By: Tom Wilemon, The Tennessean
Deanna Piotrowski wound up on the wrong side of the Kentucky-Tennessee border.
She suffers from chronic conditions, cannot afford her medicine and is without health insurance. If she had settled 10 miles up the road, she would be getting Medicaid coverage.
"That's ridiculous," Piotrowski said. "That's really a shame."
Portland, Tenn., where Piotrowski lives, is not that different from Franklin, Ky., the next town up along a two-lane highway that runs past cornfields and modest homes.
Kassandra Clark says she's lucky to live in the Kentucky town. Uncertain of prospects for health coverage at her new job, she's grateful politicians in her state have given her a backup option.
"It shows that they care about their people, that they are there for them," Clark said.
Kentucky has accepted federal funding from the Affordable Care Act to expand the government insurance program for the poor. Tennessee, where political opposition to "Obamacare" runs strong, has not. Kentucky is an anomaly in the South. Most Southern states have taken actionsto either block or hinder the implementation of the federal health law. Supporters of the law say it is foolhardy of politicians to refuse generous federal funding for ideological reasons, but the law's critics say the money comes with a hefty financial hitch.
The federal government will pick up 100 percent of the costs of insuring new people brought onto state Medicaid rolls through 2016. It then phases down to a permanent 90 percent matching rate in 2020.
Joseph Smith, executive director of the Kentucky Primary Care Association, said politicians there made a pragmatic decision.
"It's a silly decision based on ideology to refuse health care coverage to the citizens of any state," Smith said.
Kentucky will expand coverage to an estimated 308,000 state residents with its decision.
'We don't have that kind of money'
But a decision about whether to expand Medicaid in Tennessee is a bit more complicated after the numbers are crunched, the state's TennCare experience is considered and the political reality confronted. Tennessee expanded Medicaid in the 1990s, then learned it couldn't handle the cost and had to scale back, forcing people off the program. It is a state with a larger population, which means about 100,000 more new enrollees would be eligible for its Medicaid program. And, unlike in Kentucky, Republicans are firmly in control of state government.
Fiscal responsibility matters to Republicans, said Rep. Glen Casada, who argues that Tennessee can't afford the 10 percent match the state would have to provide beginning in 2020.
He said estimates run between $198 million and $250 million, which he believes is the closer mark. Democrats in the legislature, however, say Medicaid expansion would ultimately save the state money by lowering its cost for uncompensated care by as much as $1.6 billion.
"We're talking probably $250 million in year four," Casada said. "That's a lot of money. We don't have that kind of money just sitting around. So the question is: Do we raise taxes or what do we cut?"
And he doubts the federal government will stand by the 90 percent commitment.
"The federal government is fast approaching insolvency," Casada said. "They cannot continue to spend money like they are spending because either the country will collapse or they will have to start cutting. The first place they are going to start cutting is the sweet deal of a 90-10 match to the states on Medicaid."
John Graves, a Vanderbilt University professor who formerly worked for the Obama administration on health care reform, said Tennessee could protect itself from any possible future decline in matching money.
"Some other states have considered a 'circuit breaker' option that limits their downside risk," Graves said. "That is, these states say they will expand for now, but if the federal government suddenly reduces its share in the future, that would immediately discontinue the expansion."
Gov. Bill Haslam has been trying to find a way for Tennessee to use the federal money for a state-tailored plan that would prevent a repeat of the prior TennCare expansion, when thousands of people were added to the rolls and quickly racked up medical bills. Haslam favors a plan similar to a private insurance model, in which shared costs curb the overuse of benefits. Instead of expanding TennCare rolls, the money would be used to help poor people buy private insurance, with some co-payments on medical visits and procedures. Adults on TennCare currently have co-pays only for prescriptions.
Haslam's path is a difficult one. He has to get his plan past the Obama administration and then before the Republican-controlled state legislature.
Arkansas Gov. Mike Beebe, a Democrat, got the Republican legislature in his state to pass an expansion plan that has some similarities to what Haslam has proposed. Federal officials are working toward approving it as a demonstration project. Under the plan, the state would use federal money as "premium assistance" to buy private coverage for people eligible for Medicaid.
Kentucky Gov. Steve Beshear, also a Democrat, envisions Medicaid expansion in his state as a job creator, not a financial drain. He projects expansion will have a $15.6 billion economic impact and create nearly 17,000 jobs between 2014 and 2021.
Hospitals will take hit
The problem with boiling down the Affordable Care Act to any kernel of fiscal certainty is that the recipes differ, according to whoever is mixing the numbers.
However, one certainty is that hospitals in Tennessee will lose money without some form of Medicaid expansion. The federal law reduces special payments to hospitals that treat a disproportionate share of the poor and uninsured. Those patients were supposed to gain coverage in every state through Medicaid expansion. The law had language that would have effectively forced states to expand coverage by cutting off Medicaid funding to those that refused. But the U.S. Supreme Court struck down that portion of the law.
Vanderbilt University Medical Center, which provides more care to the uninsured than any other hospital in the region, announced last week that it is cutting expenses and eliminating jobs. The Tennessee Hospital Association has warned that small rural hospitals might be forced to close without some type of Medicaid expansion.
Renard Murray, the regional administrator for the Centers for Medicare and Medicaid Services (CMS), said there is no deadline for Tennessee to make a decision.
"That option is always on the table for a state," Murray said, noting that when Medicaid was first created in the 1960s, some states delayed offering the optional program.
"But after several years, several decades have passed, every state now has a Medicaid program," Murray said. "Medicaid expansion is no different."
Kentucky is the only one of the eight states in CMS region 4that has agreed to expand its Medicaid program. Alabama, Florida, Georgia, Mississippi, North Carolina, South Carolina and Tennessee have not.
2 women, 2 scenarios
Piotrowski, who moved to Portland, Tenn., from Michigan this summer, knows little about Tennessee politics. She does know she can't afford her medicine. A doctor in Michigan who had treated her family for generations charged her only $30 a visit and gave her drug samples for hypertension, diabetes and depression.
She left that medical arrangement and came to Tennessee so her children would have better job opportunities and live in a place with less crime. She applied for TennCare coverage and got denied.
She is trying to connect with community health centers and faith-based clinics in the area that treat people regardless of their ability to pay.
"Everything else in Tennessee I love," Piotrowski said. "I really was disillusioned. I know there's a lot of people that are worse off than me, but my health issues could be serious."
Up the road in Franklin, Ky., Ashley Austin, a part-time job juggler without health insurance, smiled as she helped children with the Boys and Girls Club sell vegetables they had raised at the farmers' market.
"I also work at Hobby Lobby," she said. "If we are a part-time employee, our hours got cut because they do not want to provide insurance for us."
Austin had been on her mother's plan until she lost her job. But come Jan. 1, she'll have health insurance because she lives in Kentucky.
Contact Tom Wilemon at 615-726-5961 or firstname.lastname@example.org.