Despite need, expanding health care not in cards

Friday, January 19, 2018, Vol. 42, No. 3

Springfield resident Felicity Palma struggled mightily when she moved to Tennessee from Florida two years ago after suffering health problems and losing her job.

The 47-year-old former social worker became homeless for a period when she came here, and now she finds herself in a health insurance coverage gap as she tries to get treatment for ulcers, sciatica, fibroids and thyroid disease. Debt is piling up on her, too, for the care she does receive.

“I’ve worked in the field for so long, and to find myself in a situation where I needed help myself because of my health was really difficult for me,” Palma says. “It was a very humbling experience, and at the same time, I remember a lot of the struggles that my clients went through and that they would tell me, and I kind of took that to heart.”

Palma qualified for disability, but those payments take time to receive, and she still isn’t guaranteed health insurance, she adds. With more medical tests required to deal with the thyroid problem she’s worried about her long-term outlook.

A move by the Legislature to close the Medicaid gap for hundreds of thousands of uninsured and underinsured Tennesseans would help her situation dramatically, she explains.

“From a person who’s going through that, it’s scary because health is something you don’t want to play with,” she adds. “You only live once.”

Rallying for change

Pro-expansion activists filled the Capitol on the opening day of the legislative session wearing purple T-shirts and urging the lawmakers to expand Medicaid through its TennCare program to cover more Tennesseans. They’d like to see a revival of Gov. Bill Haslam’s Insure Tennessee, a plan designed to use more than $1 billion annually from taxes paid to the federal government to set up a market-based plan for recipients, an idea incorporating health-savings accounts.

“We’re just here to show our legislators that health care is still a very high-priority issue for the state of Tennessee, and we’re losing money every day that’s going to other states,” says Nashville’s Bill Howell, one of the purple-shirted protesters.

Decatur County Hospital in rural West Tennessee is on the verge of closing, the latest victim of Tennessee’s insurance failure, and he notes more are likely to follow if the Legislature and Washington fail to act.

Yet another joining the rally cry, Christina Norris, echoes Howell’s concerns about rural hospitals closing, with Decatur County Hospital the 10th set to shutter.

“Even Republican legislators are saying now it’s because we have not taken the federal dollars that have been offered. And if we took the money that has been offered we would have a lot more jobs, thousands more jobs in Tennessee, put money into the economy. So, it’s about jobs, dollars and health care,” says Norris, a retired disability lawyer from Nashville.

Knoxville resident John Stewart, the father of Democratic state Rep. Mike Stewart, also points out health care is the No. 1 issue in Tennessee based on the most recent Vanderbilt poll and could become a factor in the 2018 elections.

“It’s an open question whether anything’s going to happen this year,” Stewart says of Medicaid expansion. “But I can say it was the determinative issue in the Virginia elections, and we think that sets a political environment where things are much more hopeful than they were.”

In Virginia, a Democratic Lt. Gov. Ralph S. Northam raced past Republican Ed Gillespie for the governor’s seat.

Renewing the call

House Minority Leader Craig Fitzhugh, a Democratic gubernatorial candidate from rural Ripley in West Tennessee, “set a tone” for the legislation session of “affordable, accessible health care for Tennesseans.”

Fitzhugh contends no matter what direction the federal government takes, even if it comes in the form of block grants, Tennessee will be better prepared to handle it by working toward expansion. He put the Republican-controlled House on notice that Democrats, “the Fighting 25,” are ready to stand behind Gov. Haslam no matter what he proposes this session.

Fitzhugh took some razzing from House Majority Leader Glen Casada for his “gubernatorial speech” and other Republicans who say he’s already turning the matter into a partisan fight.

Yet both parties are clearly on opposite sides.

“Two years ago, we debated this issue, and we as conservatives realized government-focused, government-centered health care not only is a failure, it drives up our lovely insurance premiums, it runs hospitals out and it makes the delivery of health care more expensive,” Casada says.

In the very next sentence, though, Casada adds Republicans voted against Insure Tennessee and participating in the Affordable Care Act because it was “good public policy” and kept hospitals open and health-care costs and insurance premiums down.

No doubt, providing health insurance for a large group of unhealthy people is expensive, which is why Tennessee’s carriers jacked up their premiums and some dropped out of the game. But Tennessee opted not to take $1.2 billion for three years in a row, with many lawmakers saying they didn’t want to kick people off TennCare rolls if the feds wound up reneging on the deal.

Fitzhugh says it’s pretty plain to see Tennessee isn’t keeping hospitals open or holding down insurance costs.

Even a senior member of the House, Republican Rep. Steve McDaniel from Parkers Crossroads, acknowledges Decatur County Hospital in his rural district would be able to continue operating if the state had expanded Medicaid and taken the federal dollars.

“I don’t know that the mood in the Legislature is to act on Medicaid expansion, but I think it needs to be brought before the people and brought before the members of the General Assembly to remind them that that option is out there and that we have real problems that that might help solve,” explains McDaniel, who is set to step down after this session.

McDaniel says he’s seen no “evidence that it’s too dangerous financially” to turn him off to the idea of Medicaid expansion.

House Speaker Beth Harwell and Lt. Gov. Randy McNally, though, are standing firm against Medicaid expansion unless the feds send a block grant here and Tennessee can design its own program.

McNally says he believes Medicaid expansion would hurt the state’s budget. “I don’t think it’ll pass in the Senate. I’m surprised the House would consider it,” he notes.

Rural hospitals are hampered by the high number or Medicaid/TennCare patients, whereas urban hospitals can survive those without insurance because they have a higher percentage of patients with coverage, McNally points out.

Asked how those rural hospitals get some kind of infusion to keep operating, McNally says, “I don’t know if it’s the state’s problem to make sure that private businesses stay alive.”

While the state has an “obligation” to ensure quality health care in rural areas, he continues, the best way is to encourage rural hospitals to become triage units for patients who aren’t critically ill and send those with special needs to hospitals capable of providing greater levels of care.

This is nothing new. Rural Tennesseans have been going to big-city hospitals for decades for major operations. When someone in Perry County needs heart surgery they usually go to St. Thomas in Nashville and so forth.

Likewise, Harwell, a Republican gubernatorial candidate, says she believes Tennessee would’ve gotten into financial trouble if it had expanded Medicaid two years ago. Other states that expanded are pulling back, she adds, because it consumes their budget.

“We are kind of in suspension because we don’t know what the federal government is going to do,” Harwell points out.

After the federal tax bill eliminated an insurance mandate set up under the Affordable Care Act, she says she wonders if Obamacare will exist much longer.

Some movement

A House panel convened by Harwell sent a Three-Star Healthy report to the governor for his consideration, one she says will give the state a “great foundation” if the feds offer some flexibility for a new program.

The Three-Star Healthy, though, appears to do many of the same things Insure Tennessee did to catch people in the gap between TennCare and the Affordable Care Act but over a longer time frame.

Meanwhile, Harwell, a Nashville Republican, and Rep. Dan Howell, a Republican from Georgetown in southeast Tennessee, are filing legislation directing the state to seek a waiver instituting work requirements for TennCare enrollees.

Harwell acknowledges the bill is “about lifting people out of poverty, while still providing the support needed” to be prosperous.

The measure would place reasonable work requirements on able-bodied, working-age adults without dependent children under age 6.

Also, recognizing the state has a problem, Republican Rep. Judd Matheny of Tullahoma is planning legislation increase payments to Medicare providers from managed care organizations and to force TennCare to pay for any operation approved by Medicaid and Medicare.

Fitzhugh explains he has no problem with either of those proposals, but he says Harwell’s work requirement won’t make much impact because TennCare covers only disabled people, pregnant women and women with young children. In fact, such legislation could require some women to go to work and then pay for child care, which doesn’t make much financial sense, he points out.

“I’d be for it if she would expand her waiver to include the expansion population. I’ve got no problem with work requirements there at all or co-pays. This is just sort of a feel-good measure or political measure,” Fitzhugh says.

The analysis

People have been rallying and protesting about insurance at the Capitol for three years, much of it falling on deaf ears in the Republican-controlled houses. Even when individual marketplace premiums tripled heading into 2018, the Legislature sat on its hands, after a few Democrats called for decisive action more than a year earlier.

Based on the comments of Harwell and McNally, the Legislature won’t do anything major this year, either, unless President Donald Trump and Congress finally put together something sensible – or nonsensical.

At least Harwell has her Three Star Healthy plan prepared, even if it’s not quite as bold as Insure Tennessee.

Amid that semi-paralysis, people in Felicity Palma’s situation are waiting, getting sicker every day in a society where, she says, “you’re not allowed to say you’re sick. You have to perform.”

Sam Stockard is a Nashville-based reporter covering the Legislature for the Nashville Ledger, Memphis Daily News, Knoxville Ledger and Hamilton County Herald. He can be reached at