Last November, Tennessee’s Republican governor Bill Haslam won his reelection effort resoundingly, taking 70 percent of the vote and every single county in the state. Just six weeks later, Haslam surprised nearly everyone in Tennessee’s Republican-controlled state assembly by announcing that one of his first orders of business in his second term would be to expand Medicaid under the umbrella of the Affordable Care Act, also known as Obamacare. But a month and a half later, Haslam’s Medicaid expansion was dead. The debate was over nearly as soon as it started.
It wasn’t supposed to be this way for Haslam. Since the passage of Obamacare, Republican governors have generally taken one of two tracks on Medicaid expansion. Some like, Wisconsin’s Scott Walker and Louisiana’s Bobby Jindal, rejected the expansions outright. Others, like Ohio’s John Kasich and Indiana’s Mike Pence, have accepted the federal dollars and expanded the eligibility for low-income residents to receive Medicaid coverage. Each of the listed governors had compliant Republican legislatures. Whatever path Haslam pursued, he might have reasonably assumed the GOP in the state capitol might have gone along with it.
If he made that assumption, it was a mistake. The governor hadn’t even given fair warning to many of the legislators he’d need to support his proposed expansion (called Insure Tennessee) before publicly announcing it last December. Republican state senator Brian Kelsey remembers finding out about the Medicaid expansion proposal from a tweet of the news on December 15 last year. Earlier in 2014, Kelsey and a GOP state representative, Jeremy Durham, had successfully championed a bill that would require legislative approval on any such expansion (state law had previously given the governor regulatory discretion). Kelsey says what they had in mind in drafting the bill was an effort by a future Democratic governor to add to the rolls of Medicaid. But from Haslam?
“We did not expect this governor to do this,” says Kelsey.
That was for good reason. In his bid for reelection, Haslam did not campaign on Medicaid expansion. In fact, he had previously touted the decision by the state not to expand Medicaid as Obamacare originally dictated. There had been talks with some in the legislature about finding a way to expand coverage for those who made too much to qualify for Medicaid but who weren’t self- or employer-insured—something Kelsey says he was interested in, so long as there were no federal dollars and Obamacare regulations.
But Haslam’s Insure Tennessee plan had been in the works for a while. Both of Tennessee’s Republican senators, Lamar Alexander and Bob Corker, worked with the governor’s office and Secretary of Health and Human Services Sylvia Burwell to develop what Haslam termed his “alternative approach” to expanding Medicaid, one that “forges a different path and is a unique Tennessee solution.” The details of Insure Tennessee may have been different from Obamacare’s directives, but the end result was essentially the same: The state would change its eligibility requirements and to place more Tennesseans on Medicaid, with the federal government footing the bill. Lieutenant governor Ron Ramsey, a Republican, originally praised it as a plan that “returns tax dollars back to Tennessee.”
But members of the general assembly weren’t convinced of the merits. The expansion would have opened up two new coverage options to Tennessee’s Medicaid program, using federal and state tax dollars, which Republicans called an unsustainable expansion of the welfare state. There were concerns about the possibility that future federal support might drop off. Ramsey, who is also the speaker of the senate and traditionally carries the governor’s agenda through the legislature, ended up remaining publicly neutral. Opposing the plan from the outside were the Koch-backed Americans for Prosperity and a free-market think tank called the Foundation for Government Accountability, which has been on the forefront of fighting Medicaid expansion across the country. And Insure Tennessee got hammered on local talk radio.
All of this prompted Haslam to take a statewide tour to promote the plan himself. And the governor certainly wasn’t alone. Business groups like the Tennessee Hospital Association and the Coalition for a Healthy Tennessee ran ads featuring those citizens who would benefit from enrolling in Medicaid. The Coalition even published a poll in early February showing plurality support across the state for the plan—even as a majority said they opposed Obamacare. “The more Tennesseans – and especially Republicans – learn about Governor Bill Haslam’s Insure Tennessee plan, the more they like it,” trumpeted a press release.
In the end, it wasn’t even close. The bill died early, in a senate committee, on February 4. The state house speaker had publicly voiced doubts that the plan would have passed the house committee to which it would have been referred. Haslam said he wouldn’t push to bring up Insure Tennessee again this year.
The Tennessee general assembly’s rejection of the proposal was a stunning rebuke to the state’s powerful hospital lobby. It also showed that Republican governors who want to expand Medicaid can’t expect their Republican legislators to comply. Indeed, just a few days later, Wyoming’s GOP-controlled legislature rejected Republican governor Matt Mead’s Medicaid expansion for the third year in a row.
Republican state senator Eli Bebout says rejecting the expansion wasn’t an easy decision; Wyoming is a rural state with plenty of unmet health-care needs. But the plan would have likely resulted in cutting back on Medicaid reimbursements to doctors, or even cutting Medicaid’s coverage of certain procedures for those already on the program. Bebout noted that many of Wyoming’s young, single population are already on private insurance.
“There were also concerns about adding to the national debt,” he adds.
Utah, meanwhile, is the only other state that has not answered the Medicaid expansion question posed by Obamacare—and it also has a Republican governor and state legislature. Governor Gary Herbert’s Healthy Utah Medicaid expansion proposal isn’t as imperiled as Insure Tennessee was, despite the overwhelmingly Republican tilt in the state house. Utah’s Mormon culture means the state is less libertarian on issues like providing for the needy than other red states. The Healthy Utah bill has already passed the state senate committee, but a competing bill that does not expand Medicaid as broadly has also passed through the same committee.
The main proponent of the Medicaid expansion alternative, Republican senator Allen Christensen, calls his proposal one that would help “vulnerable Utah.” As the Deseret News reports, Christensen sees it as a compromise between the complete Medicaid expansion under Healthy Utah and doing nothing about those uninsured who do not qualify for Medicaid. Christensen’s plan covers those who make up to the poverty level and includes those who are medically frail.
Which bill will the Utah legislature take up and pass? Senate and house leaders say they aren’t sure what’s more likely to get the support of the majority of members, though as in Tennessee, Wyoming, and many other states, the political and business establishments in Utah are pushing hard for the full expansion, along with leaders in the Church of Jesus Christ of Latter-day Saints and the Salt Lake-area Catholic church. More than a dozen of these leaders flanked Herbert last December when he made the announcement of the Healthy Utah Medicaid expansion.
“Utahns are known for caring for the less fortunate among us,” Herbert said. “Turning a blind eye to those in need is not the Utah way.”
But full Medicaid expansion and the intrusion of the federal government, Christensen argues, isn’t the Utah way either. “Is the state’s responsibility to provide everything for everyone? I say no,” Christensen said, according to the Deseret News. “Socialized medicine is not the responsibility nor is it a constitutional guarantee of this country. America grants opportunities. It doesn’t grant benefits.”
Would Herbert sign a narrower Medicaid expansion like Christensen’s rather than accept no expansion at all? The governor’s office won’t say, but a spokesman provided this statement.
“The governor is still committed to adopting the Healthy Utah plan and he continues to work with legislative leadership and individual members of the legislature to see if there are ways to improve his proposal,” said spokesman Marty Carpetner. “So far, other plans proposed cover far fewer people at nearly the same cost to the state. The governor is working to give Utah taxpayers the best bang for their buck.”
According to the Utah legislature’s estimates, Herbert’s plan costs just $36 million more than Christensen’s, but “brings back” nearly $2.5 billion more in federal tax money. That’s a good return for the green eyeshade-wearers in the state budget office, but not all of Utah’s GOP legislators seem quite ready to sign off on what amounts to a hefty addition to the national debt.
