PROBLEM STATEMENT:

(a) Atwater will protect Tennesseans at all costs. Our state government should include protecting the health and safety of state residents and helping us prosper. As the next Governor of the State of Tennessee, I will work unconditionally with the General Assembly to bring about positive medical coverage changes for Tennesseans.

(b) The refusal of the state of Tennessee since 2014 to accept over $10 billion in federal health care benefits for the working poor, some 300,000 low-income, uninsured Tennesseans who may be the most disadvantaged people of this state. This rejection of federal funds by Tennessee (and 11 other states) has done considerable damage.

(c) Many of the 300,000 uninsured include essential workers who have served us food in restaurants, built or remodeled our homes, and cared for children and the elderly who are homebound. Some have lost or left their jobs because of the COVID-19 pandemic. These unfortunate Tennesseans cannot afford private health insurance offered on the Affordable Care Act exchange, and they cannot get TennCare’s Medicaid insurance mainly because they are not pregnant, elderly, or disabled, have no dependent children, or make too high a wage.

(d) they are stuck in the health insurance coverage gap, they often delay care for an injury or infection. Why? Because they fear receiving an unaffordable medical bill. Some die early, preventable deaths as a result. Others go to the emergency room late for needed care, receive an unreasonably high medical bill and declare bankruptcy. As a result of unpaid exorbitant medical bills, Tennessee has one of the nation’s highest numbers of personal bankruptcies.

(e) The state’s rejection of Medicaid expansion has damaged rural communities. In at least 14 of these, their hospitals have closed because few residents are insured and have the ability to pay medical bills. As a result, highly paid doctors and other healthcare employees have left, reducing support for town businesses, churches and charities. State officials know it is futile to try to attract new businesses and industries to rural communities with no hospital services. State politicians should not be proud that, after Texas, Tennessee holds the record for having the highest rate and number of hospital closures in the nation.

(f) Under the American Rescue Plan Act of 2021, states that adopt Medicaid expansion have to pay only 5%, not 10%, of the cost, with the rest being federally funded. When this law was passed, Tennessee hospitals jointly pledged as a group to pay the state’s contribution to Medicaid expansion. A recent poll indicated that 65% of Republican lawmakers in the Republican-led Tennessee General Assembly support Medicaid expansion whereas only 15% oppose it while 20% have no opinion.

(g) Many of the supportive lawmakers probably know that Tennessee exceeds the national chronic diseases: diabetes, high blood pressure and cardiovascular disease. Most know that a growing number of Tennesseans suffer from mental illness and drug abuse. At least a few are aware of the published Harvard-Vanderbilt study titled “Medicaid expansion slowed the rate of health decline for low-income adults in Southern states.” Are some legislators holding back on supporting Medicaid expansion because of campaign funds they receive from Americans for Prosperity, the Beacon Center of Tennessee and the National Federation of Independent Business (all of which oppose expansion)? Are some rejecting the deal because they were fundamentally opposed to the former president whose administration enabled Medicaid expansion? Do they really see the additional funding as an entitlement for unfortunate folks they view, or stigmatize, as lazy and unwilling to work? Are they truly afraid that the federal government might pull out of the deal and leave the states responsible for funding most of the Medicaid insurance for a larger population?

With the Strategic Planning of the Healthcare Impact Tennessee ORANGE Volunteer Health Committee, I would launch a progressive "Medicaid for All" Plan to ensure that all Tennesseans have access to quality healthcare. Healthcare should be a human right. Tennesseans should not be medically suffering because they are poor. I would immediately assess the fiscal budget to cut governmental waste, abusive government contracts, and duplication of governmental services, such as electric government cars or retrofitted with solar panels or hydrogen

1. Nationwide, over 1.6 million adults fall into the Medicaid coverage gap, lacking any affordable health coverage option — their income is too high to qualify for their state’s Medicaid program but too low to qualify for financial assistance in the Affordable Care Act (ACA) marketplace. In Tennessee, some 95,000 uninsured adults in the coverage gap would become eligible if the state expanded Medicaid. Expanding Medicaid to 138 percent of the federal poverty level ($20,780 for an individual in 2024) would provide coverage to Tennesseans who are now shut out of coverage. To qualify for Medicaid in Tennessee, parents must earn less than 82 percent of the federal poverty level (or less than $21,170 for a family of three annually).* Adults without dependent children are not eligible for Medicaid at all.

2. Medicaid expansion in Tennessee could cover roughly 150,000 to 300,000 uninsured residents, potentially lowering rural hospital closures and improving health outcomes. Proponents argue it provides crucial care and economic benefits, while opponents raise concerns about long-term state costs exceeding $1.7 billion and increased taxpayer burden.

3. Increased Coverage: Over 300,000 uninsured Tennesseans could gain access to healthcare.

4. Rural Health Support: Expansion could help prevent rural hospital closures, with data suggesting expansion states see a 62% decrease in such risks.

5. Financial Security: Increased coverage helps lower medical debt and improves personal finances.

6. Economic Impact: The American Rescue Plan could offer an additional $1 billion to Tennessee, with studies suggesting expansion could save the state millions annually.

7. Long-Term Costs: Critics estimate a 10-year cost to Tennessee taxpayers of over $1.7 billion. The cost would be recouped from the billionaires who are not paying their excise taxes at present, which is an abomination to the working class that is paying their taxes and struggling to stay afloat due to inflation.

8. Fiscal Responsibility: Opponents fear the federal government could reduce its 90% matching rate, leaving the state responsible for more funding. Governmental waste and the collection of taxes from billionaires would balance this presumption. A possibly, change from the 90/10 match for Medicaid expansion to a “blended rate formula,” which would create a federal funding level somewhere in the middle, but below 90/10.

9. "Woodwork Effect": Concerns exist regarding the influx of newly eligible individuals ("woodwork effect"), increasing costs unexpectedly. Creative maneuvers will be integrated to offset this concern.

10. Philosophical Opposition: Some, including state leadership, have hesitated to support expansion due to political and fiscal concerns. I have no hesitation in supporting Medicaid for All. It is overdue, and it is time for a Governor to step up and do what is in the best interest of all Tennesseans.

Closing the Coverage Gap Will Help Tennesseans:

(a) Improving access to care and health outcomes - Expanding coverage increases the use of preventive care, reduces utilization of emergency care, and improves health outcomes for pregnant and postpartum people, babies, and people with cancer, mental health conditions, and other health conditions. Medicaid expansion prevents premature deaths; due to the state’s decision not to expand Medicaid, 964 Tennesseans aged 55-64 died prematurely between 2014 and 2017 alone.

(b) Reducing racial and ethnic disparities - People of color make up 65 percent of the coverage gap population nationwide and 36 percent in Tennessee. Closing the coverage gap is one of the most effective ways to reduce inequities in coverage and health outcomes, as well as reduce inequities in delayed care and unmet need for care.

(c) Covering more children - When parents have coverage, children are more likely to be enrolled and to access health services. Between 2016 and 2019, a time of rising uninsured rates, the uninsured rate among children in non-expansion states grew at nearly three times the rate in expansion states.

(d) Improving financial security - People with coverage are less likely to face catastrophic medical costs, leave bills unpaid, face eviction, or borrow money to pay for medical care. Between 2013 and 2020, states that expanded Medicaid in 2014 experienced a decline in new medical debt that was 34 percentage points greater than that of states that did not expand Medicaid over this period.

(e) Reducing uncompensated care costs and creating state savings • Research shows that state costs of expanding coverage are largely or fully offset by savings in uncompensated care and other areas. • The American Rescue Plan offers an additional $1 billion to Tennessee should it expand Medicaid.

(f) Keeping Rural Hospitals Open - Since 2010, 15 rural hospitals have closed in Tennessee. Being located in a Medicaid expansion state decreases the likelihood that a rural hospital will close by 62 percent. When rural hospitals close, a critical source of health care and employment disappears in rural communities, and strain falls on surrounding hospitals.

WIN-WIN SITUATION FOR MEDICAID EXPANSION (MEDICAID FOR ALL):

Expanding Medicaid in Tennessee (often referred to in advocacy as "Medicaid for All" in the context of covering the "coverage gap") offers significant potential benefits, primarily aimed at improving health access for over 300,000 uninsured residents and bolstering the state's economic and healthcare infrastructure. Key pros include the infusion of federal funding, increased financial stability for rural hospitals, and improved health outcomes.

1. Significant Federal Funding and Economic Growth: Tennessee could gain roughly $1.4 billion in federal tax dollars annually. Additionally, the American Rescue Plan offers an estimated $900 million over two years, providing a net gain in the state's economy and supporting approximately 15,000 to 18,000 new jobs.

2. Rural Hospital Stability: Tennessee has one of the highest rates of rural hospital closures in the country. Expanding Medicaid decreases the likelihood of a rural hospital closing by 62%, as it reduces uncompensated care costs when residents gain coverage.

3. Coverage for the "Coverage Gap": Roughly 95,000 to 300,000 uninsured adults who currently earn too much for Medicaid but too little for Affordable Care Act (ACA) marketplace subsidies would become eligible for coverage.

4. Improved Health Outcomes: Expanded coverage is associated with improved access to preventative care, chronic disease management, and a reduction in mortality rates for conditions like cancer. Specifically, studies show expanding Medicaid could reduce the high number of premature deaths among Tennesseans aged 55-64.

5. Access to Mental Health and Addiction Treatment: Tennessee has high rates of opioid overdose deaths and mental health issues. Expansion provides coverage for necessary mental health services and substance use disorder treatment, including medication-assisted treatment.

6. Enhanced Maternal and Infant Care: Medicaid expansion would provide one full year of postpartum coverage for mothers and support prenatal care, addressing Tennessee's low rankings in maternal and infant health.

7. Reduced Uncompensated Care Costs: Hospitals would see a reduction in the costs of treating patients who cannot pay for their medical care, which helps stabilize health systems.

8. Increased Financial Security for Families: Residents with coverage are less likely to face catastrophic medical debt, eviction, or bankruptcy.

9. High Federal Matching: Tennessee has a high federal Medicaid matching rate (FMAP) at 66%, meaning for every $1 spent by the state, the federal government matches $1.85.

10. Public Support: A 2018 survey found that nearly two-thirds (63%) of Tennessee voters support expanding Medicaid. As the next Governor of the State of Tennessee, it is time for Medicaid Expansion.

Optional Alternative:

State-Based Universal Health Care Act of 2023

This bill establishes the option for states, or groups of states, to apply to waive certain federal health insurance requirements and provide residents with health insurance benefits plans through a state-administered program. Such programs must cover 95% of the residents in the state within five years, and plan benefits must be at least as comprehensive and affordable as the coverage under the equivalent federal program.

State programs are supported with funds from the federal programs that the state programs replace, which may include Medicare, Medicaid, the Children's Health Insurance Program, the Federal Employee Health Benefits program, certain federal tax credits, and premium-assistance funds, among others.

The bill requires the Department of Health and Human Services to appoint an Independent Assessment Panel for Comprehensive Care to review and recommend whether to approve state applications. Each approved state program must be independently reviewed every five years to evaluate changes in health benefits access, quality, and coverage, including whether the state has met the 95% coverage requirement.

The federal government must pay all health insurance costs for American Indians and Alaska Natives who enroll in a plan through a state insurance program.

ATWATER GOAL AND STRATEGIES:

TBA