Josh Elliott-Traficante

January 9, 2014

A few years ago, Oregon chose to expand Medicaid coverage to the population now under consideration for coverage here in New Hampshire. In Oregon’s case, state funds would cover the total cost of the program. The problem for Oregon policy makers was that there was only enough money available to cover some, not all, of those eligible. To remain fair, coverage in the expanded Medicaid program was chosen by lottery.

This lottery presented a unique opportunity for researchers. Given the nature of the process, it created a randomized sample that received Medicaid coverage, while those that did not became a de facto control group. Budgetary limits had created the perfect case study to analyze the effects of Medicaid Expansion.

So far the results have been mixed, but the recent data on emergency room (ER) usage is troubling. After 18 months, the study has found that ER usage among the newly covered Medicaid population was 40% higher than the control group. Not only is this a sharp increase in real terms, but keep in mind who the control group is: people with no insurance coverage at all, who often uses emergency rooms as their primary source of healthcare.

That being said, just stating that ER utilization has gone up does not explain the nature of the usage. Thankfully, the study also breaks out usage by the type of visit based on an algorithm designed by New York University and used universally by the Medicaid program. The algorithm sorts out visits into three main categories: Emergent[1], non-Emergent[2], and a catch all of ‘other’,[3] as well as a number of sub-categories diagrammed below. It found Medicaid coverage increased visits that were classified as ‘non-emergent’, ‘primary care treatable’ and ‘emergent, preventable’, while finding no statistically significant change in the use of visits classified as ‘emergent, non-preventable.’

Source: NYU Center for Health and Public Service Research

Taking a look at the three categories that saw increased usage, showing up to the ER with a bad cold would be classified as ‘Non-Emergent’. Essentially, any illness that does not require medical care beyond bed rest and over the counter medication would be classified as non-emergent.  ‘Primary care treatable’ is any condition requiring the attention of a doctor, but it could have been easily and safely taken care of by a primary doctor. Any ER visits that fall into these two categories are generally a waste of emergency resources.

‘Emergent, Preventable’ are conditions that do require a trip to the emergency room, but could have been taken care of by a primary physician, had they sought care sooner. Typical examples include complications arising from chronic conditions, such as asthma or diabetes.

There were only two categories that saw no increase over the control group. Based on the data there was no statically significant increase in the number of ‘emergent, non-preventable’ ER visits. These are health issues that require immediate medical attention but are not foreseeable, such as heart attacks, appendicitis, and strokes. In addition, there was no increase in the number ER visits that resulted in admission to the hospital.

So what does this tell us? The upshot is that ER usage is not increasing because the newly covered are now taking advantage of that coverage. If it were, there would be an increase in the ‘emergent, non-preventable’ category, as well as in hospital admissions from the ER. Instead, usage is increasing because the newly covered are using the ER improperly. Ironically, one of the selling points of expansion was to reduce this practice. Despite now having access to primary care doctors to take care of minor health issues, or catching them before they required emergency attention, this population is now using ERs more than people whose only source of healthcare might be an emergency room.

[1] Emergent: Emergency Care is required

[2] Non-Emergent: Emergency Care is not required

[3] Other: Injuries, Mental Health, Alcohol/Substance abuse/overdose

Josh Elliott-Traficante

December 2013

The latest data released by the Department of Health and Human Services showed that a total of 1,300 New Hampshire residents have selected a health insurance plan through the federal exchange during the month of November. Since open enrollment began on October 1, a total of 1,529 have signed up.

A total of 8,763 applications have been received by the federal exchange to cover a total of 17,234 individuals.

It is interesting to note that of the 12,768 that have been determined to be eligible to enroll in exchange provided insurance plans, only 4,927 qualify for subsidies, roughly 38.5% of the total.

The balance, 7,841 individuals, (61.5%), do not qualify for any assistance. There are two categories of people this might fall into: either people who have had their insurance policies canceled due to the law itself, or people who did not have insurance and though had the resources to buy it, did not.

The end result is that though Obamacare was designed to improve access to affordable healthcare, the majority of New Hampshire residents buying health insurance through the exchanges likely doing so either because their existing plan was canceled, or because they did not want to have insurance and are now required to have it.

All of these numbers stand in contrast to the nearly 22,000 who will lose coverage because their existing plans were not compatible with the new law. Though they were granted a temporary reprieve, the policies are still due to be canceled.

Link to full report from DHHS:

Charlie Arlinghaus

November 13, 2013

As originally published in the New Hampshire Union Leader

On Medicaid expansion, there is no relevant difference between the Republican and Democratic proposals being considered by the special session. An important flaw in the Senate Republican plan makes it roughly the same as the proposal pushed by the governor and the House Democrats.

Today, Medicaid covers people in specific eligibility categories rather than basing eligibility on income. To be eligible, one has to be poor (or middle income depending on the category) and also in a specific population (disabled or pregnant or diagnosed with breast cancer for example).

The expansion envisioned by the federal government would change the program to make everyone under 138% of the federal poverty level Medicaid eligible.

The largest newly eligible population under this scenario would consist of childless adults who are not covered at any income level today. About 135,000 people are currently covered by Medicaid. The proposed expansion would increase that total by as much as 50%.

In New Hampshire, a little less than half of the newly eligible population already has insurance or access to insurance through their employers. Both Republicans and Democrats would require those individuals to access that insurance and then use the Medicaid expansion budget to provide wrap around coverage for co-payments, deductibles, and additional premiums.

The governor’s plan would simply make everyone else in the expansion population eligible for one of the Medicaid plans offered by the three Medicaid managed care companies we are contracting with.

In the first year of their plan, Senate Republicans would do the same thing. They call it a bridge program but it is specified in the law as the same Medicaid coverage offered by the same Medicaid managed care companies and paid for with the same Medicaid dollars. There is no difference.

There is no need to consider the Republican plan any further because everything beyond that is moot. Their other ideas could only begin IF the federal government approved a waiver to their Medicaid rules. Except they wont.

They will deny the waiver and the program “will end.” Except it won’t. The future path is quite predictable.

Medicaid rules are set in Washington. To design our own program or make any significant change, we need to ask the federal government for permission or a “waiver” of the specific regulations. Waivers are often granted for little things but are rarely granted for large scale approaches that differ from what the administration then in power wishes.

We have no bargaining power to get a waiver when the administration strongly prefers the status quo to the change we are asking for.  Currently we are in an unusual situation. The powers that be would very much like us to expand Medicaid, preferably in the manner they’ve fashioned. Because they want a change to the status quo, we are in the unusual position of having bargaining power.

To adopt the Obamacare style expansion even for a year is to abandon all bargaining power for a position of weakness. The administration no longer needs us to change, they’ll just want us to continue the newly adopted program. And they know it won’t really expire no matter what the law says.

The future looks something like this: After the federal government denies our requested waiver, the governor will immediately call another special session in September, 2014 to “deal with the crisis.” The House will pass a continuation of the Senate Republicans’ “bridge program” which is the same as what they want anyway. “We tried but the federal government said no. Let’s join together to continue this program. It won’t cost any state dollars and that way we don’t throw 40-60,000 people out of their Medicaid bridge insurance.” In September or October of an election year, the current Senate is very likely to acquiesce.

If the later years of the Republican program were a good idea (and there are kernels of good ideas), it only makes sense to ask for permission now when you still have some bargaining power. To abandon that bargaining position turns your theoretical future plans into meaningless window dressing.

There are many reforms that people drafting the law would agree to if they didn’t worry about the federal permissions. But if any changes are worth having they are only possible if you do them first. Changes you save until after you expand and hope the feds approve anyway will never ever happen.

Charlie Arlinghaus

As originally published in New Hampshire Business Review

In a special legislative session scheduled to begin November 7, the state will consider not just expanding the Medicaid program in New Hampshire but also a dramatic change in what sort of program Medicaid is. The dramatic nature of those changes and very uncertain finances make finding the common ground needed a difficult task at best.

Today, Medicaid covers people in specific eligibility categories rather than basing eligibility on income. To be eligible, one has to be poor (or middle income depending on the category) and also in a specific population (disabled or pregnant or diagnosed with breast cancer for example). The expansion envisioned by the federal government would change the program to make everyone under 138% of the federal poverty level eligible.

The largest newly eligible population under this scenario would consist of childless adults. Today, a monthly average of about 135,000 people are covered by Medicaid. The proposed expansion would increase that total by as much as 50%.

It’s important to remember that Medicaid does not pay for health coverage. It pays a small fraction of health coverage, nowhere near the cost, and expects the provider to make up the difference on those of us with private insurance. Medicaid rates are roughly one-third of what most of us or our insurance companies pay.

If a single provider has too great a share of Medicaid patients, he goes out of business because there simply aren’t enough paying patients to shift the cost to. So, to as great an extent as possible, private insurance is to be preferred and preserved with Medicaid as a last resort.

In New Hampshire, about half of the newly eligible population already has insurance. An additional percentage is eligible for heavily subsidized through the health exchanges. People at 100-138% of federal poverty will receive insurance with premiums capped at 2% of their income.

It would be wasteful and counter-productive to move any of that population to Medicaid. The plan favored by the recently concluded state commission would preserve private coverage for only a small subset of those with insurance or access to it.

The governor and supporters of hers have suggested a principle that should be more widely applied. For one category, those with breast and cervical cancer, they would keep the lowest income people in Medicaid but cover those at higher income levels through the exchange and private insurance. If we expanded that principle to the entire Medicaid population, we would move as many people into private but means-tested coverage as we added with expansion.

If the program is changed to make everyone below certain income levels eligible, it would be natural to try and ensure that Medicaid and its fractional reimbursement rates don’t consume an ever increasing share of the market forcing our costs higher.

Just as important, the financial costs of the program are unpredictable. The experience of the very few states that have expanded to childless adults in the past

is that the eventual costs were much higher than estimated – five times higher in one case. The only thing the researchers seem to agree on is that the expected cost is unpredictable.

It would be sensible for the state to impose a structural limit on its costs. Both total enrollment and, more important, total expenditures could be capped consistent with the projected budget upon which expansion decision making will be based. This is a reasonable restraint which would allow the program to exist but with a degree of financial certainty.

Many changes will require the state to play mother may I with the federal government but that should not be an obstacle. Any compromise that is acceptable will necessarily involve things that are not off the federal shelf.

Grant D. Bosse

October 28, 2013

As Originally Published in the Concord Monitor

There’s a very easy way to tell if you’ve been the victim of one of the many scam websites that popped up this month to take advantage of people trying to sign up for Obamacare. It worked. If you’ve tried to buy insurance through, you almost certainly couldn’t log on, couldn’t enter your personal information or couldn’t get accurate pricing for your limited insurance options.

President Obama says “the product is great” and that “it’s more than just a website.” But he’s scapegoating the online disaster for problems with the law that we’ve known were coming for three years.

New Hampshire Sen. Jeanne Shaheen led the charge this week to extend the open enrollment period, citing the failed website and insisting that she was not changing her opposition to delaying the individual mandate to purchase insurance.

But that’s exactly what she wants to do, and it has nothing to do with the internet. Obamacare’s individual mandate requires all of us to have a certain level of health insurance in 2014 or face a fine of $95 or 1 percent of our income, whichever is greater. The IRS is in charge of collecting this fine, which allowed Chief Justice John Roberts to declare it a tax and slip most of the law through the eye of his constitutional needle.

The penalties were designed to kick in if you went without insurance for three months, and that’s why Health and Human Services Secretary Kathleen Sebelius set the open enrollment period to run through March 31, 2014.

But the law actually taxes you if you are without insurance for a single day in any three months, moving the actual deadline to get coverage up to March 1. Since you need to complete your application two weeks before coverage takes effect, the real deadline to avoid Obamacare penalties in Feb. 15.

President Obama is going to waive enforcement of the penalties for six weeks, moving the enrollment deadline back to March 31.

Obama and Shaheen still oppose efforts to delay the individual mandate through legislation but are perfectly willing to ignore the existing law through executive fiat.

Perhaps we should blame former Massachusetts senator Scott Brown for the law’s sloppy drafting. His special election to the Senate in 2010 gave Republicans enough votes to filibuster the controversial bill.

Democrats feared that any attempt to fix the mistakes baked into the law would erode the fragile party unity needed to get the bill to the president’s desk, so they just voted for it, warts and all. These errors would inevitably sabotage the law’s implementation.

Undermining the plan

But there are structural problems that Democrats built into the law on purpose. Two of the most popular provisions are guaranteed coverage for pre-existing conditions and a mandate that adult children be allowed to stay covered under their parents’ policies through age 26.

We needn’t debate the merits of these two policy choices to see how they are undermining the entire scheme. In order for the insurance companies offering plans through the exchanges to be profitable, they need to get many young, healthy people to buy more insurance than they currently do. Keeping people in their mid-20s on their parents’ plan keeps potential customers out of the exchanges. Many more will wait to buy insurance until they need it.

The Obama administration is trying to convince these “Young Invincibles” to purchase coverage. But the reason young people don’t buy as much health insurance as the rest of us is because it’s a bad deal. It’s much cheaper for health people with lower incomes to pay a 1 percent Obamacare penalty and sign up for insurance after they get sick. Imagine if you could go without car insurance, and call State Farm after your accident to cover the repairs. Economists call this a moral hazard, and it’s ObamaCare’s biggest flaw. But not it’s only one.

Health insurance policies have to strike a balance between coverage, access and price. Obamacare pushed that balance toward comprehensive coverage, forcing people to insure against risks that they’re unlikely to face. That choice forces premiums much higher, and many insurers, including Anthem in New Hampshire, have compensated by limiting their coverage network.

Court complication

The Supreme Court’s decision leaving Medicaid expansion up the states has also blown a hole into the law. Congress planned on shifting everyone below a certain income level into Medicaid and made them ineligible for subsidies under the exchanges. This creates a perverse situation where you might earn too little money to qualify for federal aid.

Congress also failed to anticipate states declining to set up their own exchanges, so it only authorized federal subsidies in state-based exchanges.

The Washington, D.C., District Court last week refused to dismiss a lawsuit challenging subsidies under the federal exchange.

The Obama administration delayed the employer insurance, and companies all over the country have responded by dumping their employees into the exchange. Others have already dropped coverage for spouses, or cut back hours to avoid the mandate next year.

The White House will almost certainly try to further delay the pain of Obamacare past November 2014. If Republicans really want to get rid of this law, they should get out of its way and let it destroy itself.

Charlie Arlinghaus

October 16, 2013

As originally published in the New Hampshire Union Leader

The Medicaid commission that ended this week was a well meaning distraction that won’t produce a compromise but may lead to some constructive conversations. Policymakers, notably the governor and the senate president, can use the commission as an example in both good ways and bad. In that respect, perhaps the commission was a useful first step toward a productive discussion.

In the budget process in June, a divided state government could not agree on any one approach to the federal enticement toward a large scale expansion of the state Medicaid program. The governor and the House insisted expansion be part of the budget, the Senate took it out. As a compromise, the budget created a commission to study Medicaid expansion with the majority of members appointed by those supportive of the expansion envisioned by the president and the governor.

I had the mixed blessing of being appointed to that commission which ended its existence on October 15th. Ultimately, some of the work of the commission will be used by lawmakers trying to negotiate some sort of compromise between those who want additional coverage and those worried about the financial risks and unintended consequences inherent in expanding Medicaid caseloads by about 50%.

For those policymakers seeking some common ground, the commission is an example of exactly what not to do but also an example of a path out of a messy mix of mistrust and politics.

The commission ended up beset by predictable pitfalls. From the beginning there was tremendous mistrust between minority and majority factions – more from outside the commission itself than within. It’s natural that a majority, convinced of the wisdom of their cause, might regard skeptics as politically motivated and more as saboteurs than conscientious objectors.

Unfortunately, that led to an overly scripted and less-then-open initial commission. Questioning was attacked, technically anonymously but only technically, as “building the case for an ideological crusade.” Data requests, apparently, are quite dangerous.

The tension led to frustration and a willingness to dismiss the commission as a meaningless sham. One observer noted “show trials are usually better choreographed” (that may have been me). Gradually, politicians who would ultimately be involved in any decision regarded the commission as something of a meaningless sideshow.

The mistrust, the willingness to assume sinister motives, and the eagerness to at least try to choreograph behind the scenes is an example to be avoided by politicians.

On the other, after three months of neutering itself, the commission created examples of what might work for people ultimately involved in the real decision. Meaninglessness created opportunity. When the outcome became very low stakes indeed, people were able to be more open.

The final three weeks of the commission became a model of discussion, dialogue, and exchange. Much of the responsibility for that change falls to Rep. Tom Sherman of Rye. Dr. Sherman is likely as liberal as I am conservative but inaugurated a discussion phase by putting a tentative plan together and being willing and eager to engage in wide ranging discussion with anyone regardless of whether or not they were likely to agree with the final product.

The only real downside to those few weeks is that time constraints pressured us and limited some discussion areas. Had those three weeks of open conversation began the discussion rather than ended it the commission might have been a very different animal.

Going forward, any negotiation has to be a real negotiation not an attempt to get one side or the other to lose and harm their electoral chances next year. A year ago, people might have argued that the federal government is asking us a yes or no question – either we expand in precisely the way they suggest or we don’t. That thought needs to be abandoned.

The populations the state might expand to are not one bloc. Almost half of them currently have health insurance, the other half do not. A fraction of those who don’t currently have insurance have access to subsidized insurance through the exchange. None of those groups should be treated precisely the same.

Too much time is spent wondering if the federal government will permit something instead of wondering if it’s a good idea. “I don’t think they’ll let us do that” is not an acceptable argument. Any compromise that is acceptable will necessarily involve things that are not off the federal shelf. And playing “mother may I?” with the federal government is never a recipe for making good decisions.

Charlie Arlinghaus

September 26, 2013

As originally published in the New Hampshire Union Leader

The government-sponsored insurance plan offered through the Obamacare exchange has come under fire this week for leaving behind some of the hospitals in the state to provide a competitive advantage to the others. People naturally bristle at the government picking winners and losers through its plan, but the situation is more complicated than it first appeared.

Under the new federal health care law, every state must have an “exchange” to offer subsidized health insurance. The latest public relations spin would change the name of these exchanges to “marketplaces” but recent events have revealed they aren’t marketplaces and aren’t subject to market forces.

In New Hampshire, only one company signed up to offer the policies to be subsidized through the exchange. That company, Anthem, is the dominant player in the regular market, issuing 56 percent of policies.

Some had hoped for competition in the new federal exchange, but there would be none. To make matters worse, the new plan, with its additional mandates and required coverages, would manage to find affordability only by limiting access to certain providers. If your doctor or hospital is in, you’re happy. But nearly half of the hospitals (and the doctors they own — most doctor’s practices are owned by hospitals) are left behind.

Let’s start by saying that limited networks are a perfectly reasonable way to save some money. Providers are limited as a way to get them to accept below-market prices. Even so, rates will increase for most consumers. Anecdotally, one consumer I know will see his rates double even with none of his doctors in the plan any longer. On the other hand, he’ll get new coverage he doesn’t want, but still has to pay for.

We’re told by Anthem that despite the increased costs over your old plan, the new, limited plan has costs that are 25 percent lower — not lower than what they were but than what they would have otherwise been.

So Anthem chose to offer a plan with limited providers who have all agreed to accept a much lower payment than they would currently receive for private insurance. Currently, Medicaid pays roughly 1/3 of the price charged to regular consumers. The new plan would be closer to Medicaid than regular insurance.

Why would a hospital accept lower payments? First of all, because if the new health care law is unchanged, the exchange will occupy a greater and greater share of the insurance market each year. It’s easier to be in from the beginning than to be left behind and try to claw your way in from the outside. Second, by leaving so many providers behind, those favored by the government-sponsored plan will get a greater share. A hospital can make less money on each patient if it has more of them and its regional competitors start to wither away.

There would be much less consternation about this plan if there were an alternative in the exchange. If one competitor chose to offer a limited network, consumers with such an interest could instead move to a perhaps more expensive but less-limited network. But consumers have no such choice. There is one company offering plans that vary slightly by deductible size. There are no alternatives, no choices, no competition.

At first, public reports seemed to indicate that the hospital left behind had opted out themselves because they chose not to accept lower rates. Instead, we learn that the opposite is true. Hospitals perfectly willing to accept lower rates were nonetheless not allowed in.

Last weekend on Josh McElveen’s public affairs show on WMUR-TV, we saw the head of the hospital in Rochester (New Hampshire’s sixth-largest community) tell Anthem’s CEO he was willing to accept her rates and ask to be allowed onto the list. She pointedly ducked the question, but the answer is clearly no.

The hospitals cut out of the plan are left with two choices: hope the new system fails miserably and is repealed, or quietly go out of business. Consumers like you and me can look forward to higher insurance rates and only hope that our providers make it onto the government approved list.

Grant D. Bosse

September 8, 2013

As originally published in the Concord Monitor

I know that there are millions of Americans who are content with their health care coverage – they like their plan and they value their relationship with their doctor. And that means that no matter how we reform health care, we will keep this promise: If you like your doctor, you will be able to keep your doctor. Period. If you like your health care plan, you will be able to keep your health care plan. Period. No one will take it away. No matter what.”

President Obama, June 15, 2009

“You can’t spend your whole life worried about your mistakes. You f—–d up. You trusted us.”

Eric Stratton, rush chairman, “Animal House,” 1978

For thousands across New Hampshire, and millions of Americans, ObamaCare is taking away their doctor and taking away their health care plan. That’s despite the empty promises used to sell a sloppy law passed by people who didn’t know what was in it.

Last week, Anthem Blue Cross Blue Shield informed the Legislature’s Joint Health Care Reform Oversight Committee that it would not be covering services provided by 12 of the state’s 26 hospitals. The smaller network will apply not only to the Anthem plans offered under the Affordable Care Act Exchange, but to Anthem’s individual and small business plans outside of the exchange. Anthem says letting patients choose any of New Hampshire’s hospitals is simply too expensive, and kicked a dozen hospitals, including Concord Hospital, out of its network.

Anthem will also refuse to cover referrals to out-of-state specialists, period. You’re still welcome to take advantage of the world-class hospitals located just a few south on Interstate 93, but you’ll have to pay for it yourself.

Anthem has since backtracked a little, putting Androscoggin Hospital in Berlin and Littleton Hospital back in its network.

Gov. Maggie Hassan has known about this for a while, and Insurance Commissioner Roger Sevigny has endorsed Anthem’s plan to the Centers for Medicare and Medicaid Services, which is setting up New Hampshire’s exchange.

We still don’t know what kinds of plans Anthem will offer, or how much they’ll cost, because the state Department of Insurance clings to the ludicrous notion that its internal rules trump the state’s Right to Know Law, and that the details of a government-run health insurance scheme are proprietary until Jan. 1, 2014, the day the new policies are supposed to take effect.

Anthem argues that such drastic decreases in accessibility are necessary to prevent drastic increases in premiums. They simply can’t afford to let you see the doctor of your choice. If you’ve been paying attention since ObamaCare passed, you’ve known this was coming.

No insurance company could provide the services mandated under the law for a price anyone would pay. So they’re limiting the options. They’re rationing care.

As we socialize our health care costs, we also socialize our health care decisions. If you were paying my hospitals bills, you’d have an incentive to make sure I’m not wasting your money. But of course, I’m never going to spend your money as carefully as my own. So you step in, through the government and the insurance companies, to limit my choices.

Even if Obamacare had been well-written and properly implemented, rationed care would be inevitable. The incompetence of the Obama administration has been optional. It’s missed deadlines and delayed major provisions of the law. Employers are cutting staff, cutting hours, and dropping dependents for their health insurance plans in order to avoid the law’s costly implications.

Even though the exchanges are scheduled to open enrollment on Oct. 1, only 13 states and the District of Columbia are far enough along to know how much the plans will cost. Avik Roy, whose been tracking this slow-motion train wreck for Forbes, calculates that nine states will see higher rates for the plans offered by the exchanges, and five will get lower rates. On average, health care premiums will jump 24 percent. He hears the Obama administration will have the relevant data for the other 37 states by Sept. 19.

The Patient Protection and Affordable Care Act neither protects patients nor makes care more affordable. It is a bad idea, poorly executed. It was never going to bring down health insurance costs, but it didn’t have to fail quite so catastrophically. They are plenty of dead-enders who insist it’s either working just fine, or would be if people like me weren’t keeping it from speeding off the cliff.

Such delusions are going to get harder to justify as health care costs continue to climb, and patients are turned away from Concord Hospital and Mass General.


Josh Elliott-Traficante

September 5, 2013

As reported by various media outlets earlier this week, the Health Care Oversight Committee held a hearing with representatives of Anthem Blue Cross Blue Shield. Anthem, who will be the only health insurance provider offering plans on the New Hampshire Exchange, confirmed that future exchange customers would only have access to only about half of the hospitals in the state.

Looking at a map of the hospitals in and out of network, (green dot: in network, red: out of network) there are some areas that are disproportionately affected, such as the Concord area, Connecticut River Valley, the Monadnock Region, and particularly the North Country.

Any resident north of the Notches has only the option of Weeks Medical Center in Lancaster, or driving to either Memorial Hospital in North Conway or Speare Memorial Hospital in Plymouth to seek care.

Limiting access will not only affect hospitals, but primary care physicians as well. Throughout the state, many hospitals have acquired primary care practices in their respective areas, building a comprehensive health system. These systems often include primary care practices, urgent care clinics, and laboratories, all under the aegis of a single hospital. While this model can promote efficiency, once a hospital is no longer considered in network, the same is true for the rest of the health system, including those primary care physicians.

This causes two major problems for consumers: those who end up in the exchanges will be forced to change their doctor and will have to travel further to get to their new one. {So much for the idea of keeping your own doctor.} This will be particularly problematic in the Concord Area, as Concord Hospital owns or is affiliated with most of the practices in the area. While it is in theory possible for insurance companies to make access contracts at the practice level, regardless of what health system they may belong to, it remains to be seen if that will be done.

Anthem will remain the only company offering health insurance policies on New Hampshire’s Exchange at least until 2015.

In Network:                                                                                          Out of Network

Androscoggin Valley Hospital: Berlin                             Alice Peck Day Hospital: Lebanon

Catholic Medical Center: Manchester                                            Cottage Hospital: Woodsville

Cheshire Medical Center: Keene                                                      Concord Hospital: Concord

Elliot Hospital: Manchseter                                                               Frisbie Memorial Hospital: Rochester

Exeter Hospital: Exeter                                                                        Monadnock Community Hospital: Peterborough

Franklin Regional Hospital: Franklin                                            Parkland Medical Center: Derry

Huggins Hospital: Wolfeboro                                                            Portsmouth Regional Hospital: Portsmouth

Lakes Region General Hospital: Laconia                                      Upper Connecticut River Valley Hospital: Colebrook

Littleton Regional Hospital: Littleton                              Valley Regional Hospital: Claremont

Dartmouth Hitchcock Medical Center: Lebanon

Memorial Hospital: North Conway

New London Hosptial: New London

Speare Memorial Hospital: Plymouth

St. Joesph Hosptial: Nashua

Weeks Medical Center: Lancaster

Wentworth-Douglass Hospital: Dover


Update 9/6: Late Thursday, Anthem announced that both both Androscoggin Hospital in Berlin and Littleton Hospital will be added to the network.

Red Dot: Out of Network Hospital, Green Dot: In Network.

Map Source: Google Maps


By Grant D. Bosse

As originally published in the Concord Monitor

Obamacare is an awful law. It’s falling apart under its own weight, and President Obama has already been forced to waive key provisions several times to prevent the law’s disastrous consequences from fully hitting us. Repealing Obamacare is a good idea, and Congress should do everything it can to get rid of it. Unfortunately, the push to de-fund Obamacare through the appropriations process just won’t work.

Utah Sen. Mike Lee is gathering allies who promise to oppose any continuing resolution to keep government operating unless it defunds the Patient Protection and Affordable Care Act, known as Obamacare. Federal programs are authorized and defined in statute, but zeroing out federal funding has the effect of repealing that statute, since there is no one being paid to administer or enforce it. House Republicans voted repeatedly to repeal the law wholesale last year, and once again this year, but Majority Leader Harry Reid will never let such a repeal come to a vote in the Senate.

I’ve covered Reid’s complete failure to run the Senate before, but it’s worth mentioning again because it’s the reason why Congress has been unable to pass the appropriations bills that fund the federal government. Instead, the House and Senate have agreed to a series of short-term continuing resolutions to keep the government running.

Lee in one of 11 senators, along with 60 House Republicans, who have said they won’t approve another continuing resolution unless it defunds Obamacare, even if that means a government shutdown like 1995.

Repealing Obamacare outright, defunding it, or simply waiving its requirements like the president did for the employer mandate are worth pursuing. But Lee’s strategy is both short-sighted and politically foolish.

First of all, failure to pass a continuing resolution won’t shut down Obamacare. As New Hampshire Sen. Kelly Ayotte pointed out, the law is funded through mandatory spending, not the year-to-year discretionary spending covered under appropriations bills. A shutdown would close national parks, but the Health and Human Services employees implementing Obamacare so badly would still get paid.

So why are Lee, and Senate firebrands Rand Paul and Ted Cruz, threatening a last stand against Obamacare that is doomed to fail? I blame George W. Bush.

It’s become cliché for the left to blame all manner of problems on the former president, and the current administration certainly isn’t shy about pointing fingers toward the ranch in Texas five years after taking office. But we can trace the origins of the current push by some Republicans to defund Obamacare or shut down government to the Bush administration.

Bush’s first budget to Congress was pretty good, and the Bush tax cuts in 2001 and 2003 helped speed an economic recovery that led to booming federal revenue. But in the aftermath of 9/11, Bush deferred almost entirely to Congress to make budget decisions. Appropriators turned to unprecedented amounts of earmarks to push through unprecedented spending that rose even faster. Deficits skyrocketed, and spendthrifts like Nancy Pelosi and Barack Obama were able to campaign as stewards of fiscal responsibility.

Despite some vocal opposition from House conservatives such as Jeff Flake and John Shadegg, and Senate efforts to curb wasteful spending from the likes of John McCain and John E. Sununu, congressional Republicans lost credibility with their base. (Disclosure: I was Sununu’s legislative staffer tracking the Senate budget debate at the time.) By 2010, discontent with bailouts, boondoggles and deficits fueled the Tea Party movement.

Without credibility, many Tea Party voters seek purity. They want senators like Lee, Paul and Cruz to hold the line, no matter what. In this case, they’re holding the wrong line. It doesn’t help that conservative organizations are eager to raise money on the false promise of ending Obamacare.

Oklahoma Sen. Tom Coburn, the Senate’s most hard-line fiscal hawk and leading Obamacare critic, recognizes that blocking a continuing resolution won’t get rid of the law.

If the Senate were to vote on defunding the law, it’s conceivable that a few shaky Democrats would take the opportunity to distance themselves from the disaster they created. But without the president’s support or two-thirds of the House and Senate, such a road would leave much of the federal government shut down and Obamacare fully funded.

I’ve not been shy about criticizing Reid and New Hampshire Sen. Jeanne Shaheen for their willingness to ignore the rules and traditions of the Senate. I’m just as willing to chide Lee and his colleagues for their failure to understand how the Senate works. Senate Republicans should demand an up-or-down vote on Obamacare repeal, and Reid and Shaheen should be branded as the real obstructionists for refusing to allow one. But refusing to fund federal programs in order to repeal an unrelated law doesn’t make sense.

Daniel Webster, then a New Hampshire congressman, tried to end the War of 1812 by defunding it. The backlash stymied his presidential ambitions for the rest of his life. Webster paid a heavy price for his futile effort. Lee, Paul and Cruz may learn that same lesson.