Dear Bill: An Open Letter to Gov. Bill Haslam

As I trust you know, I have long admired and respected you.

I endorsed you when you ran for mayor despite the objection of most of Metro Pulse's editorial staff, who favored your opponent. I also saluted your accomplishments as mayor and your superb appointments, especially Bill Lyons, Larry Martin, and Madeline Rogero.

I also enthusiastically supported you for governor. And when Zach Wamp, then Bill Baxter, spuriously attacked you, I went after them with tongs in my column to set the record straight.

When you were mayor, you were always good about returning my calls and making time for informative, candid meetings. Since you've risen to higher office, though, I've somehow felt inhibited from calling you. But that's not because you've spurned me.

The one time I sought a meeting, you carved out time for me to talk about an issue of paramount concern, namely implementation of the provisions of the federal Affordable Care Act, over which the state has control. I'm talking, of course, about extension of health care coverage to some 300,000 uninsured Tennesseans with incomes below the federal poverty line ($11,450 for an individual), which the ACA would cover by expanding eligibility for Medicaid in states that opt to do so.

As an alternative to TennCare (Tennessee's Medicaid) expansion, you have proposed covering them with insurance purchased on the new Exchange that is an ACA centerpiece. And federal officials have expressed receptivity to this "private option" approach with the same full federal funding of the cost through 2016, not only for those below 100 percent of FPL but also those up to 138 percent.

The rub comes over the extent to which those covered on the Exchange would have to share the cost through out-of-pocket expenses for co-payments. Your plan "would include co-pays for those that can afford to pay something, so the user has some skin in the game when it comes to health care incentives," you told the state Legislature when unveiling it in March.

I'm sympathetic to the proposition that such cost-sharing can make people generally more sensitive to the cost of health care and contribute to containment of its escalation. But folks with incomes below the poverty line simply don't have much skin to spare.

Moreover, the federal Medicaid statute stipulates that any cost-sharing on their part must be "nominal." On July 5, the federal Centers for Medicare and Medicaid Services (CMS) issued a rule defining nominal to mean no more than $4 for a doctor's visit, $75 for a hospital stay, and $4 for a prescription drug.

Since the rates and other terms on which insurers will (starting October 1) will be offering coverage on the Exchange in Tennessee have yet to be announced, the amount of cost-sharing is unknown at this point. But it's safe to assume that co-pays, deductibles, and the like will exceed the Medicaid-prescribed nominal amounts.

On July 3, your director of communications, Alexia Poe, told me you believed you were "making steady progress" in negotiations with CMS that would yield the state the $2 billion a year in Medicaid funding needed to cover everyone up to 138 percent of FPL on the Exchange (with higher cost-sharing allowable for those above 100 percent). But since the CMS rule came out on July 5, you've been singing a different tune. Although Tennessee is "still having discussions," the rules are "not encouraging," you told reporters in Nashville.

Some commentators have contended from the outset that your "skin in the game" criteria were intended to be a "poison pill." And even your former health care aide, Brian Haile, has been quoted as opining that you don't want to put participation in "Obamacare" to a required vote in the Legislature until after next year's Republican primary—those who support it wouldn't face the threat of Tea Party opposition.

In all the years I've known you, I've never seen you resort to subterfuge or guile, and I don't want to believe anything different now. But when I look just to the west in Arkansas, I see Gov. Mike Beebe, who's gotten a Republican supermajority in his Legislature to approve a "private option" plan under which all cost-sharing for insurance purchased on the Exchange for those with incomes below 100 percent of FPL will be covered with public—exclusively federal—dollars. And I ask myself—and you—why can't Bill Haslam do the same, or at least accept that CMS' definition of statutorily "minimal" cost-sharing is reasonable.

When I look at so much effort on the part of so many to encourage Exchange enrollment on the part of the 500,000 uninsured Tennesseans who are eligible for federally subsidized coverage, it will be a terrible shame if they have to tell the 300,000 in direst need, "Sorry, you are ineligible." Yet that will be the case under the terms of the ACA if you don't get both federal and state approval of a plan that includes them.

In your address to the Legislature presenting your plan, you also said, "A lot of us in this room have a real concern for those the Bible refers to as ‘the least of these.'" That's precisely who would and should be covered for three years (2014-2016) at minimal cost to the state.