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Obamacare Medicaid Expansion in TN a Tough Sell Among Republicans

Governor will likely have to win legislative authorization for any ACA-related boost in low-income health coverage

Both chambers of the Tennessee General Assembly have passed a measure requiring Gov. Bill Haslam to obtain legislative approval “by joint resolution” for any deal he makes with the federal government to expand Medicaid in the state.

On a 23-6 vote last week, the state Senate passed what sponsor Brian Kelsey has dubbed the “Stop Obamacare Act.” The House OK’d the companion bill Feb. 24 on a 69-24 vote. The House version is sponsored by Jeremy Durham, a Republican from Franklin.

Following the Senate’s vote Thursday, Durham and Kelsey each described the legislation as a big win for opponents of the Patient Protection and Affordable Care Act.

Signing the state up for Medicaid expansion under Obamacare “will definitely be more difficult now, and that was our intent,” Durham told TNReport.

“Making any proposed Medicaid expansion deal go through subcommittee in the House is a very significant hurdle,” said Durham. He called approval of the bill “a very significant victory for the people who do not want Medicaid expansion.”

“I don’t want to take money from schools and roads and projects that we care about to expand a very flawed Medicaid system that doesn’t even provide quality health care,” he said.

Likewise, Kelsey, who was initially pushing to altogether prohibit the state from participating in Medicaid expansion, said after the Senate’s vote that “my hope is Tennessee will not take the bait and cost our taxpayers $200 million.”

Under the Affordable Care Act’s Medicaid expansion provisions, the federal government promises that until 2016 it will pay 100 percent of the costs associated with widening eligibility for government-financed health-care coverage for the poor. After that, the state’s portion of the bill will begin ticking incrementally upward until 2020, when it tops out at 10 percent.

Kelsey argues that not only can the state ill afford allocating budget resources to pay for Medicaid expansion — at least absent a tax increase or cuts to existing programs — but that the federal government can’t be trusted to pay its share of the expansion over the long term.

“The Affordable Care Act has been broken promise after broken promise,” said the Germantown Republican. “The president told us we could keep our health care plans and keep our doctors if we wanted them. That was a broken promise. The administration promised that use of emergency rooms would decrease with expansion of Medicaid. That was a broken promise — they actually increased 40 percent in Oregon. And now they promise they will pay 90 percent of the costs going forward, and I feel that that will also be a broken promise.”

As with during House discussion on the legislation last month, Democrats in the state Senate tried unsuccessfully to tack on amendments to immediately initiate health coverage for certain groups who’ll become eligible if full expansion ever occurs — like low-income veterans and Tennesseans suffering long-term illnesses and disabilities.

Only one amendment was adopted by the Senate — an addition offered by Minority Leader Jim Kyle, D-Memphis, stipulating that if members of the General Assembly are called back to Nashville for a special session to discuss a Haslam-negotiated Medicaid expansion deal, lawmakers won’t get paid per diem. That provision is not contained in the House version and will require lower-chamber concurrence before the legislation heads to the governor’s desk.

Durham said he regards Kyle’s per diem amendment as “kind of petty,” but will nonetheless recommend that the House agree to it.

Asked if he thinks there’s any chance Haslam will reach an agreement with the federal government on Medicaid expansion that would be palatable to enough Republicans to win approval in the Legislature, Lt. Gov. Ron Ramsey said, “There is a possibility there.”

The likelihood, however, “is far-fetched,” he added.

“I don’t think the federal government wants to give flexibility,” said Ramsey, R-Blountville. “They don’t trust the Republican leadership of the state of Tennessee to take care of the medical needs. They don’t trust us and they think there is something sinister about that, so I don’t think we will ever reach that agreement. But is there a possibility that we could reach that agreement? Yes.”

Haslam has said for months that he’s trying to formulate a government-financed medical coverage system for lower income Tennesseans that both controls health care costs and promotes patient responsibility — one that is agreeable to the Obama administration and Republicans who control the Tennessee Legislature.

Democrats have tried to head-off the Legislature imposing any additional procedural roadblocks to Medicaid expansion, which they argue will grant much-needed access to health care coverage for thousands of needy Tennesseans. They’ve argued that requiring Haslam to obtain legislative approval shows a lack of trust in the governor. “If you vote for this bill you are voting against the (Haslam) administration,” Kyle said on the Senate floor Thursday.

Senate Majority Leader Mark Norris, R-Collierville, said there’s actually nothing in the legislation that prohibits the governor from negotiating with the Obama administration how ever he sees fit. All that’s required is that whatever Gov. Haslam and his policy advisers settle on with the feds has to gain the Tennessee Legislature’s approval as well, he said.

Democrats have trust issues of their own with the Haslam administration. Last month the governor asked U.S. Secretary of Health and Human Services Kathleen Sebelius to give Tennessee guidance on a what sort of unique Medicaid expansion initiative the federal government might approve, beyond what’s outlined in the Affordable Care Act. Members of the Legislature’s minority party took that as evidence the governor hasn’t made much progress developing a politically viable “Tennessee Plan,” as he’s promised is in the works.

Senate Democratic Caucus Chairman Lowe Finney suggested that making Haslam seek approval from the GOP-dominated General Assembly actually provides him political cover if he can’t or doesn’t end up producing a Medicaid expansion agreement.

“I don’t quite see this bill as tying the governor’s hands as much as I see it giving the governor an out on this issue,” said Finney.

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