Politics could threaten Haslam's 'Insure Tennessee'

In less than a month, Gov. Bill Haslam embarks on possibly the biggest political challenge of his career: trying to pass "Insure Tennessee," his plan to use federal Medicaid expansion dollars to create new health programs for an estimated 200,000 lower-income Tennesseans.

The Knoxville Republican's administration is adamant the proposal is not traditional Medicaid expansion, a move made possible by the polarizing Affordable Care Act — also known as "Obamacare" — and popular in many Democratic-controlled states. Haslam said his plan emphasizes personal responsibility, requiring Tennessee residents newly eligible for some publicly financed health coverage to take an active role in making better health care decisions.

Republicans win elections railing against entitlement programs and blasting the Affordable Care Act. It's worked in Tennessee: The GOP has supermajorities in the state House and Senate in addition to controlling the governor's mansion. And that means some Republican leaders are questioning Haslam's plan, creating potential political hurdles for the legislative form his proposal must take.

"It's just that a lot of us are getting cold feet real quick," said House Republican Caucus Chairman Glen Casada, R-Franklin.

"I have grave reservations."

No concrete details

Those cold feet are based both on the idea the plan expands government and on the fact the governor hasn't presented the exact plan to legislative leaders, Casada said. Or at least not to the leaders who typically present bills for the governor: Casada said Haslam hasn't spoken with House Majority Leader Gerald McCormick, R-Chattanooga, or himself about the precise details of the plan.

Senate Majority Leader Mark Norris, R-Collierville, said the governor hasn't shown him his plan, either. Asked Friday when he expected Haslam to present the plan to him, Norris said "two weeks ago."

"It weighs heavily on me and the rest of us," Norris said. "Everybody in the General Assembly. I've spent an inordinate amount of time studying the options during the holiday, and you know, I've just about exhausted my limited knowledge of where he's headed. Don't really know what more can be done at this point."

Scheduling could also pose a problem, Norris argued: The U.S. Supreme Court is scheduled to hear a case challenging the Affordable Care Act in March. That puts the court on pace to potentially rule on the legality of the federal legislation by June.

"It's conceivable that the General Assembly could make some affirmative action on the governor's request and it could be undermined in a matter of months by an adverse ruling by the Supreme Court," Norris said.

Norris said he's not being critical of the governor and would keep an open mind about the proposal. Casada also pledged to reserve final judgment until seeing the actual plan in writing.

Haslam, whose spokesman declined to comment for this article, clearly outlined what he wants his plan to be when he announced the creation of Insure Tennessee in December: People who earn up to 138 percent of the federal poverty line would be newly eligible for one of two pilot programs. The first would offer vouchers to help offset the cost of any employer-provided health coverage someone newly eligible could not previously afford. The second would offer a health savings account that could be used to offset some medical costs and provide financial incentives for "healthy behaviors" such as preventive care and correctly using an emergency room.

He has said the plan won't require any additional spending by Tennesseans, and he'll end the program if at any point the federal government or hospitals — who've agreed to cover some costs — change their funding levels.

Haslam is expected to submit the state's waiver to federal health officials outlining his proposal sometime in January, and call a special session specifically for Insure Tennessee in early February.

Expect Republican opposition

Medicaid expansion by any other name is still Medicaid expansion, argued House Majority Whip Jeremy Durham, R-Franklin. Durham spearheaded a bill last year to require legislative approval for any form of Medicaid expansion — Haslam had already agreed to present any proposal to the General Assembly — and said Friday he doesn't see a way he or many other Republicans could support any Haslam idea that is in any way related to the Affordable Care Act.

"There are a few folks that are open to the idea, but I think you'll see most Republicans vote no. There's definitely a very large part of our caucus voting no," said Durham, typically considered one of the more conservative members of the House.

"You can put window dressing and some conservative ideas out there, but if it really is Medicaid expansion, I just don't see many Republicans buying that argument."

If the heads of the House and Senate buy in, Haslam is likely to see his plan become law.

Lt. Gov. Ron Ramsey, R-Blountville — who recently ranked himself an 8.5 out of 10 on a scale from 1 to very conservative — has changed his tune on Medicaid expansion and recently expressed support for ideas included in Haslam's plan.

"Unlike Washington, D.C., we in Tennessee like to actually read the items on which we vote. In broad strokes, Insure Tennessee looks to be an opportunity to take power away from the federal government, reclaim Tennessee tax dollars and enact authentic state-based, free-market health care reform," Ramsey said in a statement.

House Speaker Beth Harwell, R-Nashville, hasn't publicly said how she feels about the governor's plan, or whether she's seen the specific details he'll present to the General Assembly. Ramsey's support almost certainly guarantees passage in the Senate, where Republicans control 28 of 33 seats and Democrats are likely to vote in support. In the House though, any hesitancy or pushback from Harwell could mean a fight for Haslam. There could also be some political pushback from conservatives for supporting the plan if Harwell, who's considered a possible gubernatorial candidate, decides to seek higher office.

Asked why the governor would go out on such a political limb if he didn't have legislative support, both Casada and Durham said Haslam is confident it's the right move, and they said he deserves credit for that. Norris said he'd like to give the governor the benefit of the doubt and thinks most lawmakers want Haslam's idea to have its "moment in the sun."

Haslam enjoying political pull

Haslam is having his own moment: He just overwhelmingly won re-election, has no public plans to run again for any office and is sitting on a 70 percent approval rating, according to a recent poll from Vanderbilt University. The same poll of registered voters also found 58 percent support Medicaid expansion in Tennessee.

Combined with the potential political sway of the hospitals, health care providers and other heavy hitters who've created a coalition in support of the governor's plan, Haslam could have enough capital to push back against critics questioning his conservative bona fides or organizations such as the conservative Beacon Center of Tennessee, who argue the plan will cost Tennessee billions of dollars.

Democrats will very likely support the plan as well, but there's a slim chance they could oppose a bill that they think doesn't go far enough.

"If we're talking about a voucher plan that pays 80 percent of someone's medical cost, Democrats can get behind that proposal. If we're talking about a voucher that covers 20 percent of a person's medical cost, that's going to be problematic on our side," said Zak Kelley, a spokesman for House Minority Leader Craig Fitzhugh, D-Ripley.

Republicans have the numbers to get any bill passed without any Democrats supporting it, but if Durham's right and there are enough Republicans opposed to any plan, Democratic support in the House will be key.

Norris agrees the House offers the biggest hurdles for Haslam, but the governor should prepare for a battle on any plan he presents.

"The politics will be very difficult in any case, and I think the governor has acknowledged that," Norris said.

Reach Dave Boucher at 615-259-8892 and on Twitter @Dave_Boucher1.