New Hampshire residents enjoy very good health relative to much of the country, and the state’s recently expanded Medicaid program is now providing realistic access to health insurance for many low-income residents. Public health and leadership’s stance on healthcare reform are significant factors that play a role in quality of life, productivity, and health outcomes.
Here’s a summary of how New Hampshire compares with other states in terms of overall health, access to health insurance, and the state’s approach to healthcare reform:
New Hampshire health ratings
In 2014, New Hampshire was ranked 2nd out of the 50 states and DC by The Commonwealth Fund’s Scorecard on State Health System Performance. The state moved up three places from 5th in 2009. New Hampshire’s Scorecard provides specific details about public health in the state and how the overall score was determined. The state is highly ranked in all categories, but particularly prevention and treatment, as well as access to care.
America’s Health Rankings placed New Hampshire just slightly lower, in 5th place out of the 50 states in 2013 in terms of overall health. The state’s rating is buoyed by high immunization coverage, a low infant mortality rate, and relatively few children living in poverty. (Although the number is still low by national standards, it’s increased from 6.5 percent of children to 10.9 percent over the past five years.)
The percentage of adults who smoke has decreased in the past year, while the high school graduation rate has increased significantly over the last decade. The state still faces public health challenges though, including a high prevalence of binge drinking and pertussis infections, and low per capita public health funding.
Trust for America’s Health provides yet another look at overall public health in New Hampshire in their 2014 listing of Key Health Data About New Hampshire. Their summary includes socioeconomic health indicators, access to care, and the prevalence of various illnesses and health outcome predictors.
You can also see how the ten counties in New Hampshire compare with one another in terms of health factors and outcomes, using this interactive map created by the Robert Wood Johnson Foundation. No single area of the state stands out as better or worse than any other; high and low ranking counties are dispersed throughout the state.
New Hampshire and the Affordable Care Act
In 2010, New Hampshire’s U.S. Senators were split on the ACA. Democrat Jeanne Shaheen voted yes, while Republican Judd Gregg voted no. In the U.S. House, Carol Shea-Porter and Paul Hodes, both Democrats, voted yes. Shaheen is still in the Senate, but Gregg has since been replaced by Kelly Ayotte, a fellow ACA opponent. In the House, Ann Kuster replaced Hodes in 2013. She is an ACA supporter who wants to keep the law but improve upon it.
In the 2014 Senate race, Shaheen was one of relatively few Democrats who fully embraced the ACA and the changes it has brought about. She defended the law, saying it was “absolutely” an achievement of which she is proud. Shaheen won re-election against Republican opponent Scott Brown in 2014.
At the state level, the legislature is politically split, with a Republican majority in the Senate, and a Democratic majority in the House. Governor Maggie Hassan, a Democrat, took office in early 2013. She is supportive of the ACA, and shortly after taking office she confirmed that the state would work with HHS to operate a partnership exchange in New Hampshire.
Hassan also prevailed in expanding Medicaid under the ACA, although New Hampshire is one of four states currently proceeding with a unique approach to Medicaid expansion that will ultimately involve subsidizing private health insurance for low-income residents.
How did the ACA help New Hampshire Residents?
Before the ACA was implemented, the uninsured rate in New Hampshire was 13.8 percent, lower than the national average in 2013. 12.4 percent of New Hampshire residents were uninsured at the end of June, six months after full Obamacare implementation.
The drop in the uninsured rate in New Hampshire was relatively small, but it should be much more significant by the end of 2014. That’s because Medicaid expansion didn’t go into effect in New Hampshire until July 1, 2014, with coverage effective dates starting in August. So the nationwide Gallup poll conducted at the end of June was too early to show results from Medicaid expansion in New Hampshire.
New Hampshire enrollment in QHPs
In late 2013, the Kaiser Family Foundation estimated that the potential market for the exchange in New Hampshire was 137,000 residents, and that about 81,000 of them would qualify for premium subsidies. By April 19, as the first open enrollment period was ending, 40,262 people had finalized their enrollment in the New Hampshire exchange, and 76 percent of them had qualified for premium subsidies.
The New Hampshire exchange has just one carrier – Anthem Blue Cross Blue Shield – in 2014. Anthem had 90 percent of the market share in the state prior to 2014, so the fact that only one carrier is participating hasn’t substantially changed things for most customers in New Hampshire. But starting in 2015, there will be far more competition and plan choice in the New Hampshire exchange.
Four additional carriers are joining Anthem in the exchange starting this November when the 2015 open enrollment period begins. They include Assurant Health, Harvard Pilgrim Health Care of New England, and two ACA-created Consumer Oriented and Operated Plans (CO-OPs): Minuteman Health and Maine Community Health. The two CO-OPs were created with federal funding under the ACA, and have been operating in their respective states – Massachusetts and Maine – in 2014, but will be expanding into New Hampshire for 2015.
New Hampshire Medicaid/CHIP enrollment
New Hampshire is currently one of four states that are expanding Medicaid in 2014, but following a path that differs from the straight Medicaid expansion outlined in the ACA. Senate Bill 413 was signed into law by Governor Hassan in March, and called for Medicaid expansion to begin this summer, with residents able to begin applying on July 1.
As of August 8, the state reported that 9,399 people had enrolled in expanded Medicaid over the past five and a half weeks, with coverage set to go into effect on August 15. That number is significantly more than the 7,235 people who had enrolled in Medicaid through the New Hampshire exchange by mid-April, before the expanded eligibility guidelines went into effect. There is no doubt that the uninsured rate in New Hampshire will be lower at the end of 2014 than it was mid-year.
Until the end of 2015, Medicaid expansion in New Hampshire will follow the program outlined in the ACA, and all legal residents with household incomes up to 138 percent of poverty will be eligible to receive Medicaid coverage. But starting in 2016, the state has plans to transition to a privatized version of Medicaid expansion, using Medicaid funds to subsidize private coverage.
The Kaiser Family Foundation estimated that about 39 percent of the uninsured population in New Hampshire would be eligible for Medicaid starting in July. There is no longer a coverage gap in the state now that New Hampshire has become the 26th state to expand Medicaid under the ACA.
Does New Hampshire have a high-risk pool?
Before the ACA reformed the individual health insurance market, coverage was underwritten in nearly every state, including New Hampshire. This meant that pre-existing conditions could result in an applicant being rejected for coverage, or offered a plan with significantly higher premiums or policy exclusions. The New Hampshire Health Plan (NHHP) was created in 2002 to provide an alternative for residents with pre-existing conditions who were not eligible to purchase private individual health insurance because of their medical history.
But the ACA brought significant changes to the individual health insurance market, including a ban on medical underwriting; all policies are now guaranteed issue, in all states. This meant that high-risk pools are no longer necessary the way they once were, since applicants with pre-existing conditions now have the same insurance choices as the rest of the population.
NHHP was originally slated to cease operations at the end of 2013, but the troubled roll-out of Healthcare.gov meant that many members were unable to purchase new coverage by the start of 2014. As a result, NHHP continued to provide coverage until June 30, 2014. At that point, any remaining policies terminated, giving members a 60 day special enrollment period during which they could purchase a new plan (involuntary loss of other coverage is a qualifying event that triggers a special enrollment period).
State-based health reform legislation
In addition to the bill that expanded Medicaid in New Hampshire this year, the legislature was quite active on health and healthcare reform, including a failed effort to legalize the sale of policies that don’t conform to the ACA’s coverage mandates. Here’s a summary of recent New Hampshire bills related to healthcare reform: