By Chas Sisk, The Tennessean
It would be difficult to argue that Joyce Coggin does not receive
medical care. Figuring out who pays for it is where things get
Pulling orange prescription bottle after orange
prescription bottle from a Save-A-Lot shopping bag, the 54-year-old Old
Hickory woman recounts a litany of health problems, many of which she
traces to early childhood. She counts off nine prescription medications
Coggin has been ineligible for TennCare,
the state's Medicaid program, for the better part of the past decade
because her husband's Social Security payments are too high to qualify.
She is delaying treatment for back pain and for a heart condition, which
has already sent her to the hospital once.
"I ain't got no insurance, and I ain't got money to do it," she says bluntly.
that does not mean she goes without care entirely, as the medicines in
her bag prove. Instead, she gets care piecemeal, visiting a family
doctor when she can scrape together the $60 fee and local hospitals when
her conditions grow intolerable.
How to handle the medical costs
of people such as Coggin lies at the heart of one of the most important
debates that will take place in Tennessee this spring - a debate that
will go a long way toward determining how health care reform plays out
Gov. Bill Haslam
faces a decision over whether to expand TennCare to Coggin and more
than 200,000 other Tennesseans who lie on the cusp of eligibility. Many
of his Republican colleagues, including Rick Scott of Florida and Bobby
Jindal of Louisiana, already have declared they will not expand their
states' Medicaid programs.
Critics of the Affordable Care Act say
extending TennCare will inflate the $9 billion program's budget at a
time when Tennessee cannot afford to take on new spending. But Democrats
and many in the health care industry argue that Tennesseans are already
paying the bills for people such as Coggin, through a patchwork of tax
dollars and insurance premiums.
"Everybody pays a hidden tax already," said Chris Coleman, staff attorney for the Tennessee Justice Center, a public advocacy group.
and lawmakers on both sides are squaring off for a battle that's likely
to last until late in the 2013 legislative session, expected to end in
April or May.
Tennessee hospitals are pressing hard for expansion.
Under the federal Affordable Care Act, they stand to lose millions of
dollars in reimbursements for treating patients such as Coggin who
cannot pay their bills. They say the only way to fill that hole is for
more Tennesseans to get insurance coverage that will steer them away
from hospitals and pay for their treatment when they do find themselves
But 16 Republican lawmakers in the state Senate and dozens
more in the House have signed onto a bill that would block Haslam from
expanding TennCare. Opposition to "Obamacare," as critics call the
Affordable Care Act, remains popular among Tennessee voters, and many in
the GOP are reluctant to support any aspect of health care reform.
said in last week's State of the State address that he would work
slowly toward a decision. The stakes are high enough that both the
governor's Democratic predecessor and Haslam's onetime Republican foe
agree he is taking the correct approach.
"This is one that takes a lot of analyzing," said Lt. Gov. Ron Ramsey, R-Blountville. "If it wasn't for the effect on hospitals, I think the decision would be easy."
Rooted in Tennessee
Republican governors and legislators nationwide are wrestling with
the question of Medicaid expansion, but the dilemma has its origins here
To help fund the Affordable Care Act, Congress
decided it would slash reimbursements to hospitals known as
disproportionate service payments - essentially paybacks for providing
care to the poor. The payments, which total more than $11 billion a year
nationwide, will be cut by nearly three-quarters in 2014, when the
Affordable Care Act's insurance mandate goes into effect.
Tennessee, hospitals have been getting about $305 million a year in
federal reimbursements, most of which will disappear next year. The
Tennessee Hospital Association says that money has defrayed some of the
more than $850 million annually that its members spent in 2011 on
providing care for the poor.
Other cuts could decrease
reimbursements to Tennessee hospitals by as much as $5.6 billion over
the next decade, according to the THA.
Hospitals did not oppose
cuts to disproportionate service payments because the Affordable Care
Act was supposed to make most of the poor eligible for Medicaid, known
as TennCare in Tennessee.
But last summer, the U.S. Supreme Court
said in its ruling upholding the Affordable Care Act that Congress could
not force states to expand their Medicaid programs. Justices cited a
brief filed by James F. Blumstein, a Vanderbilt University law professor
and expert on health care, that argued the federal government could not
unilaterally change the terms of Medicaid programs.
"They're leaving it at the right level of government," Blumstein said of the Supreme Court ruling.
Gov. Phil Bredesen, a Democrat who wrestled with TennCare costs during
his tenure from 2003 to 2011, said Haslam may be able to work out a
better deal for Tennessee by moving slowly on expansion.
he's handling it properly," Bredesen said. "I hope we expand the program
here in the state, and I hope we can do it in a way that the state can
keep its hand on the lever in terms of the cost."
No one disputes
that expanding TennCare would be a momentous step. A University of
Memphis study released last year estimated that 224,994 more Tennesseans
would be eligible for expanded TennCare. Most of those people are the
working poor who cannot get on the program because they make too much
money, are not disabled and have no children.
The Affordable Care
Act - which set out to remove those people from the ranks of the
uninsured - requires the federal government to pay the full cost of
expanding TennCare for three years and at least 90 percent through 2020.
Republican lawmakers say even that deal is bad for Tennessee. They
estimate the state would need to budget $200 million - roughly what it
spends on the Department of Safety, or double what it collected in
estate taxes before a cut last year - to cover an expansion of TennCare.
taxpayers simply can't afford $200 million a year," said state Sen.
Brian Kelsey, the Memphis Republican who filed the measure, Senate Bill
1, that would block expansion.
But the math is not so simple, say
many in the health care field. They argue that without an expansion of
TennCare and without disproportionate share payments, hospitals will be
hard-pressed to make ends meet.
Bad debt and charity care already
eat up between 10 percent and 20 percent of many hospitals' budgets,
according to the THA. Without some way to fill that gap, many hospitals
would have to cut services - such as surgical procedures and care for
expectant mothers - and might even be forced to close some rural medical
Alan Watson, chief executive of Maury Regional Medical
Center, said he is not yet ready to plot out scenarios if TennCare were
not expanded. But with the hospital and its two affiliates losing more
than $42 million a year to bad debt and charity care - about 16 percent
of its total operating budget - Watson said major changes would be
"That's a huge gap of funding that's going to be lost," he said.
The impact could be felt in urban hospitals as well, and not simply
those that deal primarily with the poor. HCA's TriStar network, which
operates 16 hospitals and surgery centers in Middle Tennessee, lost more
than $340 million to uncompensated care in 2011.
receiving that care was Coggin, who was hospitalized for a heart
ailment. Medical bills related to that visit contributed to a $23,000
debt that forced her and her husband to file for bankruptcy late that
"That cost is passed on to everybody," said Coleman, the
health care advocate. "The way that we're going to reduce health care
costs is by making sure everybody has enough access to primary care."
Hospitals and other advocates for TennCare expansion will have a difficult time convincing skeptical lawmakers, however.
16 sponsors, only one more lawmaker would need to support Kelsey's bill
for it to pass the state Senate. And with Republicans holding more than
two-thirds of the seats in the House, it likely would pass easily in a
floor vote there.
Ramsey said he wants to give Haslam some time to
decide. The leader of the Senate said last week that he will ask Kelsey
to delay his bill.
But Ramsey also was careful not to suggest he
favors expansion of TennCare, expressing doubts that hospitals'
situation is as dire as they say.
"They will be left in the lurch,
but I'll be honest, the hospitals are notorious for inflating numbers,"
Ramsey said. "I'm in no hurry. There's no deadline."