Tennessee governor's race: See where the candidates stand on how to expand access to health insurance

Joel Ebert | The Tennessean

Show Caption Hide Caption First day of Tennessee Legislature Health care was on the agenda during the first day of Tennessee Legislature 2018

On April 4, Gov. Bill Haslam met with legislative leadership to discuss pursuing Medicaid expansion.

At Haslam's meeting, the leaders discussed possible federal grants and concerns over costs. Among the issues weighing on the back of their minds was how a new governor will be entering office in January 2019.

Lawmakers left Haslam's meeting without a resolution. That means the hundreds of thousands of Tennesseans who do not have access to affordable health care need to look to the next governor for a solution.

► More: Behind closed doors, Haslam asks again: Can Tennessee expand health care for working poor?

The USA TODAY NETWORK-Tennessee asked the six top-tier gubernatorial candidates to weigh in on how they would expand access to care.

The following answers from the candidates or their representatives are in alphabetical order by party.

Traditional Medicaid expansion provides states with federal money. While federal officials promise to fund 90 percent of the program costs over time, critics have argued they don't trust the federal government and dislike the parameters required to receive the funds.

The four Republicans oppose such an expansion, instead favoring something called block grants.

Block grants are chunks of money provided by the federal government with far fewer stings attached, in theory allowing states more flexibility in how they create a program to expand access to care.

But opponents warn it could lead to less money in the future while creating parameters that could prevent many of Tennessee's uninsured from receiving coverage.

As they have said before, the two Democrats in the race said they support Medicaid expansion.

Would you consider expanding Medicaid through the Affordable Care Act?

Diane Black, Republican: No. Unlike some of her Republican opponents, Diane Black has never supported expanding Medicaid under Obamacare. Working as a nurse, Diane saw first-hand the negative impact on the state budget and the quality of care for patients when the state tried to greatly expand the TennCare program.

Randy Boyd, Republican: No, Obamacare has failed us, and it is time to move past the old debate and for Tennesseans to make our own healthcare decisions by working with the federal government to secure block grant funding for our state to create our own Tennessee plan.

Beth Harwell, Republican: Obamacare has raised premiums and the cost of healthcare for the average working class family, and the cost is not sustainable as it is currently designed. We have a new Administration that is more willing to work with the states to design plans that work best for them and the populations that need to be covered, and I would certainly discuss those options.

Bill Lee, Republican: Tennesseans should have access to quality healthcare, it’s how they get that access that people differ on. Expanding Medicaid is not the way to approach that. Federal dollars with strings attached is not free money, and we’ve been down that path before in Tennessee, and it didn’t work.

Karl Dean, Democrat: As governor, expanding Medicaid would be my top healthcare priority. I believe the decision not to do it was one of the worst decisions our state lawmakers have made in decades. It has cost the state billions of dollars in federal funding ‒ funds that we pay into as taxpayers. The legislature’s decision not to expand Medicaid has contributed to the closing of now 10 hospitals since 2010. These hospital closures are devastating particularly to our rural communities.

Craig Fitzhugh, Democrat: Expanding Medicaid will be my first priority on my first day in office. I will not rest until it is done.

Federal CMS officials have told some states that haven’t expanded that they are welcome to submit plans to the federal government that would rely more on block grants to implement expansion. Would you commit to entering talks with federal officials about exploring the idea of block grants further?

Black: As Governor, Diane will work with President Trump and Vice President Pence to get a Medicaid block grant that will allow the state to design a better TennCare program and provide greater access to care for Tennesseans. It will also allow the state to institute work requirements for Medicaid recipients and create a high-risk pool to lower costs. She also supports expanding county health departments and telehealth so patients don’t have to travel far to get the care they need.

Boyd: Yes, our first priority will be to explore the feasibility of a Tennessee-specific block grant plan. We want to work with the federal government to secure full flexibility for Tennesseans to make our own decisions about how best to meet our health care coverage needs.

Harwell: I have been advocating for several years for the federal government to give the states, including Tennessee, a block grant and allow us to design a program that best works for our state. This is what the Founders intended; that the states be the labs of experimentation.

Lee: As governor, I'll work with the legislature, CMS, and our providers to provide expanded choices and accountability for patients, and deliver more rewarding reimbursements for providers who innovate to bring down costs. I think block grants are one of the solutions in finding state-based, real reform of our health care system.

Dean: I’m concerned that the use of block grants would mean less dollars from the federal government, and in turn, a greater burden on our state government. That said, as governor, I would be open to having any conversation with our federal government that could lead to more Tennesseans having access to affordable healthcare.

Fitzhugh: Although I feel that block grants are not the best route for expansion, after losing over $4 billion in Medicaid funds, I would talk with federal officials as a starting point. Insure Tennessee was pretty much a block grant plan in reverse, and I backed the plan.

In Virginia, the legislature is currently considering expansion, with support among Republicans apparently gaining steam, provided the plan is structured in a conservative way and created collaboratively. Should you become governor, do you plan to sit down with legislative leadership to discuss this issue further?

Black: Yes, but expanding Medicaid is a non-starter.

Boyd: Yes, I will work closely with legislative leaders on a new block grant proposal to address the needs of the uninsured. Two other immediate areas we need to look into is how we drive greater transparency in the cost of healthcare services so we can reduce overall costs, as well as improving Tennessee's overall health in areas like obesity and smoking.

Harwell: Healthcare is always a topic legislative leaders discuss, and that will not change under my administration.

Lee: Absolutely. I look forward to working with the legislature as governor. We are living in a health care system in our country that is fundamentally flawed. In my company, health care costs have increased by 29 percent and 19 percent over the past two years alone. Policymakers at both the state and the federal level have to work on new creative solutions to lower costs, and that is something I look forward to working towards.

Dean: Yes, what we need are sincere efforts around this issue that prioritize getting the job done, not party ideology. Any plan is going to need bipartisan support to be enacted. We need to reach across the aisle and decide what we can agree on to make sure Tennesseans have access to affordable, quality healthcare.

Fitzhugh: In my 24 years in the legislature, I have served as a member of the majority, and the Republican Party now has a super majority. When I am elected governor, I may work with a Republican majority. We will have to work together to create a plan for all Tennesseans, in every district. I believe that my work as the minority leader and my relationships with members uniquely positions me to get this and other issues passed as governor.

Would you support expansion if the state’s portion of expansion cost did not come from the state budget? That includes other methods, be it hospital taxes or by private industry.

Black: No.

Boyd: No, we first need to see what we can negotiate and accomplish in securing flexible federal block grant funding for the state.

Harwell: Medicaid costs are continuing to grow at an unsustainable rate. I will not support raising taxes or putting the burden on private industry to prop up a program that has never demonstrated that it can control costs. I will continue to advocate for more flexibility from the federal government to design a plan that works for our state and controls costs.

Lee: No, increasing taxes and spending more money is not the solution. We need to rethink health care, so we’re focused on driving down health care costs, rewarding innovation, and expanding choice. That means bringing accountability to our TennCare system and bringing real competition to our insurance market. If we can’t work together to make these kinds of changes, then spending more money won’t solve the problem.

Dean: Yes. I supported Haslam’s Insure Tennessee plan, which included a cost-covering measure funded by hospitals. Expanding access to affordable health insurance provides an economic benefit to the healthcare industry and it’s appropriate for that to be reflected in the funding plan.

Fitzhugh: Yes, I would support expansion through hospital assessments or private industry. All methods to expansion are on the table. It is too important to ignore any one avenue.

Would you support expansion if it included a work requirement component?

Black: Diane will work with President Trump and Vice President Pence to get waiver for a block grant for Medicaid that will include work requirements. Tennessee can design a better Medicaid program that meets the needs of our state and increases access to care than federal bureaucrats. Expanding Medicaid is not the solution.

Boyd: As we put together Tennessee’s block grant plan, we will explore whether or not such requirements actually save the taxpayers any money or simply increase the size of government.

Harwell: I believe anyone who is able-bodied and fits the criteria outlined by the federal government receiving a TennCare benefit should be required to work, volunteer, or attend school. That is why I sponsored House Bill 1551 this year to implement this program using existing resources.

Lee: I have 1,200 employees at my company, and I know first-hand that working is not just about a paycheck, it is about the dignity that comes from work. I believe work requirements can help people over time in ways that are beneficial to all of us.

Dean: This is already being discussed as a requirement for current TennCare recipients, and I have not seen a proposal that makes any sense yet. We need to consider those recipients that might have a condition that could limit their ability to work. And, we need to be careful about creating a bureaucracy that would cost taxpayers more to operate than it saves.

Fitzhugh: Yes, I would support work requirements because this is already a working population. These people are working and being caught in the cracks of the coverage system.

Tennessee governor's race candidates weigh in on health care. The forum featured five gubernatorial candidates who discussed various aspects of health care in Tennessee.

If elected, would you consider calling a special session in early 2019 to specifically tackle this issue?

Black: Those issues will be discussed during the transition with legislative leadership, but Diane is committed to finding innovative solutions to increase access to care and improve the quality of care.

Boyd: We must first put together a comprehensive plan with full legislative buy-in and then negotiate that plan with federal officials to secure block grants and develop Tennessee’s own plan. Only then will it be time to address the proposed plan in a legislative session.

Harwell: Special sessions are not always necessary to tackle big issues — I would take into consideration what is best for taxpayers.

Lee: This is one of many issues facing our state, and we can work through all of our issues through the normal legislative process.

Dean: That is a decision I will make at the time. This will be a top priority and so I will be aggressive about the timeline.

Fitzhugh: Yes, I would consider a special session for expansion.

If you don’t support expansion, what do you propose doing?

Black: There are still hundreds of thousands of Tennesseans who are uninsured. As Governor, Diane will work with President Trump and Vice President Pence to get a Medicaid block grant that will allow the state to design a better TennCare program and provide greater access to care for Tennesseans. It will also allow the state to institute work requirements for Medicaid recipients and create a high-risk pool to lower costs. She also supports expanding county health departments and telehealth so patients don’t have to travel far to get the care they need.

Boyd: We must craft our own Tennessee plan. I will work closely with legislative leaders on a new block grant proposal to address our health insurance needs. Two other immediate areas we need to look into is how we drive greater transparency in the cost of healthcare services so we can reduce overall costs, as well as improving Tennessee's overall health in areas like obesity and smoking.

Harwell: I appointed a task force called the 3 Star Healthy Task Force. The plan they developed would extend coverage to those who need it the most, but was fiscally sound and ensured our state could handle it. The plan included benchmarks and circuit breakers related to eligibility and costs per member per year, evaluating actual health outcomes, and cost-sharing practices like health savings accounts.

Lee: We should be looking at block grants and flexibility so that we can begin to rein in costs for our existing TennCare program, which at nearly 40 percent of our state budget takes up a significant portion of the budget. As governor, I'll work with the legislature, CMS, and our providers to provide expanded choices and accountability for patients, and deliver more rewarding reimbursements for providers who innovate to bring down costs.

Dean: There are still hundreds of thousands of Tennesseans who are uninsured.

Fitzhugh: I support expansion fully. Expansion has been the focus of my legislative work since we have had to ability to expand. In my office I keep a running tally of the money we have left on the table, and Tennessee has now forgone over $4 billion dollars. I look forward to stopping that tally as governor.

If you don’t support expansion, please say exactly why you oppose using federal dollars to find a way to provide coverage for the state’s uninsured.

Black: Money coming from the federal government is not free money. It’s Tennessee taxpayer dollars, and Diane believes those dollars should be spent wisely. Not to mention the fact that those federal dollars decrease over time, increasing the burden on the state and crowding out other priorities. Diane is focused on finding innovative solutions to increase access to care, rather than expanding a bloated and inefficient program with poor quality of care.

Boyd: As insurance premiums continue to skyrocket, with some seeing rate increases over 35 percent just this past year, combined with fewer and fewer options; it's clear that Obamacare has failed. It's time to move past the old debate and for Tennesseans to make our own healthcare decisions by working with the federal government to secure block grant funding for our state to create our own Tennessee plan to support the state’s uninsured.

Harwell: I was a member of the legislature when Governor Bredesen had to remove people from the TennCare rolls because of out-of-control costs. “Federal dollars” are still taxpayer dollars, and we have shown that in Tennessee, we are much more responsible with taxpayer funds than our counterparts in Washington, D. C.

Lee: As I mentioned earlier, federal dollars with strings attached is not free money, and we’ve been down that path before in Tennessee, and it didn’t work. We need to find ways to lower costs in health care coverage, and top-down federal solutions have been proven not to work.

Dean: N/A

Fitzhugh: I am for expansion.

Dave Boucher contributed to this report.

Reach Joel Ebert at jebert@tennessean.com or 615-772-1681 and on Twitter @joelebert29.