NASHVILLE - Tennessee officials received nearly 1,800 public comments - most of it overwhelmingly negative - on Gov. Bill Lee's controversial plan to convert most federal financial support for the state's TennCare Medicaid health insurance program into a block grant.
The block grant would mean fewer rules on how the $12.1 billion program covers 1.4 million low-income residents.
In all, the state received 1,769 comments over a 30-day period that ended Oct. 18, TennCare spokeswoman Sara Tanksley said. The comments came from emails and five public hearings, including one last month in Chattanooga. In all, the emails amounted to 2,272 pages.
Only nine comments from seven individuals and two organizations - one of them from Chattanooga-based insurer BlueCross BlueShield of Tennessee and one from a Florida-based conservative lobby group - offered explicit support. But BlueCross did have an issue on one provision.
Lee is developing the waiver of federal Medicaid rules at the direction of fellow Republicans, who control the state Legislature.
He is seeking to convert some $7.9 billion of TennCare's federal funding into the hybrid block grant. He also is pushing a big ask of the Trump administration, which hopes to use block grants to cut federal Medicaid expenditures.
He's arguing that under TennCare's managed care approach, Tennessee is already saving the federal government $2 billion annually versus if the state ran a traditional Medicaid fee-for-service program.
The governor hopes to negotiate getting upward of half that - as much as $1 billion a year - to use for TennCare and other health initiatives in Lee's drive to improve health services and outcomes and assist rural parts of the state.
Tennessee's proposal also "carves out" some major areas from the waiver, leaving them as they are. That includes people eligible for both Medicare, the federal program for seniors, and Medicaid.
So far, both Lee and administration officials have downplayed negative comments.
But officials do plan to make some changes to the proposed Section 1115 Medicaid waiver they must submit to the federal Centers for Medicare and Medicaid Services (CMS) by Nov. 20.
"I think CMS knows that this would be a really good thing for Tennessee and Tennesseans," Lee told reporters last week, pointing to the Trump administration's support of block grants for the Medicaid health care program for low-income children, caretakers, pregnant women, seniors and the disabled. "It's why they want to work with us to get this done.
"We certainly know as well we take all of those [critical] comments and listen to them and determine if, how they might impact our approach to CMS. But I'm very encouraged about the opportunity we have here," Lee added.
But he also injected a degree of doubt on whether his effort will win approval.
"But if we do," he said, "Tennesseans are going to be grateful for that. I believe that they see what it's going to provide for our population."
Earlier this month, Lee characterized opposition to his proposal as coming from people who are "misinformed or [have] not taken the time to really understand it."
Reaction in Chattanooga
At least 75 Hamilton County residents submitted comment, most of them against the plan, and at least 40 others spoke out during the state's October public hearing in Chattanooga.
Many were sharply critical or, in a number of cases, filled with concern and even fear of what it would mean for them.
"I am a disabled individual who worked hard and sacrificed a lot to finally get on the [federal Supplemental Security Income] program and receive Medicaid," wrote Kale Sartor, of Chattanooga. "I need frequent treatments that I would not be able to afford out of pocket, and sometimes I require expensive testing."
Without Medicaid coverage, Sartor added, "I will not be able to get the care I need. Many others like me, disabled, elderly and children, are the weakest among the population. Medicaid block grants would strip away the already very limited protections we have."
Another Chattanoogan, Kacey Carson, wrote: "My family, my children and myself, rely on TennCare and the blatant disregard for people and their health is appalling and the most inconsiderate thing about this."
Charles McCullough, of East Ridge, was the only county resident to endorse the plan in emailed comments to TennCare, saying: "I fully support the block grant proposal. Cost savings and fraud reductions are imperative in any government program."
BlueCross BlueShield was generally supportive, as well, noting that the nonprofit insurer has been a key part of TennCare's managed care approach since the program's 1994 inception.
Lee's waiver creates "a novel approach to the traditional Medicaid block grant concept," wrote Amber Cambron, CEO of BlueCross BlueShield's BlueCare Tennessee program, the company's TennCare managed care organization.
The approach "protects the state from significant financial risk from future economic uncertainty, preserves key programs by thoughtfully crafting the scope of the block grant, and promotes innovation in health care within the state by requesting flexibility to innovate through policy changes and invest shared savings from the program in key activities to pave the way for future improvements in public health," she wrote.
Still, Cambron did have at least one ask in her comments: "We also respectfully offer a comment on the state's request to remove the requirement for federal approval of the state's capitation rates."
Capitation payments are used by managed care organizations to control health care costs.
"We request that the state continue to abide by the section of the federal regulations that requires that CMS review and approve capitation rates paid to Medicaid managed care contractor," Cambron wrote.
Many of the critical comments across the state mirrored those from Chattanooga. Those included many commenters lambasting Republicans for refusing to expand Medicaid to an estimated 300,000 uninsured working-age Tennesseans under the federal Affordable Care Act, also known as Obamacare.
And many also noted that the shuttering of 12 hospitals across rural Tennessee since 2010 - it's the second largest number in the nation - could have been avoided if Medicaid had been expanded.
Among the nine positive commenters was the Opportunity Solutions Project, the lobbying arm of a conservative Florida-based research institution, the Foundation for Government Accountability.
The Opportunity Solutions Project, which hired and paid a Tennessee-based lobbyist between $25,000 and $50,000 this year on welfare and health care issues, called Lee's plan an "innovative proposal that will preserve Tennessee resources for the truly needy and taxpayers, and protect the program from fraud and abuse."
Several groups such as the Tennessee Hospital Association spoke favorably of the waiver, but the association also wants to hear more on just how the proposed shared-savings provision could benefit providers and also on protections for provider rates. The group is asking for a future public comment opportunity if an agreement is struck with the Trump administration.
The Tennessee Justice Center, a Nashville-based nonprofit advocacy group and law firm advocating on TennCare issues, strongly opposes the block grant proposal. The center submitted a critical comment and also created a portal through which critics could funnel their criticisms to the state site.
Hundreds took advantage of that, many of them using a Tennessee Justice Center submission form but a good number of those personalizing it with their own stories and perspectives.
Tennessee Justice Center Executive Director Michele Johnson said she found it significant that only BlueCross BlueShield among TennCare's three managed care organizations submitted favorable comments.
She argued that "you can't get people who are in business to say it's a good idea. The reason is it makes [TennCare] financially unstable."
In response to criticism from groups, TennCare Director Gabe Roberts said the administration is "already making some clarifications," including pharmaceutical manufacturers, which objected to the state's waiver request to reduce drug formularies in some cases to just one drug.
"We're committed that there won't be eligibility cuts, there won't be benefit limits that'll be put on as a result of this," Roberts said. "Because we believe this will actually provide more, not fewer, federal dollars into our program. Which in turn means we can provide more services to the folks we're covering - and potentially cover."
Lee, who has said he won't pursue final approval of the waiver if he doesn't think it benefits Tennesseans, has not ruled out extending health coverage to at least some uninsured Tennesseansshould the state drawn down enough money through his shared cost savings proposal.
Contact Andy Sher at email@example.com or 615-255-0550. Follow on Twitter @AndySher1.