Professor Lucy Hodder discusses the end of continuous Medicaid enrollment from the COVID-19 public health emergency and the impact of hospital mergers in New Hampshire. Produced and Hosted by A J. Kierstead
Learn more about our Health & Policy Programs at https://law.unh.edu/health-law-policy-program
Get an email when the latest episode releases and never miss our weekly episodes by subscribing on Apple Podcast, Google Play, Stitcher, and Spotify!
UNH Franklin Pierce School of Law is now accepting applications for JD and Graduate Programs at https://law.unh.edu
Legal topics include health, healthcare, medicaid, policy, state, HHS, antitrust, business
Read the transcript
A. J. Kierstead, Host:
This is The Legal Impact, a podcast presented by the University of New Hampshire, Franklin Pierce School of Law. Now accepting applications for JD and graduate programs, learn more and apply at law.unh.edu. Opinions discussed as solely the opinion of the faculty or hosts, and do not constitute legal advice or necessarily represent the official views of the University of New Hampshire in UNH Franklin Pierce School of Law. I'm your host, A.J. Kierstead, and today I'm joined by Professor Lucy Hodder, director of the Health Law and Policy Programs. How are you?
Professor Lucy Hodder:
I'm great, A.J. Good to see you. I'm glad to be on.
A. J. Kierstead, Host:
All right. So we are going to talk about two different topics today, but we're going to start off right now with continuous Medicaid enrollment, that is officially over. This has been something that's implemented during the Covid 19 public health emergency. A whole can of worms that could go down when it comes to the public health emergency. We're going to focus specifically on continuous Medicaid enrollment. So at a high level, what did it mean when this was enacted?
Professor Lucy Hodder:
Right. Well, this was originally part of the public health emergency. When the public health emergency was declared. There were some changes that allowed for anybody enrolled in Medicaid as of a certain date, the beginning of 2020, to remain enrolled in Medicaid except for really rare circumstances. So real voluntary termination, move it out of state, but for the most part, states in exchange for getting an enhanced federal match, so more dollars to help take care of people's health in the Medicaid program. In exchange for that, the states had to keep people continuously enrolled. People did not have to engage in the annual redetermination process, which is required under Medicaid to affirm ongoing eligibility. So this went on and on and on, and a lot of people were unable to access enhanced coverage in whatever eligibility category they came on to Medicaid in. So if you were eligible for the Granite Advantage program, you stayed in the Granite Advantage program. If you were eligible for long-term services and supports, you stayed in that eligibility category without having to reaffirm your eligibility because of that deal that the Feds struck with states.
A. J. Kierstead, Host:
What was the goal of having it happen? Is it just to kind of take some of the workload off of local like HHS departments and things like that, which are already quite busy with the public health emergency?
Professor Lucy Hodder:
I think it was much broader than that, A.J. I think the original goal, and remember this was a prior administration. The original goal was to make sure if people were getting sick with Covid, they had health insurance coverage and they were able to access, remember telehealth services for mental health and physical health. It was just to make sure we had that support for people during the public health emergency and to ensure there wasn't this extra amount of disruption in people's lives if they'd originally been eligible for Medicaid, instead of having them churned through commercial insurance or on and off based on because they lost their job, et cetera. There was so much disruption during the PHE. It was just a stability factor that allowed for much more predictability in the insurance markets during this public health emergency process and allowed people to access the kind of care they needed depending on what type of insurance they have.
So remember when we also during the public health emergency made telehealth available, some states and the feds also made telehealth services paid at the same rate as in-person services. A lot of the things that happened during the public health emergency allowed the healthcare system to manage people's health in different ways because of the nature of Covid, and how sick people got with Covid, and because of the need for the healthcare system to respond to those sick people, and take care of others in a way that was consistent with some of the restrictions to try and get rid of the spread of Covid. So it was one of those many things that determined that. I think ultimately New Hampshire ended up doing pretty well. We had a lot more people on Medicaid, but the federal support helped support our Medicaid program as a whole.
The end of the public health emergency is now happening, I think May 11th. The states really did say, "Hey, look, we need some predictability. If we're going to return our Medicaid programs to regular operations and people are going to have to start determining every year; we need time, we need to get back to normal and we've got to have a date certain." So that's what happened in a recent congressional action where they actually set the date that Medicaid had to return to regular operations as of April one. Now, the good news is New Hampshire has been planning diligently for this and has been a leader, in fact amongst states in getting ready for this transition and been very diligent along the way to continue as best as possible, having people get their addresses in, get their information in, redetermined if they can. So when this date, April one hit as many people as possible had confirmed their ongoing eligibility, certainly not everybody.
We're seeing a number of people who are having to transition to other coverage. New Hampshire structured their transition so that the people who were most likely to be eligible for other coverage were transitioned first. So people who were ineligible due to higher income or age, still might be eligible for Medicare, or had aged out of kids and might be able to go on parents coverage. Or return to Medicaid in a different eligibility category. Those people have been transitioned first. We've gotten incredible help from the Navigator program, which is tremendous. I hope we keep it because we have money now in the state from the feds to support people who are dedicated solely to answering people's questions about their health insurance.
They can navigate them to the marketplace where people can get subsidized coverage, which in New Hampshire is really helpful. We have significantly affordable coverage on the marketplace due to the subsidies, and the navigators can help with that. Navigators can also help with people who have questions about their Medicaid coverage. And we have Health Assist, Health Market Connect, as well as First Choice Services who are both helping, and I hope you put their website and their telephone numbers on our website because it's an incredible resource for people.
A. J. Kierstead, Host:
Now, I also have linked to healthcare.gov, which is the marketplace, which is very helpful unless all these different resources are also available on there. I mean, what are some big takeaways after seeing such an extended amount of time with people being on Medicaid? Are there any lessons learned from that? The big thing politically is we need to get more people on Medicaid, we need to expand it so that we have a single payer sort of system or an option to be on the market. Did this end up being a dry run for anything in the future, do you think, for healthcare reform?
Professor Lucy Hodder:
No, I don't think this provision during Covid had anything to do with a single payer system. I think that the Medicaid support provided a really great resource for a public health program to continue to provide care without having the churn that's typical in the Medicaid program. So I think the one thing we did learn is that people access better care when they're not going on and off their healthcare program, that's for sure. We also did learn that our basic system of health insurance coverage, where people have employer sponsored care, some fully funded, some self-funded, the feds can regulate through ERISA, the self-funded plans, but not the fully insured, which have to be regulated by the state; Medicare, Medicaid.
We do have a complicated health insurance program, so trying to get something consistently done is difficult, but we did it. I would say that what we realized is that having a strong Medicaid program and an innovative Medicaid program, which we have in New Hampshire with Medicaid expansion, which was a hugely important category of coverage for people who were especially north country, rural areas where people were dropping their salaries and compensation during Covid because of a lot of the things we had to do to protect ourselves from Covid. It was a really hugely important thing for families to have coverage available.
A. J. Kierstead, Host:
And it kind of, I think raised a lot more awareness in for the general public also with regards to what exactly health insurance looks like. Because everyone, the general assumption is you just get it through your employer, but guess what? When the entire economy kind of go into the fans, so to say, it raises many questions with regards to how we pay for various services and what resources are available out there.
Professor Lucy Hodder:
Absolutely, and one of the things we also learn is that having that coverage helps connect to other services. So we end up being able to map together what supports anybody needs or any family needs during a crisis like this, and during everyday life. We know that the mental health issues have been really skyrocketing, especially amongst youth, and access to supports in schools has been a big push of the Medicaid program. And access to mental health and substance use treatment has been something the Medicaid program has done exceptionally well to try and support those services. Never enough, especially when one in three people has a diagnosis of mental illness, never enough, but we've really seen that that continuous coverage was critical in that component.
The good news is we're seeing that people are navigating, so there's lifeboats for people and the navigators are a huge part of that. So getting people to their employer-sponsored coverage, if that's what they're eligible for. Medicare, if that's what they're eligible for. Again, marketplace coverage and we have special enrollment periods, so hopefully people won't get lost in the transition. What's really hard is everyone has to be reaching out to friends, family, constituents, community, because lots of people have moved. People aren't used to filling out the information, even though there's lots of online access and in-person access to help. Not everyone, given the struggles of life, has that at top of their list.
A. J. Kierstead, Host:
Yep, definitely. And if you're one of these individuals that was in continuous enrollment, definitely check out nges.nh.gov, which is a great resource. And in addition to the navigators, if you're not sure what your next steps are, which once again, we'll put in the episode description @lawunh.edu/podcast.
All right, let's move over. I want to touch on this because it's such a super important subject for health policy in the state of New Hampshire, which is hospital mergers. Which we're going to try and condense as much as possible. This is probably a huge thing that could be an all day conference to discuss. But overall there's been many instances, especially in New Hampshire, where hospitals are merging together, larger organizations are scooping up smaller hospitals. Is this a trend that is specific to a rural state like New Hampshire? Is this something that's more nationwide?
Professor Lucy Hodder:
It's nationwide. It's been particularly endemic in New Hampshire. If you look at our map, we've tracked the activity amongst hospitals over the past 10, 15 years. Almost every hospital has combined with another one. Some of them have combined and gotten divorced, but almost every single one has combined, and we have seen in the past seven, eight years a huge increase in the number of New Hampshire hospitals who are now owned or parented. As I say, in the nonprofit world, you're parented by an out-of-state health system, which oftentimes sounds good. It can mean access to specialty services with a unified health record. It can add to some conveniences in some specialty lines of care. But it also means that your community hospital is no longer necessarily a community hospital. It's driven and decisions are made at a much higher level. So that doesn't mean good or bad.
It just is completely changing, completely changing the face of healthcare in New Hampshire, and we're a very small state. So I think we're going to wake up in a few years and think what happened and what was our plan and what did we want to accomplish with this? Or did we just let it all happen? So I think it's a real change and a real shift. Some of it is necessitated by sort of hospital financial demographics. The risks that honestly, it was not Covid just brought to light some of the underlying health disparities and system disparities that have been plaguing our system. We have enhanced specialty services, which are expensive and take lots of years of training and lots of years of expertise, and everybody can't pull it off. It's one thing to have primary care and an emergency room at your hospital with the ability to send real trauma down the road, but to pull off all the specialty services that you need to operate an acute care hospital or even a rural critical access hospital is really hard.
So what we're seeing is a lot of takeovers. And just to rattle off a few, Mass General Hospital partners, it's now Mass General Brigham, big multi-billion dollar Massachusetts Health teaching hospital system now operates Wentworth Douglas. And they've also established a site in Southern New Hampshire, a big ambulatory site, HCA, which is a for-profit hospital system, now owns Frisbee Memorial as well as Parkland Medical Center and Portsmouth Regional Hospital. We have Tufts right now we have pending before our charitable trust unit, a number of transactions. We have Exeter Health Resources, who's trying again for a marriage this time to Beth Israel Lahey Health, which will get another out-of-state hospital system into New Hampshire. We have a proposed transaction between Valley Regional Hospital and Dartmouth Hitchcock Health, remember Dartmouth Hitchcock and Granite One we're trying to merge? That's Catholic Medical Center and its progeny were trying to merge before Covid, and during Covid it really stalled and ended up on not getting final approval or reaching agreement or fruition on that one. So a lot going on.
A. J. Kierstead, Host:
Big metrics that I'd say most consumers would care about on this one is either health outcome metrics and the cost of service. Is there any real data at a macro level to show that this is helping at all with either of those things?
Professor Lucy Hodder:
So what's interesting in New Hampshire is we stopped tracking that. We used to look at new services, cost of new services, cost of new construction, and the impact on community access, quality, affordability of care. We don't do any of that anymore. So we don't do any analysis about the ultimate impact of these transactions or the services that we provide in the health system in New Hampshire. We do license certain services, and then we do have the Director of Charitable Trust as a charitable trust director, not a health policy expert, looking at charitable nonprofit transactions, healthcare transactions of a certain amount they will look at. So for example, they're looking at a proposed transaction between a federally qualified health center, Health First Family Care, and MASCO Community Healthcare, where Health First is trying to support a sort of failing clinic in very underserved areas. And these are health clinics providing primary care services to certain populations across our state who really need access to those services. We have a really good network of federally qualified health centers in New Hampshire providing family and primary care.
The transaction with Dartmouth around Valley Regional, they've been aligned and shared resources for a long period of time. Valley Regionals in Claremont, very small critical access hospital, but in a very important part of our state that Claremont region. We have higher rates of poverty there, higher rates of substance use, and Valley Regional has been an incredibly strong, and doing pretty well, critical access hospital in that area. The alignment with Dartmouth is open for review. There's a hearing next week, next Thursday, about the community impact of this transaction. Dartmouth is becoming the parent, and Valley Regional is becoming sort of a mirror governed subsidiary aligned with Mt. Ascutney, which is a small hospital in Vermont several miles away. And Dartmouth is ultimately the sole member of both those organizations and will make the decisions about services and budget and resources.
A. J. Kierstead, Host:
The constant theme through many of the professors I speak to on this show is antitrust. When you hear about all sorts of things like this, does antitrust have any sort of impact when it comes to hospitals and the healthcare field in this sort of way?
Professor Lucy Hodder:
Yeah, absolutely. And I don't want to... I know that the struggle we have in New Hampshire is we're a small state and we have to spend our healthcare resources really carefully. We don't have a plan as to how we're doing that. We don't have a plan as to what our service system should look like. We don't have a plan as to how we're going to manage over the next 20 years. As you see huge innovations, I mean, just think about the cost of the drugs coming on for obesity. What's going to give in our healthcare cost structure as we go forward? Don't know.
But what I would say is that the national look at antitrust, the Department of Justice that enforces with the FTC has put on a huge enforcement effort and is changing the rules around how to look at antitrust in healthcare because they feel like these transactions are driving up the cost of care and no one is stepping in for the patient's interests and access, cost, and quality. Now, I can guarantee that the intentions for our combinations in New Hampshire are very good ones, but the Feds really look hard at these because they haven't seen a merger yet that lowers the cost of care. It doesn't save administratively, it doesn't save on the cost of services. It oftentimes does a lot of good, but the question is how do we know that?
So I think the feds are really trying to redefine what their oversight role is and what their standards are. Meanwhile, you have a lot of this burden fall on charitable trusts in most other states. You have another type of review that actually looks at the data, looks at your answers, the questions you're asking, which is what's likely to happen? What are we going to measure? How are we going to determine this is in the best interest of our community? Which in New Hampshire, you could argue almost we have a statewide healthcare system. I think the hospitals would say their boards are charitable boards and they really are committed to the communities, which they are. So I think that's going to be a really important conversation we have going forward in New Hampshire, is how do we want to spend our healthcare resources because we don't have an endless supply of them.
A. J. Kierstead, Host:
Do you think that these sort of mergers and this kind of appears as a consumer flailing around institutions, is leading to the innovations we're seeing in the private sector with healthcare, where you're seeing the minute clinics, the convenient MDs, and these other for-profit corporations moving in and able to really explode in this newer market?
Professor Lucy Hodder:
Yeah, they are. We have now the three for-profit hospitals, there's a lot of private equity associated with those for-profit. They don't have to do community needs assessments. They don't have any real tie to the community other than providing a good product to the community. So they certainly do a lot of good. Oftentimes our HCA hospitals are top quality. But what is unclear is what then is left open for need? And you're right, private sector oftentimes steps in. May or may not be what we wanted, but it certainly does step in to fill the gap. And right now we are seeing lots of minute clinics, lots of urgent care, lots of places people can go after work, Saturdays and weekends to get the primary care. They're not able to access in our health systems.
A. J. Kierstead, Host:
Which is kind of filling an equity hole. That's a big term that's brought up a lot in healthcare sectors. Equity and being able to, people that are working during the day don't necessarily have sick time, need to go after hours in the evening till eight or 9:00 PM where some of these facilities are now open. It's got to be a confusing thing from a health policy perspective to say, "Is this the outcome we ultimately want?"
Professor Lucy Hodder:
Yeah, I think that is the question. And you know what? We really want our big systems to be able to provide good high-end specialty care and to stay in the competitive market for that kind of care. We need it here. At the same time, we also need mental health, substance use, primary care, and we're not getting it in our commercial space. And so I think there's been a huge effort by the state to really figure out mental health delivery and substance use delivery. And that is planful, and that involves a lot of our public programs and our Medicaid programs and our state funded programs.
It's been harder to penetrate how we manage for people who have employer sponsored coverage or no coverage as to what kind of delivery system they're going to get. I would say our hospitals did an incredible job during Covid. They took care of us, they worked together, they elevated their game on the inpatient side to really manage what was an untenable situation and did a fantastic job. So we certainly owe our hospitals an incredible debt and our providers for what they did to care for all of us. And I have complete faith that we will figure this out. It's just a lot of resources, a lot of skills, a lot of expertise, and we don't have a great process for figuring out what we're going to do in the future about it.
A. J. Kierstead, Host:
Professor Lucy Hodder, director of Health Law and Policy Programs, thank you so much for joining me.
Professor Lucy Hodder:
Thank you.
A. J. Kierstead, Host:
Thanks for listening to The Legal Impact presented by UNH Franklin Pierce School of Law. To learn more about the show, please be sure to subscribe and comment on your favorite podcast platform, including Apple Podcast, Google Podcast, and Spotify. Get the back episodes of the show and podcast links at law.unh.edu/podcast.
