Editor’s Note: This story was first published on New Hampshire Bulletin.

Lawmakers must decide this year whether to continue spending millions each year to provide an estimated 50,000 to 90,000 additional low-income people Medicaid health coverage through its Medicaid expansion program. The New Hampshire Fiscal Policy Institute, which lawmakers have long looked to for nonpartisan financial analysis, released a report this week with several arguments for doing so.

Continuing Medicaid expansion has done more than improve recipients’ health through earlier cancer screenings, increased dental treatment and enhanced pregnancy care, according to the analysis.

It has also allowed beneficiaries to get the health care they need to stay in the workforce, a plus for them and the state’s employers desperate for workers.

Medicaid expansion has given the state’s hospitals millions of dollars to cover health care costs for uninsured people who would otherwise be unable to pay. It has lowered the state’s cost of health care for inmates, according to the analysis.

And the state foots just 10% of the cost, with the rest covered by the federal government. Between 2015 and 2022, the state put $210 million into the program, much of it paid for by insurance companies. That is a fraction of the federal government’s $3.22 billion contribution.

The question is, will that data persuade lawmakers to continue a program that drew skepticism before it was enacted in 2014.

Here are five takeaways from the institute’s analysis:

Who has gained health insurance?

There was a 42.3% percent drop in the number of uninsured Granite Staters in the five years following the start of Medicaid expansion compared to the five years prior.

The newly insured live in rural parts of the state, and about half are under 45. About 74% of recipients are white, and people of color are disproportionately likely to be Medicaid expansion beneficiaries relative to the overall population, the analysis found.

Like traditional Medicaid recipients, they are low-income. But they don’t meet Medicaid’s other eligibility rules, which require someone to have a physical or developmental disability or be younger than 19, pregnant or caring for children or other family members.

In December, about 154,000 Granite Staters qualified for traditional Medicaid, according to the state Department of Insurance. New Hamsphire’s expanded Medicaid population has traditionally been less than half that, about 52,000 people.

Eligibility for Granite Advantage, the state’s expanded Medicaid program, considers only age and income.

Beneficiaries must be between 19 and 65 and earn less than 138% of the federal poverty level. In 2022, that equaled $18,754 a year for a single person and $38,295 for a family of four.

The expanded Medicaid population jumped to over 90,000 during the pandemic due to job losses and public health concerns that kept people home. That number is expected to drop as the state reviews beneficiaries’ post-pandemic employment and financial status.

Compared to the state’s population, a disproportionate number of beneficiaries identify as Hispanic, at 5%, or Black or African American, at 2.1%, according to the analysis. A higher percentage of beneficiaries live in the state’s more rural areas; Coos County has the highest percentage at 16.5%, followed by Sullivan County at 13.8%.

Granite Advantage beneficiaries often work in low-wage or seasonal jobs that don’t offer consistent employment or health benefits. And they may enroll and leave the program as work becomes available.

The analysis found that to be particularly true in lower-wage industries such as retail, accommodations and food service, among the state’s largest employment sectors.

Has drop in uninsured adults made NH healthier?

It looks that way.

The analysis pointed to research showing that parents who enroll in expanded Medicaid are more likely to enroll their children in Medicaid. Parents covered by Medicaid are also more likely to ensure their child has an annual wellness visit, critical to monitoring a child’s physical and mental health and keeping them current with vaccines.

There are additional indirect health benefits, the analysis found, when adults are able to work and don’t have the financial burden of health insurance. That includes steady access to housing and food.

The analysis includes research by the Kaiser Family Foundation on the impact of expanded Medicaid. It found a connection between expanding Medicaid and reduced mortality, including mortality during pregnancy or childbirth, and from some cancers, as well as heart and liver disease.

The analysis noted that states with expanded Medicaid saw a bigger decline in infant mortality than states without it. But it noted that research has not been conclusive.

The New Hampshire Fiscal Policy Institute found conclusive evidence, however, that tens of thousands of Granite Staters on expanded Medicaid used it for treatment in the last fiscal year.

More than 30,000 got mental health treatment and/or medication. Nearly 12,000 used their benefits for hospital stays, and more than 10,000 people sought treatment for substance use disorder. About 30,000 sought care for COVID-19, and nearly 64,000 people used their coverage at pharmacies.

Granite Advantage has benefited state’s hospitals

When hospitals treat a patient without insurance, they use their revenues and funding from the state to cover the costs.

The state’s hospitals have seen those uncompensated costs go down since the start of expanded Medicaid, the analysis found.

It quoted findings from the New Hampshire Hospital Association showing the average cost of uncompensated care fell from $157 million across 2012-2014 to $65.1 million across 2017-2019. Those savings allow hospitals to remain open and avoid reducing services, the analysis found. That, in turn, helps maintain health care options for everyone.

Granite Advantage saves taxpayers money

Yes, the state has spent more than $200 million since 2015 on expanded Medicaid. But because the federal government picks up 90% of the program’s cost, it has seen a drop not only in what it sends to hospitals for uncompensated care but also what it spends on other services. That includes health care for inmates, the analysis said.

Traditional Medicaid covered just under 7% of medical care given to inmates by community providers. Expanded Medicaid’s more generous compensation has saved the Department of Corrections $10.2 million between 2015 and 2021, according to the analysis.

State gets creative in covering its share

State officials emphasize that the general fund, which pays for nearly all state services, does not pay for Medicaid expansion. That’s technically true.

In 2022, insurance companies paid a significant portion, about $31 million, of expanded Medicaid costs. The state pulled just over $10 million from its alcohol abuse, prevention and treatment fund and $8.7 million from liquor commission funding to cover some of its cost. Most remaining funding came from the prior year’s surplus or money that had been refunded to the program.

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