Andy Axel's picture

He wrongly assumed the ACA

He wrongly assumed the ACA would be found unconstitutional. So why bother preparing?

Now he and Ramsey's boots can use the federal exchange to demagogue the issue, all while reaping the benefits of having the federal exchange and net tax dollars imported in support of it.

EricLykins's picture

full transcript (link...)

full transcript (link...)

Somebody's picture

The Medicaid expansion is

The Medicaid expansion is still up in the air, however.

According to the Tennesseean, "Haslam said the decision about the exchange would have no impact on deliberations over whether to expand TennCare, as the Affordable Care Act calls for.

"Some conservatives have urged the governor to reject TennCare expansion, but Haslam said expansion might make up for the indigent care payments that hospitals are expected to lose once the Affordable Care Act goes into effect."

This may not be a bad thing. If Haslam goes ahead and approves the expansion, we may get the best of both worlds in the end. The expansion would yield funding to help a lot more low income people have access to healthcare, and the Feds operating the exchange would keep goofballs in the legislature from being able to tinker with it. It also occurs to me that saying "no" to having the state manage the exchange may let the Tea Party pretend they won, while making it easier to let the Medicaid expansion slip through.

reform4's picture


the Feds operating the exchange would keep goofballs in the legislature from being able to tinker with it

ding, ding ding.

R. Neal's picture

I'm somewhat of a mind that

I'm somewhat of a mind that we might be better off if the federal government runs our exchange instead of the doofuses over in gooberville. On the other hand, it seems like the state would be in a better position to get the best deal for citizens of the state.

From what I understand, there are basic minimums that insurance companies must meet if their policies are offered on the exchanges. And, if I understand it correctly, states can set the bar higher. So, for example, the state could say they must meet the federal minimums plus this or that, and if they don't then not only will they not be able to sell hundreds of thousands of new policies in our exchange, the state will take a closer look at their TennCare MCO contracts and employer group plans etc. Because as it is right now, states regulate health insurance. I think they call that leverage.

(There should be more federal regulation and standardization, including allowance for policies that are portable across state lines, but it is what it is unless and until we get national single payer.)

The feds don't know anybody down here, and don't have the time or inclination (especially for a Tea Party state like Tennessee) to expend much effort on getting us a good deal in the exchanges beyond the minimum requirements.

But, like I said, I don't know much about it except that we had previously been caught in the black hole of not being able to buy private health insurance in Tennessee even though we could afford it because the state doesn't require insurance companies operating here to provide it. A federal exchange where people could get private polices would at least be an improvement over that.

marytheprez's picture

Groups of us are going to sponsor public Forums on the ACA!

And ole Haslam did just what he said he would do as Romney's Campaign Mgr! He was quoted in the KNS a week before the election that 'if Romney wins, I will work to 'repeal Obamacare'. HE DOES NOT know it is a law, even now. And you all have pieces of the law correct (I took a training class on how to inform the public on the details.) the fact that about 23 hospitals here in East TN are in trouble of folding because they WILL lose their DSH payments from the Feds if we don't add approx. 500,000 folks to TennCare...and for each $1 we pay for each new applicant, we will receive $9 from the Feds.
Haslam was also telling health care folks that he would do the very best for the people of Tennessee, letting them think he would consider that TN would set up and run the exchange...
And he was awarded $9 million over 2 years ago to 'study' how the ACA could benefit our State. Wonder what happened to THAT money??
So stay tuned; we already have speakers lined up. You can learn a lot...

Anonymous2's picture

I think the Supreme Court

I think the Supreme Court ruling said the feds could NOT strip current Medicaid funding from the state, ONLY the fed could withhold new funding.

"In NFIB, the Court held that Congress did not have the authority under the Spending Clause of the U.S. Constitution to require states to implement the Medicaid Expansion
provisions or lose their existing federal Medicaid funding. This was unduly coercive. The Court also held that the violation is fully remedied by prohibiting the Secretary of Health and Human Services (HHS) from enforcing a long-standing Medicaid provision, 42 U.S.C. § 1396c, that would otherwise authorize her to withhold all the existing federal
Medicaid funding of a state that does not properly implement the Medicaid Expansion. Thus, the NFIB holding is a narrow one, finding only that it was coercive for Congress to force states to adopt the Medicaid Expansion or lose all federal funding for their existing Medicaid programs."


Plus, all the talk the feds will pay 100%, 95% and 90% years down the road ignores the fact that a state's share of 5% or 10% could be a ton of money.

Especially without the cost controls the ACA lacks.

EricLykins's picture

they WILL lose their DSH

they WILL lose their DSH payments from the Feds if we don't add approx. 500,000 folks to TennCare

I think the Supreme Court ruling said the feds could NOT strip current Medicaid funding from the state, ONLY the fed could withhold new funding.

These are two different things, and every Republican in the legislature needs to understand this VERY clearly.

Disproportionate share payments are money the feds give to hospitals to reimburse care given NOT covered by Medicaid, and these funds WILL decrease regardless of IF the state expands Medicaid.

Think of it as the ACA defunding, or drowning baby-in-a-bathtub-style, the Reagan-era notion of "universal coverage" in which federal money covers anybody's emergency room visits and replaces it with insurance coverage via Medicaid (or nothing if a state so chooses). I haven't seen anyone yet compare the numbers in TN between money to be lost via DSH payment reductions vs. new money that would be spent as TN's share of Medicaid expansion.

EricLykins's picture

I haven't seen anyone yet

I haven't seen anyone yet compare the numbers

Wait, I lied. The link above details the schedule by which DSH payments will decrease nationally.

Also, Tennessee will receive $1.08 billion additional federal dollars between 2014 and 2019.

Also, it is estimated that the state’s uncompensated care costs will be reduced by as much as $1.6 billion from 2014 to 2019.

Rachel's picture

I'm actually not all that

I'm actually not all that worried about this, since the exchange will happen regardless.

What I'm worried about is the Medicaid expansion. The State REALLY needs to take that $$. I hope the hospitals will push them hard enough that the legislature will get over its lack of concern about the uninsured.

R. Neal's picture

Good point about the $9

Good point about the $9 million in federal funding to set up an exchange. Will Tennessee have to give it back?

R. Neal's picture

Here's a document comparing a

Here's a document comparing a state plan (California's) with federal requirements. It's a good overview of what the exchange is and how it works. It's also a good reminder of how much simpler all of this would be with single payer national health insurance.

EricLykins's picture

So California got their

So California got their homework done last February. Here's the Draft Blueprint for Approval of Affordable State-based and State Partnership Insurance Exchanges.

The 800-plus pages Haslam references can be found here, and the "scary" "lack of information from the federal government" comment can be found to be disingenuous horsepoop. See B. Stakeholder Consultation and Input

If the Gov or legislature is interested in doing any work, "Because you and I believe that the heart of real health reform is affordability and not mandates, I wanted to bring this feature of Section 1332 to the attention of you and the legislature."
Insert at the end of b)(1) ―and with citizen input through a referenda or similar means;‖ – In b)(2) strike ―a‖ and insert ―this‖ – Insert b)(4) ―the State submits a ten-year budget for the plan that is budget neutral to the Federal government.‖ – Insert at the beginning of c)(2) GRANTING OF WAIVER.— The Secretary shall approve the plan only if it meets criteria consistent with that of the America’s Healthy Future Act, including that it shall lower health care spending growth, improve the delivery system performance, provide affordable choices for all its citizens, expand protections against excessive out-of-pocket spending, provides coverage to the same number of uninsured and not increase the Federal deficit.

Rachel's picture

I don't know if this figured

I don't know if this figured into Haslam's decision or not (maybe it was all the Feds fault for not having all their ducks in a row), but....

He seems to have gambled that a) SCOTUS would throw out the ACA, and then b) that Obama would lose and the ACA would get repealed, so didn't start doing the work necessary to set up the exchange until VERY late in the game.

That's on him, not the Feds.

R. Neal's picture

Another thought that occurred

Another thought that occurred to me is that this isn't really Haslam's call to make, is it? Not that it would ever happen in a million years, but the state legislature could pass a bill to implement it and override any veto, right? And isn't that where the decision should be made? It would be interesting to see it put to a vote so we can get them on the record.

And I'm guessing they will have to pass a bill of some kind to participate in the federal exchange, because I believe there are fees and eligibility rules and other stuff like that involved.

cwg's picture


The legislature would have had to approve Haslam setting up a state-run healthcare exchange. Which probably wasn't going to happen. So he decided not to bother.

R. Neal's picture

The point was that Haslam

The point was that Haslam can't unilaterally set up an exchange even if he wanted to. There has to be enabling legislation, not just approval. Likewise, he can't just opt out by decree. Legislation will be needed to join the federal exchange. So it's not really his call, it? Seems like there should at least be a resolution bill or something. The people's elected representatives have yet to be heard on the record, other than bloviating tea party press releases.

R. Neal's picture

In fact, there was a bill

In fact, there was a bill filed to start the process of implementing an exchange: HB2839. It was withdrawn in Feb.

It was introduced by Rep. Charles Sargent, a Republican from Franklin. According to his bio, he's an insurance man. His bill said, among other things:

(2) In order to maintain traditional state control of insurance regulation, maximize the stability and competitiveness of this state's health care and insurance industries and minimize federal disruption of Tennessee’s health insurance industry so that insurance agents, healthcare providers, and insurance companies continue to provide valuable services in our state it is necessary to authorize executive agency activity;

(4) The state’s control of health insurance would be greatly lessened if health insurance exchanges are not created by state law to enable the sale of health insurance by state regulated non-governmental providers;

(6) Federal law allows many policy and operational options with respect to health insurance exchanges. Executive agency activity is necessary to evaluate various options using the criteria that apply to health policy issues and to evaluate the extent to which each option would enable the state to encourage long-term economic growth, a business-friendly environment, and this state's global competitiveness;

(9) It is therefore necessary to establish a statutory framework for the operation of health care insurance exchanges operated in the public interest by the state in the event that the PPACA is sustained by the courts and implemented according to the schedule now specified in the PPACA and related federal regulations and guidance.

B Harmon's picture

Haslam on Fox on KNS

EricLykins's picture

Greg Johnson underlines a

Greg Johnson underlines a bunch of Haslam quotes and adds exclamation points


EricLykins's picture The Missouri

The Missouri Hospital Association and Missouri Foundation for Health have released a report examining the effects of Missouri participation in federal Medicaid expansion as outlined in the Affordable Care Act. The report found that if Missouri participates, it could add $9.6 billion! to the state’s economy, and create more than 24,000 jobs!.

EricLykins's picture

Humphrey: Harwell, Ramsey

Humphrey: Harwell, Ramsey Oppose Medicaid Expansion (but willing to listen)
Decision likely in April or May.

HHS clarified today that half-measures to expand Medicaid will not receive full federal funding.

R. Neal's picture

Vanderbilt Poll Snapshot 53%

Vanderbilt Poll Snapshot

53% of registered voter would rather have the State of Tennessee create and run its own health care exchange system, while 33% would rather have the state use the health care exchange system created by the federal government.

Rachel's picture

The hospitals will be pushing

The hospitals will be pushing the governor hard to take the additional Medicaid funding. If the state turns it down, the hospitals will be hurting.

Not only does taking it make financial sense, it would help many Tennesseans who are currently uninsured.

Which probably means that it's hopeless to get the legislature to take it.

EricLykins's picture

THA says 24 hospitals will

THA says 24 hospitals will close, leaving 22 counties without one, and "in some of THA’s modeling, hospitals will have 25 percent less dollars by 2019 than they are getting right now."

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