GOP leaders are content in this year's legislative session to support Republican Gov. Bill Haslam's decision not to expand Tennessee's Medicaid program for the poor.
But Democratic lawmakers say they intend to spotlight the issue in every possible way when legislators return to the state Capitol on Tuesday.
House Minority Leader Craig Fitzhugh, D-Ripley, said thousands of Tennesseans are losing out on needed health care benefits and struggling hospitals are missing out on an infusion of about $2.3 million of federal money per day in the last half of the 2013-14 fiscal year.
Democrats will do whatever they can "to try to convince people that this is the right thing to do," Fitzhugh said about pushing for Medicaid expansion. "We're going to try do our best to get a budget hearing or an amendment."
The expansion for people who earn up to 138 percent of the federal poverty level took place Jan. 1 in 25 states under President Barack Obama's Affordable Care Act. But in 23 states, including Tennessee, Republican governors refused to go along after the U.S. Supreme Court left expansion up to state leaders. Two other states hope to move forward with expansion after 2014, according to the Kaiser Family Foundation.
Haslam says he is holding out for federal permission to cut the costs of expansion, which the state estimates would cover an estimated 180,000 people. The federal government is paying the entire tab for the first three years. In fiscal 2014-2015, Tennessee would gain about $1 billion. The state would gradually pick up a share after that, topping out at 10 percent.
Citing budget constraints and the need to keep TennCare, the state's version of Medicaid, under tight rein, Haslam says he needs changes in federal Medicaid rules to protect Tennessee's fiscal health.
The governor says he wants to control expenditures better, for example, by increasing co-pays for unnecessary emergency room visits and encouraging enrollees to embrace healthy behavior.
The state estimates expansion would cost $200 million over the program's first 5 1/2 years. After fiscal 2019, it would "cost in excess of $100 million" per year, TennCare spokeswoman Kelly Gunderson said. The state's share of the $10 billion program now is about $3 billion, Health Care Finance and Administration figures show.
Top House and Senate Republicans back Haslam's play and will oppose minority Democrats' efforts.
Lawmakers need to be "intellectually honest" with Tennesseans, said House Speaker Beth Harwell, R-Nashville. If Democrats push expansion, she said, she will ask them what taxes they will increase or what services they will cut to pay for it.
According to TennCare estimates, expanding Medicaid would bring Tennessee some $6.4 billion in new money through the end of fiscal 2019. Hospital executives have warned that some rural hospitals will go under because other parts of the federal law slash special Medicare payments.
"We're talking about businesses leaving counties" and businesses "not looking to locate in small communities," said House Democratic Caucus Chairman Mike Turner of Nashville.
If rural hospitals close, smaller communities face difficulties, Harwell acknowledged. But Obamacare is not really reforming the massive health care system, she said, and rural residents these days have "easy access" to hospitals in major cities like Chattanooga, Nashville, Knoxville and Memphis. It's time to "rethink" what services rural hospitals provide, she said.
Contact Andy Sher at asher@times freepress.com or 615-255-0550.