NASHVILLE - Gov. Bill Haslam concedes he has a "very difficult needle to thread" in persuading fellow Republicans in the state Legislature and the Democratic Obama administration to accept his plan to expand Medicaid for at least 180,000 Tennesseans.
"Well, that's the challenge, I mean just to be really frank with you," Haslam told reporters Wednesday. "That's the challenge and that's why it's been eight months. We keep having those conversations to see if we can come up with something that we think again that Tennessee will approve and that they [Obama administration] will accept."
Haslam's comments came as he grappled with blow-back from statements by U.S. Secretary of Human Services Secretary Kathleen Sebelius last week and by state Senate Speaker Ron Ramsey on Monday.
Sebelius told reporters in Memphis that months after Haslam announced his "Tennessee plan" to expand TennCare, the state's version of Medicaid, "We don't have specifics from the governor's office."
"There are lots of conversations," she added. "I talked to the governor probably three or four times directly. I know that our Medicaid staff is in close communication with Medicaid staff here at the state. We would love to work with Tennessee around Medicaid expansion."
Ramsey told state Capitol reporters he "would absolutely love to see a middle plan" like Haslam has proposed, "where people would be covered -- but they have to pay co-payments, that they have to limit the number of doctor visits they can make, that they have to have some personal responsibility on their own to follow a health plan and lose weight."
But, he said, "this [Obama] administration is not going to let that happen."
He thinks Haslam is "wasting his time," Ramsey said.
Expanding Medicaid to single low-income adult men and women with incomes of up to 138 percent of the federal poverty level is a key element of the Affordable Care Act. But the U.S. Supreme Court said states can decide whether to expand their Medicaid programs. If they don't, many of their poorest citizens may be left in the cold.
Asked about Sebelius' remarks, Haslam said his administration "presented a specific plan."
"What I told them is I'm not going to waste your time with a plan that I can't get approved in Tennessee and that I know that you all [Obama officials] won't accept."
The governor said "it's not right say we haven't had some specific conversations." Among them, he said, is how to define "medically frail."
That issue has assumed major importance in Haslam's plan to use Medicaid expansion money to buy the poor affordable private coverage on the online insurance exchanges.
Haslam wants the Medicaid expansion population to be treated like others in the exchanges. But Medicaid rules are very specific about things like providing "wrap-around" services like transportation.
Tennessee-based Medicaid experts question whether the federal government will give on that or other proposals, such as higher co-pays for services that everyone else in the exchanges will pay.
The governor also is finding it harder in Washington to implement cost-cutting measures for providers.
Asked about Ramsey's comments, Haslam said "that probably speaks a little bit to the difficulty, quite frankly."
He acknowledged that even if expansion is approved, it probably won't take effect in 2014. Ramsey has suggested it could take two years.
Beginning next year, the federal government will pay the expansion's entire cost for the first three years and 90 percent thereafter.
Meanwhile, Tennessee's hospital industry says that losing the Medicaid expansion will force hospitals into big-time cuts because their special Medicare payments for handling nonpaying poorer patients are getting slashed.
"I realize the difficult situation they're in," Haslam said, noting he plans to meet with hospital executives again later this month. "But again, we have a very difficult needle to thread here."
Twenty-five states and the District of Columbia have so far approved expanding their Medicaid programs. The vast majority of these have Democratic governors, although Ohio last month joined three other GOP-led states in extending Medicaid to single adult men and women.
Contact staff writer Andy Sher at firstname.lastname@example.org or 615-255-0550.