NASHVILLE -- Republican House Speaker Beth Harwell and Senate Speaker Ron Ramsey voiced skepticism Tuesday over expanding Medicaid coverage to thousands of Tennesseans under the federal health care law.
But the leaders aren't quite ready to rule it out, saying they need more time to study the issue.
President Barack Obama's Affordable Care Act provides new money to states that expand Medicaid programs such as TennCare to millions of low-income people at mostly federal expense.
In Tennessee, as many as 330,000 new people could qualify, with the federal government picking up 100 percent of the tab the first three years, decreasing to a 90 percent share in 2019 and thereafter.
Republican Gov. Bill Haslam, who on Monday rejected creating a state-run health insurance exchange, has said he hasn't decided yet on the Medicaid expansion. Among his concerns are that the federal government at any time could cut the funding, leaving the state on the hook financially for the expanded enrollees.
The federal government now provides 65 cents of each dollar Tennessee spends on TennCare.
Harwell and Ramsey voiced similar worries Tuesday.
"I don't think we're going to go that way," Harwell said of the expansion. "I think it would leave our state vulnerable after they [the federal government] run out of money."
Still, Harwell added, she is "open to learn more facts about this situation."
Ramsey, too, harbors doubts the federal government's promised extra funding will remain at the same levels if it survives at all.
"On the surface, I'd have to say it [expansion] is a bad idea," Ramsey said.
He recalled how then-Democratic Gov. Phil Bredesen was forced to slash TennCare in 2005 because the state's mid-1990s expansion of the program was financially unsustainable. An estimated 200,000 Tennesseans lost their coverage.
The Senate speaker noted that Haslam took one of the federal Affordable Care Act controversies off the table Monday by rejecting a state-run health insurance exchange in favor of having the federal government operate the online insurance marketplace for non-Medicaid eligible, low-income people.
That leaves the Medicaid expansion. While voicing skepticism the federal government would keep up its end of the bargain, Ramsey said he nonetheless "will be discussing this. And I'm the kind of person who tries to be pragmatic, tries to study, not just do the political thing but do what's right for the state of Tennessee and taxpayers.
"We'll be studying as we go along, I don't have any more answer than that right now," he said.
On Monday, House Majority Leader Gerald McCormick, R-Chattanooga, applauded the governor's rejection of the exchange, calling it the "right decision." But he said he is only now turning to the TennCare expansion question.
"I think everyone was so focused on the health care exchange issue that people will only now turn to that," McCormick noted. "I will say if it costs the state money we will have to weight that with higher education, prisons and K-12" education.
It boils down to "a matter of priorities ... [and] debate," he said.
Meanwhile, the U.S. Department of Human Services has complicated Republicans' calculations. In its advice to governors, the department says "a state may choose whether and when to expand, and, if a state covers the expansion group, it may decide later to drop the coverage."
It also added another wrinkle. While some Tennessee officials have discussed the possibility of beginning a TennCare expansion by limiting it to residents at or below the federal poverty level, new guidance issued Monday says that's not allowed.
Health and Human Services Secretary Kathleen Sebelius said there will be no half-way measures, noting "the law does not create an option for enhanced match for a partial or phased-in Medicaid expansion to 133 percent of poverty."
Tennessee Hospital Association President Craig Becker, whose members support expansion, said states "obviously" have the option of dropping the expansion population at any time.
"If you find that you can't afford it or can't do it any more, there's an option to get out," Becker said.
He warned that hospitals are "looking down the barrel" at a loss of $4.5 billion over the next 10 years if Tennessee doesn't go along with the TennCare expansion.
That's because the Affordable Care Act eliminates special indigent care payments because the law envisions most Americans will be covered through Medicaid, the health insurance exchanges or their private insurance plans.
Fifty-eight of his group's 124 members already are losing money, he said.
"I am not saying every one of the 58 is in danger of closing, but those are the ones most vulnerable," he said.
Meanwhile, Senate Democratic Caucus Chairman Lowe Finney predicted Haslam won't attempt to expand TennCare, given the governor's decision Monday not to proceed with a state-operated health insurance exchange.
"If the governor doesn't have the votes for exchanges, expanding Medicaid doesn't stand a chance," Finney said.
Haslam faced opposition from fellow Republicans in the GOP-led Legislature, and last week tea party activists urged and one even threatened to find a challenger to Haslam in the 2014 Republican primary if he went along with a state-run exchange.
Contact staff writer Andy Sher at firstname.lastname@example.org or 615-255-0550.