by Holly Fletcher
The Incoming class of elected officials will encounter a variety of outstanding — yet often overlooked — health care policy questions that will impact health and providers across Tennessee.
Health care, particularly protection of pre-existing conditions, rallied voters across the country, yet Tennessee campaigns focused on other issues, so Vanderbilt’s Department of Health Policy reached out to the gubernatorial campaigns in the final weeks before election day. They posed both candidates questions about five issues pegged as priorities for Tennessee.
“Voters didn’t hear very much detail during the campaign, and we wanted to establish a line of communication with the next administration, so we reached out,” said Melinda Buntin, PhD, Mike Curb Professor and chair of the Department of Health Policy.
The midterm was a “pivotal election” and will impact the tone and path of policy for the next decade, Buntin said.
Republican governor-elect Bill Lee will take office in early 2019 and inherit a web of issues, poor health, volatility in coverage, and rising health care costs.
Mark Cate, president and principal of Stones River Group and former chief of staff for Gov. Bill Haslam, speaking at a bipartisan look forward forum hosted by the Health Policy department, quoted Haslam as saying health is the biggest issue going forward.
Cate and Lisa Quigley, chief of staff to U.S. Rep. Jim Cooper, D-Tenn., joined Buntin on Nov. 13 for a discussion about what lies ahead for health policy in Tennessee. The conversation touched heavily on the prospect of Medicaid expansion or an alternative.
“In reality in Tennessee, I worry about Medicaid expansion being a litmus test on both sides,” said Cate. “I think both sides can look at that and forget there are other health policy issues.”
Looking forward
The campaign trail didn’t elicit nuanced views on health care policy or new ideas from either side. Candidates primarily stuck to the views of their party on Medicaid expansion without exploring the complicated landscape facing rural hospitals or tension about who pays what for care.
“There’s not a depth of health care policy that was thought of during the campaign,” said Cate.
Buntin said there is agreement on the need to lower the cost of health care and preserve existing coverage gains and Medicare benefits — although there is divide on other issues.
Lee, who talked about the rural economy on the campaign trail, often says, “we’ve got a broken health care system,” said Cate. Lee is proponent of preventive care and behavioral health care and is opposed to expanding Medicaid.
“He talks about innovation,” Cate said.
Even though Republicans maintained a supermajority in both the state House and Senate, there will be new faces in legislative leadership positions, which will set the tenor going forward, said Cate.
There are limited ways the executive branch can implement unilateral policy initiatives. But there could be a push to further use schools in the fight against childhood obesity — a ranking in which Tennessee is worst in the nation per the Commonwealth Fund — or leveraging incentives for employers who encourage healthier choices by employees, said Cate, when asked where the next governor might see opportunities.
Medicaid expansion
Tennessee is one of 14 states to hold out on Medicaid expansion even as the optional component of the Affordable Care Act (ACA) swept across the country, with voters in three Republican-controlled states approving expansion via referendum in the mid-term election.
But in Tennessee, the future of Medicaid expansion is as murky as ever since Lee is opposed to expansion and Republicans retained a supermajority in both the state House and Senate. In Tennessee, the state legislature must approve expansion, and it tasked TennCare with proposing work requirements for the existing program to federal officials.
Expanded access to coverage rallied proponents, but Tennessee voters elected leaders who oppose expanding the program which, Cate noted, is still intertwined with the partisan sentiment toward Obamacare.
But Cate said not to “read too much into the rhetoric even, ‘I don’t believe in Medicaid expansion,’ as there are other alternatives.” He said Republicans are aware of the conversation around health care “and feel challenged to do something about that.”
Quigley signaled the Democrats would be open to a compromise on work requirements if it meant expansion.
The referendums earlier this month, she said, point to a “pretty robust consensus” on Medicaid expansion and that if work requirements were a bridge to expansion in Tennessee that “most of us on this side of the aisle would take that deal.”
Quigley later joked, “Let’s call it Bill Lee-care” if it helps the new administration take a new approach.
Federal level
Quigley and Cate agreed the anticipated Blue Wave was more of a blue trickle in Tennessee. The outcome of the midterm puts Tennessee on track to be a reliably red state for another generation, said Quigley.
Nationally, the flip of the U.S. House to the Democrats’ control is a “bit of a draw,” said Quigley, explaining that Democrats can block ACA repeal attempts but won’t be able to fix components or advance new initiatives without Senate support.
An upcoming ruling in Texas in a challenge to the ACA’s individual mandate could thrust the law back into the spotlight as the new Congress kicks off. Quigley said it’s time for people to think about whether they like the employer-sponsored coverage system enough to commit to fixing it or prepare for a stronger push for Medicare for All.