Reaction in Knoxville and across the state over the past week to the final passage of a federal health-care bill seemed to follow two very different tracks: the policy and the politics.
In the policy realm, you have longtime advocates of health-care reform sounding at best lukewarm about what the legislation signed by President Barack Obama on March 23 will actually do.
"It doesn't have any cost-containment measures in it," says Dr. Debbie Allen, the medical director of Knoxville's Interfaith Health Clinic, which serves thousands of uninsured patients each year. "It doesn't do anything to support patient-based medicine. The drug companies are heavily involved. It doesn't do anything about self-referral, doctors referring patients to centers that they have a financial interest in. Nothing about tort reform."
Allen, who thinks the best way to expand access and control costs would be a European-style Medicare-for-all system, thinks the bill makes too many concessions to the private interests that already have huge influence on American health care: drug companies, insurance companies, and for-profit medical operations.
"I think Obama's heart is in the right place," she says. "I think the profit motive just needed to come out."
Needless to say, that's not quite how the legislation is being painted in the world of Tennessee politics. Rep. Zach Wamp of Chattanooga and Oak Ridge, one of the three leading Republican contenders for governor this year, promised on his campaign website to "Fight Against the Federal Healthcare Takeover!" (Capital letters and exclamation point are his.) Lt. Gov. Ron Ramsey, also in the gubernatorial sweepstakes, called the bill "a disaster for Tennessee citizens," because of expected cost increases in Medicaid/TennCare.
And the state House of Representatives took up consideration of the Tennessee Health Freedom Act, which the state Senate passed in February on a vote of 26-1. Taking aim at the federal legislation's "individual mandate" that everybody purchase some form of health insurance, it asserts the right of citizens "to choose or decline to choose any mode of securing health care services without penalty or threat of penalty." It requests that the state attorney general file suit to block the federal bill. (Attorneys general from 13 states filed a similar suit the day Obama signed the bill. A 14th state, Indiana, joined the suit this week, and Virginia has filed a separate challenge.)
But by the end of last week there were already signs of uncertainty about the political staying power of the issue. Gov. Phil Bredesen, whose 2009 characterization of health-care reform as "the mother of all unfunded mandates" has been widely quoted by Republicans, struck a more conciliatory tone after the bill's passage. In an interview with Knoxville's WATE, he said, "It wasn't exactly what I was hoping would come out of it, but I accept we had a vote. This is the way democracy works, and we're going to make it work."
As for state Attorney General Robert E. Cooper Jr., a Democrat and a former legal counsel to Bredesen, he immediately issued a press release that said that his staff is conducting "a thorough and detailed analysis" of the federal bill. Although it noted that Cooper is "mindful of the concerns" expressed by the General Assembly, it added that the individual mandate and the expected expansion of Medicaid "will not take effect for several years." (Not until 2014, to be exact.) That at least hints that Cooper is in the legal camp that thinks that part of the bill may not be ripe for challenge.
Maybe the most telling sign of hedging about how health-care politics will play in August or November is the position gently staked out by Knoxville Mayor Bill Haslam, whose own gubernatorial campaign has been careful to sound indignant (on March 21, he called the bill "an intolerable expansion of federal power") without making any particular promises about how he would address the issue. While Wamp has been belligerently pledging to meet federal regulators "at the state line," Haslam says, "I will pursue every means necessary to protect our state's interest."
Asked whether he supports the Health Freedom Act, Haslam issued a statement that he is "interested in pursuing every available option for preventing or lessening the damaging impact this bill will have on our state and its citizens." But what exactly does he mean by "our state's interest," and which particular "damaging" impacts does he have in mind? A campaign spokesman said Haslam didn't have any more specific comments at the moment.
In any case, all the Nashville posturing seems far away and off the mark to Dr. Mark Green of Maryville, an internist who runs a website called Ourhealthreform.com and who wrote about the issue for Metro Pulse last fall. Observing the reaction to the federal bill last week, he said, "I'm incredibly disappointed at how political everything is."
Like Allen, Green thinks the legislation does too little to rein in insurance companies or to control unnecessary medical procedures. And while he applauds its expanded access and its limits on exclusions for pre-existing conditions, he doubts that its costs are sustainable. "We already spend well more money on health care in America than we should, and adding another trillion dollars on top of it, I can't imagine what the per capita expenses are going to be."
At the Interfaith clinic, Allen doesn't expect to see any real effects from the federal bill for several years, if then. In the short term, she says, it will allow a few of her college-aged patients to return to their parents' insurance plans (under the legislation, children can remain on a family policy until their 27th birthday). But she says that will be more than offset by the continued effects of the recession and the rising costs of private health insurance. Interfaith is adding 125 to 150 new patients a month, many of them people who have insurance available through an employer but can't afford the premiums.
"We've seen a nurse who works for a major company here who just gave up her insurance because her husband lost his job," Allen says. "She has four children."
She adds, "We've never been busier."