Medicaid expansion: Three deep-red states just did it. Why not Tennessee?

Brett Kelman | Nashville Tennessean

Show Caption Hide Caption Nearly one-third of Tennesseans have 'pre-existing' health conditions If the Affordable Care Act were repealed, would it mean a return to a time when not all of them could get health insurance?

Correction: A prior version of this story misstated the terms of eligibility for Tennessee's medicaid program. The error has been corrected in the story below.

When polls closed on Election Day, one of the biggest winners wasn’t a politician at all.

Medicaid expansion – a government policy that extends taxpayer-funded health coverage to the moderately poor – saw significant victories against long odds two weeks ago. Although loudly opposed by Republicans lawmakers, ballot initiatives to expand Medicaid were approved by voters in the deep-red states of Utah, Nebraska and Idaho. Kansas and Wisconsin also elected new Democrat governors who vowed to expand Medicaid when their Republican predecessors had not.

The results appear to show increasing non-partisan voter support for expansion, which was once a political lightning rod because of its legal framework under the Affordable Care Act, commonly known as Obamacare. But, as nearly three-fourths of the nation have now expanded Medicaid, a critical question remains: Will Tennessee?

Based on the election results, probably not.

Tennessee is of the unhealthiest states in the country. Nearly 7 percent of the population – or about 450,000 Tennesseans – do not have any health coverage, largely because they cannot afford it, according to a recent University of Tennessee study. Medicaid expansion would extend coverage to most of these residents, but the only pathway to expansion leads through a Republican-dominated legislature that has previously rejected similar proposals. And if expansion somehow sneaks past lawmakers, it will also face opposition from a new governor.

Gov.-elect Bill Lee, a Republican businessman, won a lopsided victory two weeks ago over Democrat candidate Karl Dean, a former Nashville mayor who made Medicaid expansion the central promise of his campaign. Lee, on the other hand, said repeatedly that as governor he would oppose expansion because he considers the proposal too expensive and the existing Medicaid program “fundamentally flawed.”

"Obamacare will not expand in Tennessee under my watch,” Lee said over the summer, when asked about Medicaid expansion by The Tennessean. “Health care costs are skyrocketing, and that would make it even worse."

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Lee: Medicaid expansion costly, short-sighted

In a series of interviews and public statements throughout his campaign, Lee instead pushed efforts to improve Tennessee’s health by reducing the cost of medical care and insurance premiums, and routinely rejected Medicaid expansion as too costly and shortsighted. He proposed expanded telemedicine and reforming the existing Medicaid program to become more efficient but never provided details on how many Tennesseans would gain access to health care under these proposals.

“I think we have to advocate for a (Medicaid) model that works, and the current model isn’t working,” Lee said during an interview in October. “It's not working because it’s a model that was addressed to meet the needs from years ago, but not the needs of the future.”

Medicaid is a government program, funded jointly by the federal and state government, that pay for health coverage for the poor and disabled. Tennessee's system uses a sliding income scale to determine eligibility for low-income parents, children, pregnant women and people with disabilities. The Affordable Care Act, passed by the Obama Administration, gives states the ability to expand eligibility to all adults with income at or below 138 percent of the poverty line, with the promise to pay for 90 percent of the increase cost.

That change might sound small, but in Tennessee, it would be massive. If the program were to expand, estimates say that more than 300,000 Tennesseans would now be eligible for coverage, which would completely transform the health care landscape across the state.

Because of this huge potential impact, Democrats often argue that Tennessee is losing out on about $1.4 billion in federal funding a year by refusing to seize the Obamacare option to expand the program.

But Lee and other opponents of Medicaid expansion argue that this funding could later vanish, leaving the state to pay for health care bills that it can’t afford on its own.

“How do we know that the rules of the game aren’t going to change once we get into this agreement?” said Stephanie Whitt, of the Beacon Center of Tennessee, a conservative-leaning think tank that opposes expansion.

“It is simply unsustainable for the government to be the ones paying for the majority of health care costs, and right now the federal government says it will pay for 90 percent,” she added. “But we don’t know that this is forever, and the states are going to pick up that cost eventually.”

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One of Gov. Haslam's biggest regrets

At least one prominent Tennessee Republican is not opposed to expansion.

Gov. Bill Haslam tried to bring coverage to these Tennesseans in 2015, when he crossed party lines to proposal Medicaid expansion to the state lawmakers. Legislative leaders balked at the proposal then killed it in committee, and Haslam’s plan never received a vote in either the House or the Senate.

Haslam has called the failed Medicaid proposal one of his biggest regrets, and now that he is leaving office, the campaign for expansion is losing its most powerful advocate. His allies in the proposal are trying to stay positive but acknowledge that the path to expansion is now steeper than ever before.

“Obviously, we took a run at it in 2015, and it was unsuccessful,” said Craig Becker, president of the Tennessee Hospital Association, which worked with Haslam towards expansion. “Since then, we’ve have continued to work with the governor and the Legislature to try to accomplish it, and frankly, we haven’t gotten too far. And we are still going to push for it during the Lee administration.”

“I’m the eternal optimistic, and I think there is always a pathway if we can sit down and talk about,” Becker added. “One thing we did hear, certainly, from the governor-elect is that he is open to talking about finding solutions to the problems we have in this state. And I take him at his word.”

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Ballot initiatives not an option

Becker and other proponents of expansion ultimately have no choice but to work with Lee and the Legislature because Tennessee law forbids them to pursue the strategy that worked in Utah, Nebraska and Idaho.

Lawmakers in these states had also blocked prior attempts to expand Medicaid, so voters ultimately used ballot initiatives to circumvent them completely. Proponents in the three states collected more than 200,000 signatures to put Medicaid expansion on the ballot and directly in the hands of voters.

But this option is not available in Tennessee, a state with no legal framework for a statewide ballot initiative that skips the Legislature completely. Signature-supported initiatives are permitted in some Tennessee municipalities, but no amount of signatures can put a decision on the ballot statewide without approval from lawmakers.

There is at least some evidence that, if Tennessee allowed a statewide vote on Medical expansion, it would pass. Despite opposition in the Legislature, a springtime poll by conducted by Mason-Dixon Polling & Research estimated two-third of Tennesseans favor expansion.

For comparison, support was not that high in any of the three red states that pass expansion initiatives on Election Day.

Brett Kelman is the health care reporter for The Tennessean. He can be reached at 615-259-8287 or at brett.kelman@tennessean.com. Follow him on Twitter at @brettkelman.