Recently, Rep. Cameron Sexton (R-Crossville), who serves as chair of both the Tennessee House Health Committee and Speaker Beth Harwell’s 3-Star Healthy Project task force, and Michele Johnson, executive director of the Tennessee Justice Center, spoke to Medical News about expanding access to care in the state.
After the U.S. Supreme Court struck down the Affordable Care Act’s Medicaid expansion mandate in 2012, it was left to individual states to decide whether or not to expand their eligibility criteria and take advantage of additional federal dollars. The ruling left millions of low-income Americans in the ‘coverage gap’ where they didn’t qualify for either Medicaid programs or financial subsidies on the insurance exchange.
As of January 2016, 19 states had not expanded Medicaid, including Tennessee where Gov. Bill Haslam’s Insure Tennessee pilot has twice been shot down. It is estimated 280,000 to 300,000 Tennesseans are caught in the coverage gap.
While ‘Obamacare’ remains unpopular with many Tennesseans, attitudes have significantly softened when it comes to expanding access and coverage. On May 18, icitizen released results from a survey of 562 registered Tennessee voters with data crossing age, gender and geographic regions to reflect the composition of registered voters in the state. Specific to improving healthcare access, 55 percent said they were satisfied with the steps legislators are taking to try to improve the problem, and 45 percent were dissatisfied. However, in a follow-up question, a full 83 percent supported the reintroduction of Insure Tennessee with only 17 percent opposing such a step.
Johnson would like to see Insure Tennessee fully implemented. Sexton and the 3-Star Healthy Project committee are exploring a range of other options.
The Task Force View
Chairman Sexton heads the six-member task force, which was created on April 12 to find viable alternatives to Insure Tennessee and now includes one Democrat. The group has been charged with presenting a plan to the Centers for Medicare and Medicaid Services in June that will be palatable to the federal agency, state lawmakers, and constituents. “It will be an initial proposal,” Sexton said, adding he expects there will be several months of negotiations and ‘back and forth’ with the federal agency to hammer out details.
The task force has held a series of meetings across the state to hear from stakeholders, including hospitals, physicians, charity clinics, employers and uninsured Tennesseans. Sexton said they are evaluating a number of approaches ranging from medication therapy management (MTM) programs, telemedicine, and home visits to creating public-private partnerships and a behavioral health pilot project. He also stressed the committee is looking at ‘cost’ from various angles and with a recognition that short-term outlays might be required for longer term savings.
“We’re looking at it more from providing healthcare than from a strictly monetary position,” he said.
A chief concern is how emergency departments are being utilized by the uninsured at hospitals around the state. “When we’ve talked to hospitals about their data on the 300,000, there are a lot of services they provide for that population in acute care that could be better served in other settings,” he said of trying to free up ERs for their intended use.
The task force is looking at a pilot project to address about 100,000-125,000 Tennesseans in the coverage gap who have a behavioral health component to their medical needs. If that plan moves forward, Sexton said it would most likely be administered through TennCare. He noted the goal would be to assess specific pieces of the pilot and then roll out successful elements to the broader TennCare population to achieve better outcomes and efficiencies.
“The task force is looking at a phase-in approach,” he said. “But in that first phase, if we just do the behavioral health pilot, then we’ll look at the remaining number of uninsureds and ask: How can they have healthcare that might not be government-run healthcare but still have some access?”
For that part of the equation, Sexton said the task force has had discussions with faith-based and charity clinics regarding their care model and how they control cost and measure performance. He also said mechanisms for supplemental funding for specialty care were being studied.
Sexton pointed out that simply having coverage doesn’t necessarily mean a person has real access to the system. “An insurance policy doesn’t mean you have healthcare,” he said, noting many people have policies with such high copays and deductibles that individuals can’t afford to see a provider. “We want to make sure we are providing access to care,” he stressed of any plans proposed.
Sexton also noted it’s important to make sure providers are able to care for any new additions to the TennCare rolls. “I know the task force is well aware of the cuts to providers over the years from the TennCare program so we’re looking at ways to have some type of better reimbursement or better incentives so that providers are more comfortable and able to see this potential TennCare population.”
Whatever plan is put into place, Sexton envisions sign-off by the full legislature. He said there were various reasons Insure Tennessee didn’t pass and noted legislative members have asked the task force to look at having triggers or circuit breakers in place so the state could pull back if costs spiral out of control. While the federal government has pledged much higher reimbursement for this added population, Sexton said Tennessee has to have a plan in case that changes in the future. “We have to be prepared to pay those costs ourselves if we need to and be comfortable with those costs.” He added no one wants a repeat of 2005 when more than 300,000 were dropped from TennCare rolls.
While he seeks to be fiscally responsible, Sexton said he doesn’t want to be financially shortsighted. “One of the things that drives me crazy about government is we’re always focused on today’s dollars,” he said. With the task force, he concluded, “We want to put in innovative approaches to see if it saves money down the road and monitor that.”
The TJC Perspective
Michele Johnson, executive director of the Tennessee Justice Center, hopes the state doesn’t have to wait for months of ‘back-and-forth’ with CMS and then another legislative session. She said the stories and immediate needs of those facing dire medical decisions are too critical to put off any longer.
“In Memphis, they (the task force) heard from a variety of witnesses who all made a compelling case for why they need to close the coverage gap,” Johnson said.
The TJC has created a video – “Dear State Legislators: A Message from the Coverage Gap” – featuring Tennesseans asking their elected officials to provide a real plan and to act quickly to implement it. At press time, the three-minute video was approaching 20,000 views.
Johnson said it is a huge misperception that many of those in the coverage gap don’t work. “The vast majority of these folks are working at least one job, many of them are working more, and many of them are really sick.” She added, “These are our friends, neighbors, the people who clean our hotel room and wait on our tables.”
Johnson said it is also a misperception that charity care could somehow take care of those lacking coverage. “It isn’t because the healthcare industry isn’t charitable enough, it’s because the system is too complex.” She added there are too many moving parts for those with chronic illnesses or a diagnosis of heart disease or cancer to be able to piece together the kind of cohesive care required.
Noting that CMS has been “very consistent” with what they will and won’t approve, she said, “If the task force submits a plan that is in the range of what has been approved before, I think CMS will act quickly.”
If that happens, Johnson said the state should move forward without waiting for the legislature to come back in session in January. “I understand why they might want to for political reasons, but there is no valid policy reason to wait when these people have been living in pain as long as they have and when it will be the seventh hospital closing this week,” she said, referring to the recent closure of rural McNairy Regional Hospital.
From a financial standpoint, Johnson said expedient approval of Insure Tennessee or a similar plan would draw down more federal dollars to the state. “We have one more year of 100 percent funding,” she said of the federal match program. “Next year, it goes down slightly until 2020 when it goes down to 90 percent.” However, she continued, “Hospitals have said they will pick up what the federal government doesn’t.” She stressed, “It’s budget neutral to Tennessee taxpayers. It’s budget neutral to Tennessee, period.”
Johnson concluded, “The testimony has been really clear that a real plan would make sense economically for our state, for our healthcare infrastructure, and will take care of citizens that need health coverage.” Now, she said, the question remains, “Can legislators set aside their own political interest and stand up for their constituents?”
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