Gov. Bill Haslam listens to a question after a speech to a Republican group in Nashville, Tenn., on Dec. 4.The lamentable spectacle of witless state legislators and myopic protesters urging Gov. Haslam not to establish a state insurance exchange in accord with the Affordable Care Act is sad enough. But if they shun that responsibility and leave it to the federal government to create the state’s exchange with higher standards and more competitive comprehensive policies, so be it. That might well be better for the huge number of uninsured Tennesseans who need and deserve access to affordable, comprehensive health insurance.
The larger risk is that Gov. Haslam will refuse to extend Medicaid to people whose income falls between 100 percent and 133 percent of the federal poverty level, and with that action blow off $7.5 billion in federal grants that would come in the first five years alone to support expansion of Medicaid for the most needy Tennesseans. This would be a cruel and heartless travesty, all in the name of blind resentment toward the national health care reform championed, and achieved at long last, by President Obama.
The isolation of people with incomes between 100-and-133 percent of the federal poverty level is an anomaly of the ACA, which envisioned — and tried to mandate — expansion of Medicaid to the typically uninsured people in this income group. That seemed fair when the ACA was written. The federal government provides two-thirds of Medicaid funds; the state, the other third. People with incomes above the 133 percent of poverty level cut-off were made eligible under the ACA for wage-adjusted subsidies to help them buy the flat-rate, comprehensive care insurance that will be available to all comers under the competitive, non-profit policies offered through state exchanges beginning in January 2014.
The Supreme Court’s June 28 decision approving the ACA, however, negated the federal mandate to states to expand Medicaid. That left it up to states to decide whether to voluntarily enlarge the Medicaid pool, and accept the increased portion of Medicaid funding that would come for that new group of members. The new federal grants for that would be sizable: 100 percent of the increased cost for the first three years, declining to 90 percent after that, and remaining at that point.
The logic for accepting Medicaid expansion is irrefutable. It would ensure preventive care for a significant group of people who otherwise opt for emergency-room care, which is a far more expensive and far less efficient way to obtain health care. It would actually save the state and insured citizens money by vastly reducing the cost-shifting of indigent-care costs for this segment of citizens to government and insurance premiums.