returning staff and students are not a necessary precondition for reopening. 

The medical debate is over, and has been for a while. All that lingers is a political debate that becomes further detached from reality with every passing week.  

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