Last November, Tennessee’s Republican governor Bill Haslam won his reelection effort resoundingly, taking 70 percent of the vote and every single county in the state. Just six weeks later, Haslam surprised nearly everyone in Tennessee’s Republican-controlled state assembly by announcing that one of his first orders of business in his second term would be to expand Medicaid under the umbrella of the Affordable Care Act, also known as Obamacare. But a month and a half later, Haslam’s Medicaid expansion was dead. The debate was over nearly as soon as it started.
It wasn’t supposed to be this way for Haslam. Since the passage of Obamacare, Republican governors have generally taken one of two tracks on Medicaid expansion. Some like, Wisconsin’s Scott Walker and Louisiana’s Bobby Jindal, rejected the expansions outright. Others, like Ohio’s John Kasich and Indiana’s Mike Pence, have accepted the federal dollars and expanded the eligibility for low-income residents to receive Medicaid coverage. Each of the listed governors had compliant Republican legislatures. Whatever path Haslam pursued, he might have reasonably assumed the GOP in the state capitol might have gone along with it.
If he made that assumption, it was a mistake. The governor hadn’t even given fair warning to many of the legislators he’d need to support his proposed expansion (called Insure Tennessee) before publicly announcing it last December. Republican state senator Brian Kelsey remembers finding out about the Medicaid expansion proposal from a tweet of the news on December 15 last year. Earlier in 2014, Kelsey and a GOP state representative, Jeremy Durham, had successfully championed a bill that would require legislative approval on any such expansion (state law had previously given the governor regulatory discretion). Kelsey says what they had in mind in drafting the bill was an effort by a future Democratic governor to add to the rolls of Medicaid. But from Haslam?
“We did not expect this governor to do this,” says Kelsey.
That was for good reason. In his bid for reelection, Haslam did not campaign on Medicaid expansion. In fact, he had previously touted the decision by the state not to expand Medicaid as Obamacare originally dictated. There had been talks with some in the legislature about finding a way to expand coverage for those who made too much to qualify for Medicaid but who weren’t self- or employer-insured—something Kelsey says he was interested in, so long as there were no federal dollars and Obamacare regulations.
But Haslam’s Insure Tennessee plan had been in the works for a while. Both of Tennessee’s Republican senators, Lamar Alexander and Bob Corker, worked with the governor’s office and Secretary of Health and Human Services Sylvia Burwell to develop what Haslam termed his “alternative approach” to expanding Medicaid, one that “forges a different path and is a unique Tennessee solution.” The details of Insure Tennessee may have been different from Obamacare’s directives, but the end result was essentially the same: The state would change its eligibility requirements and to place more Tennesseans on Medicaid, with the federal government footing the bill. Lieutenant governor Ron Ramsey, a Republican, originally praised it as a plan that “returns tax dollars back to Tennessee.”
But members of the general assembly weren’t convinced of the merits. The expansion would have opened up two new coverage options to Tennessee’s Medicaid program, using federal and state tax dollars, which Republicans called an unsustainable expansion of the welfare state. There were concerns about the possibility that future federal support might drop off. Ramsey, who is also the speaker of the senate and traditionally carries the governor’s agenda through the legislature, ended up remaining publicly neutral. Opposing the plan from the outside were the Koch-backed Americans for Prosperity and a free-market think tank called the Foundation for Government Accountability, which has been on the forefront of fighting Medicaid expansion across the country. And Insure Tennessee got hammered on local talk radio.
All of this prompted Haslam to take a statewide tour to promote the plan himself. And the governor certainly wasn’t alone. Business groups like the Tennessee Hospital Association and the Coalition for a Healthy Tennessee ran ads featuring those citizens who would benefit from enrolling in Medicaid. The Coalition even published a poll in early February showing plurality support across the state for the plan—even as a majority said they opposed Obamacare. “The more Tennesseans – and especially Republicans – learn about Governor Bill Haslam’s Insure Tennessee plan, the more they like it,” trumpeted a press release.