Tennessee's population is one of the nation's sickest, and we lead the country in kicking kids off Medicaid — in our case, TennCare, the state's insurance for the poor. We also are 10th in the U.S. for residents who in debt because of medical costs.
Yet our Republican governor is following the conservative direction of Tennessee's supermajority GOP General Assembly — seeking to be the first state to give the Trump administration one of the things it wants most in the world: To slash Medicaid spending through block grants — a strategy conservatives in Congress have repeatedly tried to implement without success. Until now, the tricky part was persuading states to accept fewer federal dollars long term than they're getting now under the Affordable Care Act — aka Obamacare.
Tennessee, however, has ponied right up, trotting out the argument that states can do it better if you give us "flexibility."
There's a catch. Saving money with block grant "flexibility" almost inevitably means carving new big holes in our health care safety net. Holes like redefining pre-existing conditions — not necessarily by saying TennCare won't cover asthma or diabetes, but rather by saying the insurance for 1.4 million of us won't cover the same equipment or the best medications as required by the current contract.
If you are worried — and you should be — today at 2 p.m. at the downtown Chattanooga Public Library is pretty much your last chance to voice concerns.
The state's official public input period on the block grant proposal ends on Friday. Based on feedback, the state could make tweaks to the waiver proposal our officials submitted on Sept. 17. State officials say they plan to submit the final block grant waiver to the Centers for Medicare & Medicaid Services sometime between early to mid-November. CMS is the part of the U.S. Department of Health and Human Services that oversees many federal health care programs, including Medicare and Medicaid, the federal government's 50-year-old agreement with states to pay for safety-net insurance for the poor.
The 1.4 million Tennesseans — one in five of us — enrolled in some form of TennCare seem destined to be guinea pigs of Republican politicians pretending to be fiscal conservatives.
In Hamilton County, about 65,770 residents are enrolled in TennCare. Nearly 90% (57,012) are women and children. The remainder are nearly all elderly, blind or have severe disabilities. This isn't a program for people who don't want to work. It's largely a program for people who cannot work or work where insurance isn't offered.
But in a nutshell, Gov. Bill Lee's proposal volunteers the Volunteer State to be the nation's first test case of how far the Trump administration is willing to go to allow a state "flexibility" on health care "entitlements." But flexibility is just code for what-can-we-not-cover.
Doctors are on the fence, not flocking to support the move. Tennessee hospitals are "cautiously optimistic," but also have concerns. Yet, with state officials driving, it seems we're careening toward trading in an OK but not great TennCare waiver for an inferior one that lets the federal government off the hook for its ACA guarantee of a continuing 2-1 Medicaid spending match. In its place, we'll take a block grant that forever caps the amount of federal dollars we can use for Tennessee health care.
Here's how this works. In April, the feds spent $7.5 billion (our tax dollars) in Tennessee to pay for two thirds of our state-provided health care. Under that ACA federal agreement, if health care costs go up for whatever reason — an increase in low-income enrollees, tornado injuries, pandemics, whatever — the federal government share must rise accordingly to cover two-thirds of the cost.
Under Lee's "block grant" arrangement, Washington will send back to us $7.9 billion of our tax dollars annually. If our costs increase — as they always have — that's for us to make up at the state level. If our costs go down — think "flexibility" — the state coffers "share" in the federal savings.
Remember: These are the same math savants who never took advantage of the federal ACA provision to expand Medicaid to cover an estimated 300,000 working adult men and women in Tennessee. Had we done that, then the federal government would have used the tax dollars we've already paid to pick up 90% of the cost. Repeat, 90%.
These are also the same math whizzes who last year pushed TennCare work requirements to save an estimated $3.6 million. Problem? The fiscal note prepared by the Legislature's Fiscal Review Committee estimated the actual price tag would include an additional $22.3 million in expenditures for case management costs (figuring out who to kick off). Minus the estimated state savings from disenrollments, based on the program starting in 2020, we'd spend an additional $18.7 million to save $3.6 million.
These also are the same tender hearts who pushed our state's administration over the past two years to drop the health insurance coverage of 130,000 low-income Tennessee children — including 5,500 in Hamilton County. That meant that during the same period when Tennessee claimed the seventh fastest growing economy of any U.S. state, we ranked No. 1 in disenrolling children from Medicaid and TennCare, leaving them without any form of insurance.
Don't let your voice go unheard. Be at the Public Library today at 2 p.m.