The Unbearable Partisanship of Expansion Denial

Peanuts, Popcorn, and a Whole Lot of Elephant Dung
Peanuts, Popcorn, and a Whole Lot of Elephant Dung
A couple of years ago, when I first published this image, I was lauded as a “chicken little” by some of my more conservative friends. They asserted that I was crying about the sky falling before a single drop had landed on my quickly balding head.

With a little time for reflection I say, “How do you like me now?”

Since last Wednesday’s decision to forego the expansion of Medicaid, and over $1b in Federal funding to do it, lots of people have sounded off on the issue. One of the best mashups of coverage came from Tennessee Values Authority over the weekend.

Pulling information from national and statewide sources, TVA shows in pretty stark terms the reality behind the rhetoric that the Governor used, to try and paint the Federal Government as inflexible and unwilling to compromise.

The Governor followed the lead of most other southern GOP lead states in effectively denouncing that favorite whipping boy of the Obama Administration…Obamacare. However, that wall isn’t as solid outside of the South. Maine is reconsidering, and seven other states with GOP Governors have accepted expansion.

This is one reason many thought Tennessee would be the next to break ranks.

Living in a dream world

In his address, the Governor invoked the “Arkansas Plan” as a model he hoped to pursue…with some tweaks.

The “Arkansas Plan” is an idea, still in the incubation stages, that would purchase private insurance through the state-run exchange for people, and include Medicaid “wrap-around” coverage.

But Gov. Haslam isn’t seeking to duplicate the idea of the “Arkansas Plan”. In fact, there are two stark differences between what Haslam proposes and what Arkansas proposes.

1. Arkansas will provide insurance to Medicaid expansion recipients with the same level of service as other Medicaid recipients. Gov. Haslam seeks to ask people to make co-pays above and beyond what Medicaid allows. This is likely in search of driving down premiums, but not actually serving more people.

2. Arkansas is running its own healthcare exchange, Tennessee is not. So Arkansas has more flexibility in terms of the market it will be seeking to provide services in. Tennessee locked itself into the Federal exchange back in December.

It should be noted, the “Arkansas Plan” has only been approved in concept, not practice. Arkansas will have to gain final approval from the Feds before they can head down this path.

In essence, Gov. Haslam has sought to make a modification to a plan that has only been tenatively approved, by adding things his administration knows full well would not be approved, and then saying “all or nothing”.

Haslam reported today that HHS head Kathleen Sebelius said “We want to work with you”. Of course, that doesn’t mean, “we’ll give away the farm”, which is what Haslam actually wants. So, nothing has changed.

In the end, this is not a good strategy if you want to get something done. Great strategy if you’re playing to a base that doesn’t like the idea in the first place.

Electoral Strategery and governance

Truth be told, Gov. Haslam is politically stuck between a rock and a hard place. On the one hand, he has his moderate image that helped bring him widespread support across the state. On the other hand, he cannot exert the same Executive authority as 44 other Governors, whose states require a 2/3 majority to override a veto.

His decision on Medicaid Expansion is part of a strategy that would allow the Governor to “save face” with Conservatives, while looking reasonable to his moderate base. What’s more, it plays into electoral politics and is hoped to hold back a primary challenge from the right. Something the Governor might not survive if the ultra-conservative wing of the GOP has a single standard-bearer to rally behind (Haslam received 47.4% of the votes in the 2010 August Primary, not a majority).

Another reality is there is little possibility the legislature would approve expansion anyway, so why risk the political capital? A bill sponsored by Sen. Brian Kelsey (R-Germantown) to prohibit the state from participating in Medicaid Expansion, has sailed through committee and currently stands in final stages of approval. The bill was opposed by the Haslam administration, but still likely had a hand in the final decision on Medicaid.

The legislature must do something to approve expansion, as it requires accepting and spending Federal dollars. Considering all these variables, from a political perspective, there wasn’t much the Governor could do, despite the support of the Tennessee Chamber of Commerce, the Tennessee Hospital Assn., the fears of Hospital CEO’s, whose patients Lt. Gov. Ron Ramsey is willing to sacrifice as victims of the free market even in rural areas which the majority of his caucus represents.

Despite those apparent challenges, the Governor could have shown some leadership instead of trying to deflect blame and come out in support of the idea, even if the nuts and bolts weren’t worked out. In doing so, perhaps some members of the GOP caucus would have given him the latitude to still uphold the Hastert Rule and Reagan’s 11th commandment, the only two rules that seem to matter in GOP politics.

I know, its asking way too much.

Yet Another Slow-Motion Apocalypse

Over the course of the past several days, I’ve sought to chronicle what will likely happen to rural communities as a result of this decision. The posts will be linked below, but in simple terms, this will be economically devastating.

Over 9000 rural jobs hang in the balance, with a direct economic impact of over $400m in actual wages lost in those areas…not to mention other jobs that will be lost in the area due to decreased demand and spending.

But the impact isn’t limited to rural counties…though it will have a far deeper and wider impact there. Hospitals in the state’s largest counties, Shelby, Davidson, Knox, and Hamilton all are impacted, bringing the total employment impact to 21,000 jobs lost.

This, after several economists predicted an increase of around 8000 jobs by 2019. Not a huge number, but better than potentially losing 21,000.

And so we find ourselves stuck between policy and politics once again. Its become a common thread in recent years. The end result, hard working people lose.

God knows, if ever there was time for a candidate that actually gave a damn about the folks who do the work that actually gets things done, that time is now. But they must get out there and start doing, rather than just talking. Talking and not doing is what got us into this mess in the first place…and it started well before Democrats started losing seats en masse in 2006.

Nationally Lampooned

Finally, I would just like to leave you with this video, that you’ve probably already seen, from the Colbert Show. Honestly, no one could have said it any better.

Previous Posts on Medicaid Expansion

Medicaid Expansion: Is there a downside?
Bill Haslam’s Death Panel
More on the Haslam Death Panel
The Economic Impact of Hospital Deserts
Distant Care – Existing Hospital Deserts
What does Medicaid expansion actually do?

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