Stakes high for Tenncare expansion

Lawmakers weigh impact before vote

Hands wring around Tennessee as the slow clunk of Nashville decision-making ratchets toward an up-or-down vote on expanding TennCare.

Experts say either way it goes, it will change the game.

Doing it risks political capital for lawmakers who ran against what some call “Obamacare” and others who remember the past expansion and reduction of TennCare’s roll.

Not doing it would see billions of dollars destined for Tennessee fly right by the Capitol building into the coffers of other states.

Doing it would bring those billions of dollars to the health care industry, which says the money would pay them for a lot of work they’re now doing for free.

Not doing it would cut government funds they have now and would eventually lead to layoffs.

Doing it would give health insurance (and in theory access to health care) to 181,700 people in the next 5 years, which is a lot of uninsured Tennesseans, but not all of them.

Not doing it would give insurance to some on exchanges. But many would remain without insurance, without a primary care doctor or managed care plan, and the emergency room would remain their point of entry for care.

Tennessee politicians expect an answer on the TennCare question by the time the General Assembly lets out this spring. If the state decides not to do it this year, lawmakers can take up the issue again next year.

It appears Tennessee Gov. Bill Haslam holds the keys to the decision right now. Assembly leaders have said they’ll wait on his decision before making moves of their own (though bills blocking the expansion are moving now in the House and Senate).

While Haslam has said he’s gathering and weighing the best information, there’s no daily scale to see which way he’s leaning. But TennCare expansion was not included in the budget he presented lawmakers in January.

Haslam said in January’s State of the State address he knew some hospitals would “struggle if not close” without the expansion but was still hesitant.

“We have to remember what the state went through seven years ago when it made the difficult decision to cut a lot of people from the TennCare rolls,” Haslam said. “We have to be very deliberate about making a decision to add that many and more back to the rolls, but I also understand that the decision isn’t just as easy as standing here today and saying, ‘We’re not going to expand Medicaid.’”

Dr. Wiley Robinson remembers the f irst expansion of TennCare, too. It is why he said if state lawmakers decide to expand Medicaid now, he said they should actually pay for it.

“If they expand it and don’t

adequately fund it, somebody’s not going to get paid,” said Wiley, a Germantown internist and sitting president of the Tennessee Medical Association, an advocacy and lobby group for the state’s doctors. “Our experience with the first rollout of TennCare was that the people who didn’t get paid were doctors.”

But it’s not just about the money.

Doctors want to see more patients, Robinson said, but they don’t want to put up with more complicated bureaucracy. They also want to be sure doctors lead the teams of those caring for all of the new patients.

Hospital leaders say the expansion was the part of the promise that got them to agree with the passage of the Affordable Care Act. The Supreme Court’s decision to let states decide on Medicaid broke that promise.

Now they’re worried they’ll end up with a lot less than what they started with. No expansion, they said, would cost them $7.4 billion in the next 10 years. That would create a $13.3 billion negative economic impact in the state and cost more than 90,000 jobs.

But the lawmakers who oppose the expansion say they are looking out for the economic future of the state, as they are unsure that the federal government would pay for the expansion like it says it will.

Sen. Brian Kelsey, RGermantown, filed a bill this year to block expansion in Tennessee.

“In 1981, Congress reduced its Medicaid funding match to help cut the federal budget deficit, and with over $16 trillion of debt, I suspect they’ll do it again,” Kelsey said in a prepared statement.

While Tennessee waits on that up-or-down signal to move forward like so many other states have, Arkansas called an audible.

Arkansas’s legislature told Gov. Mike Beebe they wanted to use the billions of dollars coming for Medicaid expansion to buy private health insurance for low-income residents.

Beebe told the Arkansas Times that under the proposal, which he called the “private option,” the state’s Medicaid program “isn’t expanding at all. Technically, this will be done with ‘Medicaid dollars’ with the money running through the Medicaid program.”

The idea was floated to U. S. Health and Human Services officials who did not immediately reject the plan but did not immediately write a check.