The House, Wednesday, May 4, 2022

Speaker PackardThe bill is on second reading and open to further amendment. Rep. Edwards offers floor amendment (1909h) in your seat pockets. The Chair recognizes Rep. Edwards to speak to his amendment.

Rep. Jess Edwards (R - Rock 4)Thank you, Mister Speaker. What this amendment does, is it reinstitutes a House Bill that we passed a few weeks ago sponsored by Rep. McLean. It went over to the other body and they put it in Interim Study. What we are trying to do is to indicate to the other body that this was a serious idea. What we proposed, Rep. McLean proposed, was that if there is a health care organization that's a membership based only or receives cash payments only, that they would not be required to accept patients that aren't within that particular payor mix. There aren't any of these in New Hampshire right now so if you've heard that this is going to hurt our critical care hospitals and the like, it's not true because these things don't yet exist and our critical care facilities and others are protected with a 15-mile radius so it's a noncompetitive situation in any case. So, a couple of years ago, we passed the direct primary care bill. There weren't any direct primary care providers at the time. That legislation fertilized the ground and now we have some direct primary care. What this is attempting to do is to lay the ground and fertilize it again so that we can create another alternative in our health care system. If we keep doing the same thing over and over and over again, we are going to get the same kind of broken results. One of the great benefits of doing this, if we can get some of these direct payment organizations in place, then we will start to really know what the true costs are. If you were to go and ask prior to a procedure exactly what they are going to charge you for a given procedure, they can't give you a price because the payor mixes are so complicated that they can't get to reality. So, this is an opportunity for us to peel it back and take a fresh look at health care delivery in New Hampshire. I hope you vote in favor of it.

Speaker PackardThe Chair recognizes Rep. Layon to speak.

Rep. Erica Layon (R - Rock 6)Thank you, Mister Speaker. What this amendment would do is it would allow hospitals to operate out of the sight of the sphere of influence of CMS, the Centers for Medicaid Services. That's all it does and that's enough. I've heard opponents of this bill say that it means that hospitals won't need to have an emergency room, won't need to have a requirement for charity care. All this changes is the requirement for a hospital to take all payors. We've seen the power of that. Right now, CMS is telling us what laws we can pass here in New Hampshire. CMS is telling us what our hospitals can and can't do and CMS is basically telling us what doctors and other health care heroes we can employ. We have direct pay primary care and so there a lot of providers who do have an option to practice outside of this sphere of CMS influence, but some doctors can only work in a hospital. Would you see a surgeon who can't go to a hospital? These doctors, right now, are forced between continuing to practice in New Hampshire while complying with all of these mandates, are going to some other state that's putting up more of a fight. Do we want our surgeons to move to Florida? Do we want them to just retire and stop practicing? We have a health care shortage. We need to pass this amendment and send this on to the Senate so we can have an option for these surgeons who otherwise would no longer practice in New Hampshire to open up their own hospitals. Allow them to negotiate with the payors, negotiate with the patients, because right now the payors decide what happens. This allows the patient to be the payor. This will be small. It will be niche. We still have the 15-mile buffer. We are not going to allow these to open up next to our critical access hospitals because this doesn't change that part of the law. Please pass this so that the patients are in control. When you write the check, you make the decision and you'd work directly with your doctor. Thank you.

Rep. Jerry Knirk (D - Carr 8)Thank you, Mister Speaker. Indeed I rise to speak against this amendment to SB 430. As stated, this amendment would add the wording of HB 1044 to SB 430. It was sent to Interim Study in the Senate. Now, first of all, contrary to what was just said, this has nothing to do with providers individual practitioners. This has to do with facilities, facility licensing. That's where this statute resides. Currently, licensed health care facilities are required to provide services to all persons, regardless of payment. This requirement was added by the legislature in 2016 to ensure access to services for low-income individuals and those covered by Medicaid. The reason for this requirement is really pretty straight forward. Medicaid would be useless if facilities will not treat patients who are covered by Medicaid. We also have uninsured patients who need care and guess what? They don't just crawl away and die. They need care. They need access. This amendment would exempt from this requirement the health care facilities which exclusively provide services on a membership basis business model or to persons who make a direct payment without any reimbursement or third-party payment. Some folks have claimed that this is actually going to help those with high deductibles, but it won't because the only way to have any payment credited to your high deductible insurance plan is if you submit the bill to the insurance company and that is prohibited by the language of this amendment. So, it seems kind of like a minor change, right? Well it isn't. The comment that we are not seeing a problem for something that doesn't yet exist, well, golly. We wouldn't, would we? The question is what will happen. Such a change will allow a very small number of for-profit institutions offering things like urgent care, birthing services or ambulatory surgery to skim off the patients who can pay a full cash price, changing the payor mix to the remaining hospitals or other facilities. Maintaining payor mix is important. Our critical access hospitals run on razor thin margins. Some of them actually run a little bit into the red, they can't really make it and they lose money on services such as full service, 24 hour per day emergency room and obstetrical services, which serve a lot of people on Medicaid or with no insurance. Again, this is health care financing 101 here. Those services, which are critical to have in rural areas are subsidized by the higher paying services and higher paying insurances. You go in and have your total hip replacement done with insurance, that's going to be some of the money that is going to help keep that emergency room open so if you get run over by a car, you have a place to be taken care of. Skimming off the higher paying patients will have a significant negative economic impact on our critical access hospitals and we are seeing closures of critical access hospitals around the country. There will be a substantial risk of closure or the need to drop critical services such as maternity and we've seen that happen in this very state because it is not a money-making proposition. This will leave a large number of individuals, especially in rural areas like where I live, with no access to timely medical care for emergencies or childbirth. The losses sustained by those facilities will be shifted to those who have insurance, driving up the cost for everyone else and not changing that total health care cost. A comment was just made about that protection with the 15-mile radius. That's not sufficient to do anything. I live just a little over 15 miles from either Huggins Hospital or Memorial Hospital. I have to drive over 15 miles for any facility care. For those of you who live in the Southern part of the state, you are not used to the kind of distances we have to drive to get any kind of care. A facility placed, for example, in Tamworth would not be governed by RSA 151:4-a because it would be outside of that 15-mile radius and it could draw from both Huggins and Memorial. So think about a woman in labor who makes the mistake of going to a local birthing center in her town only to discover between contractions that they only serve an elite group. She packs up, drives perhaps another hour to get to the only remaining hospital that still offers maternity services or she may deliver in her car in the parking lot and we have certainly see that happening a great deal more after some of our places have closed their maternity services as we see an increased number of babies who are delivered by the police. EMTALA, which is the Emergency Medical Treatment and Labor Act actually prohibits turning her away. This proposal would violate EMTALA. Now the sponsors presented this bill as allowing the free market to function. That's an unusual way to think about the free market because this bill does not support a free market. If you give favored treatment to facilities using one business model at the expense of others, as far as I know that's not the free market. The business model of our health care system should not be to make money off of the healthy and wealthy while letting the sick and less fortunate suffer and die. This amendment will decrease access to health care and will not drive down the overall cost of health care. Please press the red button to vote no on this amendment and I do request please a division vote.

Speaker PackardDoes the member yield to questions? The member does not yield. The motion before us is the Edwards floor amendment. A division has been requested. Members take your seats. Rep. Osborne has requested a roll call. Is that sufficiently seconded? It is sufficiently seconded. This will be a roll call vote. The motion before us is the Edwards floor amendment. This is a roll call vote. The Chair recognizes Rep. Hunt for a parliamentary inquiry.

Rep. John Hunt (R - Ches 11)Thank you, Mister Speaker. Mister Speaker, if I know when I was sitting here listening to a model that actually was the original managed care model and it's in California known as Kaiser Permanente. Maybe you have heard of it. Mister Speaker, if I know that Kaiser Permanente is a member only hospital system. Mister Speaker, wouldn't I love to have them come to New Hampshire as another competitive model for our health care system? I think, Mister Speaker, I might want to press the green button.

Speaker PackardThe Chair recognizes Rep. Knirk for a parliamentary inquiry.

Rep. Jerry Knirk (D - Carr 8)Mister Speaker, if I know that our critical care access hospitals run on razor thin margins and require a payor mix, which includes private pay, in order to maintain revenue losing services such as 24-hour full-service emergency rooms and obstetrical services. And if I know that I worked for a large managed care health organization, Harvard Pilgrim Health Care. That's not the insurance part, but the provider group, and we took Medicaid after a while. We didn't in the beginning, but we did later. And if I know that skimming off those higher paying patients would have a significant negative economic effect on our critical care access hospitals leading to closures of obstetrical services and of critical access hospitals which are needed to provide timely care in our rural areas. And if I know that the hospitals don't want this. The New Hampshire Hospital Association testified against HB 1044. And lastly, if I know that this amendment will decrease access to health care and will not drive down the cost of health care, would I then press the red button to vote no to defeat this amendment? Thank you, Mister Speaker.

Speaker PackardThe motion before us is the Edwards floor amendment. This is a roll call vote. If you are in favor, you'll press the green button. If you are opposed, you'll press the red button. Voting stations are open for 30 seconds. Have all members present had an opportunity to vote? The House will attend to the state of the vote. 167 voting Yea, 147 voting Nay, the Edwards floor amendment is adopted. The motion before us now is Ought to Pass as Amended on SB 430. Are you ready for the question? All those in favor, say Aye; those opposed, Nay. The Ayes have it and the committee report is adopted.