NASHVILLE — As 2014 rolls in, millions of low-income Americans in 26 states will become eligible to join their states' Medicaid health programs under the federal Affordable Care Act.
But here in Tennessee at least 144,000 low-income people won't get that chance.
Republican Gov. Bill Haslam has declined so far to accept 100 percent federal funding to expand TennCare, the state's Medicaid program, and continues to press federal officials for a special deal he says will save the state money and deliver better health care results.
Georgia Gov. Nathan Deal and Alabama Gov. Robert Bentley are among other Republicans governors who also have turned down the expansion, optional under a U.S. Supreme Court ruling.
Tennessee Republican legislative leaders back Haslam, arguing that while Uncle Sam pays the full bill during the first three years of Obamacare, future expenses would fall increasingly on the state.
"It would be an easy decision for us to go ahead with the federal government paying for all of it and let future legislatures worry about paying for it when the bills come in," House Majority Leader Gerald McCormick, R-Chattanooga, said last week. "And they are going to come in, and they're always bigger than the federal government estimates."
The Affordable Care Act says the feds will pay 90 percent of the tab for Medicaid expansion after the first three years.
House Democratic Caucus Chairman Mike Turner, of Nashville, said it's "unfortunate" that Republicans "are not not trying to represent all Tennesseans."
"They're playing to their radical base. I think moderate Republicans are in favor of expanding Medicaid," Turner said.
A Vanderbilt University survey of 860 registered voters this month found 63 percent backed expanding Medicaid to those with incomes below 138 percent of the federal poverty level ($15,856 for an individual and $32,499 for a family of four).
Eighty-nine percent of Democrats and 64 percent of independents favored expansion, compared with just 42 percent of Republicans. The poll's margin of error was 4.1 percent.
Noting Republicans dominate the state House and Senate, Turner said, "When you're lucky enough to be blessed to be in a position of power, the chance to really do something great for somebody only comes along every so often. Sometimes it takes courage to do it."
TennCare estimates 144,000 would join the program the first year, with the number rising to 181,000 by the 2019 fiscal year. A White House website puts the figure at 245,000.
McCormick and other House GOP leaders spoke with reporters last week at the state Capitol. Republican Caucus Chairman Glen Casada, R-Franklin, also defended Haslam.
"I feel passionately that expanding Medicaid would be an economic mistake," Casada said. "And so, granted, 180,000 maybe suffer because they're not covered. But in two years, we as legislators will have to come back to the state of Tennessee and ask six and a half million people for more of their money."
He said the state's "bare-bones minimum" liability by year three is $200 million or more.
"That's money we just don't have. And so we're being guardians of the taxpayer dollars by not committing to something we don't have the money for," Casada said.
Last year, the TennCare Bureau cited a $199.1 million price tag for expansion over 5 1/2s years.
But the state also projects it will have to spend $78 million in the coming fiscal year to provide Medicaid coverage for 52,000 Tennesseans already eligible for TennCare but not enrolled. Officials expect them to joinsbecause of the federal health law's mandate that most people have health coverage.
The Tennessee Hospital Association says the expansion would bring the state some $6 billion over the 5 1/2 years. Hospitals say they badly need the money to make up for hospital reimbursements in other areas. Without it, some hospitals may go under and others face major cuts, the hospital association has warned.
Haslam and state Republican lawmakers, however, say there are no guarantees the federal government will maintain its commitment, given U.S. deficits.
The governor is less opposed to the expansion than many state Republicans and has said he has a "very difficult needle to thread" on what he calls his Tennessee Plan for expansion. Haslam wants to use Medicaid expansion funds to pay for coverage through the online insurance exchanges.
While it's too late to do the expansion in 2014 -- meaning the state will lose $1.4 billion in federal funds -- the governor says if he gets what he wants, it can occur in 2015.
He said his administration has been in talks with the feds for months, but it was just this month that he sent a written proposal to U.S. Health and Human Services Secretary Kathleen Sebelius. And he has yet to submit a formal request for a waiver of federal Medicaid rules with a specific outline of what he plans to do.
Earlier this month, House Minority Leader Craig Fitzhugh, D-Ripley, called Haslam's letter the "latest in a series of farces."
"It's more of the same hand-wringing, ducking and dodging we've come to expect from this administration, all in an attempt to absolve themselves of the worst moral and mathematical failure in a generation -- denying health care to 330,000," Fitzhugh fumed.
Republican Senate Speaker Ron Ramsey, of Blountville, dismissed the recent Vanderbilt poll.
"I haven't seen the question, but I bet it did not say, 'Would you be willing for your taxes to go up,' or other areas to fund the Medicaid expansion."
Ramsey said, "I understand the humanitarian part, that you want more people to have health care coverage. I understand that.
"But the way this all came about, the American Hospital Association sat down with the Obama administration and said we will take less reimbursement in Medicaid if you require the states to expand their Medicaid rolls. They all shook hands and walked off, and there we were."
Then came the Supreme Court ruling making expansion voluntary.
"So what's the solution here?" Ramsey asked. "You go back to the one you shook hands with -- the Obama administration -- and say, look, we made this deal that's not working very well.
"You don't come to us and make us as a state look like the bad guy, when we didn't shake hands, we weren't in on the deal."
Contact staff writer Andy Sher at asher@timesfree press.com or 615-255-0550.
Andy Sher is a Nashville-based staff writer covering Tennessee state government and politics for the Times Free Press. A Washington correspondent from 1999-2005 for the Times Free Press, Andy previously headed up state Capitol coverage for The Chattanooga Times, worked as a state Capitol reporter for The Nashville Banner and was a contributor to The Tennessee Journal, among other publications. Andy worked for 17 years at The Chattanooga Times covering police, health care, county government, ...