NASHVILLE Salesman Bill Haslam was in high gear last week, urging Tennessee county mayors to get on board with his Insure Tennessee proposal as he also worked to persuade the GOP-led Legislature to OK his conservative take on expanding Medicaid.
"It's a real opportunity to say, here's what we think health care should look like," the Republican governor explained to several dozen county leaders during their winter gathering in Nashville.
It didn't take much convincing for Madison County Mayor Jimmy Harris. He thanked Haslam for unveiling his "market-driven" plan.
The two-year pilot project would provide health coverage to as many as 200,000 low-income adults under President Barack Obama's Affordable Care Act. A November poll by Vanderbilt University found 56 percent of registered Tennessee voters surveyed supported expanding Medicaid.
But Harris also offered another reason why lawmakers should pass it, noting most mayors have hospitals "that have been really struggling [financially] for the past few years."
Not one to miss an opening, Haslam agreed, pointing out that hospitals "may be one of your largest employers and critical to your health care needs."
"I would urge you to engage," he said. "We would love to have your voices as part of this."
Though Haslam doesn't have the votes locked up, the hospitals' plight may help push the plan across the finish line.
The annual legislative session starts Jan. 13, and Haslam said he plans to call a special session in late January or early February to consider his plan.
Hospitals say delaying Medicaid expansion already has cost them dearly as the state lost out on hundreds of millions of dollars from the federal government in 2014.
"We've probably had five of them [hospitals] that have gone, basically, or declared they're going to go" out of business, said Craig Becker, Tennessee Hospital Association president. "In many ways, all five of them were in direct reference to that."
That's because the Affordable Care Act, dubbed Obamacare by critics, counted on states to expand their Medicaid programs to cover people with incomes of up to 138 percent of the federal poverty level: $16,100 for an individual. The federal government agreed to pay 100 percent of the cost for the first three years and 90 percent thereafter. At the same time, the law cut or eliminated much federal aid to hospitals for unreimbursed care.
Republican-led states such as Tennessee that said no to expansion saw tens of thousands of poor residents go uncovered by insurance even as the state lost out on the special payments for charity care.
So some Republican governors, and now Haslam, have sought to come up with more-conservative twists. In fact, a Haslam spokeswoman last week insisted to Politico, "We aren't expanding Medicaid. We unveiled Insure Tennessee."
It's taken Haslam nearly two years to get verbal approval from U.S. Health and Human Services officials for his plan. That came Dec. 12.
His two-pronged proposal would offer federally subsidized health coverage under the Affordable Care Act. One portion would offer vouchers that low-income workers could use to participate in employers' insurance plans.
The other is a retooled version of TennCare, the state's Medicaid program. New enrollees will pay modest premiums and copays, and the plan will include incentives for things such as annual health screenings and quitting smoking.
Hospital officials were ready to push TennCare expansion last year but held off when Haslam asked for time to develop a plan that could pass muster with GOP lawmakers and the Obama administration.
His plan also seeks to address critics' concerns about increased state costs beginning in 2017.
Tennessee hospitals have agreed to extend a voluntary 4.5 percent "assessment" on net revenues that generate about $450 million for TennCare annually. Becker said hospitals hope to raise the percentage modestly to generate more money.
And last week, hospitals and some 80 other business and advocacy groups announced they have formed the Coalition for a Healthy Tennessee to push the governor's plan.
After announcing the plan a week ago, Haslam spent much of last week zig-zagging across the state to promote Insure Tennessee with newspaper editorial boards in Chattanooga, Knoxville, Nashville, Memphis and Jackson.
Top Republican leaders, including Senate Speaker Ron Ramsey, House Speaker Beth Harwell and House Majority Leader Gerald McCormick, who is from Chattanooga, have reacted positively but cautiously to the governor's plan.
McCormick said he sees "some good things" in the proposal. "You know we [Republicans] all along ... have said, give us some tools to work with to control costs and add some free-market elements to Medicaid and we'd love to run with it."
But all emphasized they need to see details. Haslam has said he'll copy them when he sends his request for a waiver of federal Medicaid rules.
Though Republicans hold a 28-5 majority in the Senate and a 73-26 lead in the House, no one's saying whether the plan will pass.
"I have a lot more confidence in the Haslam administration's way of coming up with something than I do the Obama administration's," said Sen. Todd Gardenhire, R-Chattanooga.
But, he emphasized, "I still haven't seen the actual plan and I know the devil's always in the actual details. The last thing I want to do is approve something like Congress does."
Sen. Brian Kelsey, R-Germantown, last week came out against the plan.
"Tennesseans elected Republicans to shrink government, not expand it -- and certainly not to expand it for Obamacare," Kelsey said.
Also opposing the governor's plan are the Tennessee chapter of the conservative group Americans for Prosperity and the libertarian Beacon Center.
And Ben Cunningham, president of the Nashville Tea Party, said Saturday that group is strongly opposed.
Citing the plan's lack of detail, Cunningham said it's "disingenuous" for the governor to call it a two-year pilot project. It will never go away, he said.
Moreover, Cunningham added, the arrangement with hospitals is "kind of a crony capitalist agreement. In effect, it's a tax."
But some Republicans predict the plan will likely pass. Most, if not all Democrats, who've spent most of two years criticizing Haslam for not expanding Medicaid, are expected to support it.
Moreover, these Republicans say, rural GOP members in particular are wary of getting blamed if Haslam's effort fails and hospitals in their districts face deep cuts or even closure.
It takes 50 votes to pass a bill in the House and 17 in the Senate.
Contact staff writer Andy Sher at asher@timesfreepress.com or 615-255-0550.