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VOL. 40 | NO. 28 | Friday, July 8, 2016

Task force’s health plan promising, includes many ‘ifs’

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A 3-Star Healthy Task Force appointed to propose a method for catching Tennesseans in a health-care coverage gap is taking a politically safe road to reach the same goal as Insure Tennessee.

Yet the route, a TennCare expansion with “triggers” and “circuit breakers,” holds so much uncertainty it’s hard to figure out if the panel will find its destination.

Appointed by House Speaker Beth Harwell to come up with a “conservative” alternative to Gov. Bill Haslam’s Insure Tennessee, the panel recently started negotiating a “grey paper” with the federal Centers for Medicaid and Medicare Services, proposing a two-year pilot program emphasizing low-income uninsured veterans and people suffering behavioral health problems. It incorporates a link to job training and education to put people on the path to independence.

Nobody in their right mind would oppose such a plan.

For instance, Michele Johnson, executive director of the Tennessee Justice Center, an advocate for the state’s poor and uninsured residents, says, “We are pleased that there is movement on this important issue and that the task force has heard the voices of thousands of people across the state.

“The task force report reflects tremendous thought. It is more conservative than we would have wanted, but it is a constructive path to closing the coverage gap. It is critical for all lawmakers to share the public’s sense of urgency about the need to act on the report at the earliest possible date, and we expect this to move quickly when the Legislature convenes.”

The Justice Center was one of the state’s primary proponents of Insure Tennessee, presented two years ago by Haslam after nearly two years of study, but saw the plan and efforts to use some $1.4 billion annually in state taxes paid toward Obamacare fall by the wayside. It never gained enough traction to reach a vote before the full House or Senate.

The Tennessee Hospital Association, which committed to paying an assessment, about $74 million, to help fund Insure Tennessee, needs more information before it signs off on the plan, especially with the feds reviewing funding for Tennessee and holding out on payments for uncompensated care, says Craig Becker, executive director of the Tennessee Hospital Association.

“But we certainly are encouraged, the fact that we are moving forward on this thing,” Becker adds. “We’re very supportive of taking on the two-phased approach. Mental health and behavioral issues are certainly a major, major issue for all of our hospitals and the state itself.

“So it’s very wise to go that way, and then the opportunity to go to full coverage after that, the following year, is also something very attractive to us.”

Becker compliments the efforts of state Rep. Cameron Sexton, a Crossville Republican charged with leading the task force, to come up with a structure the feds could approve so the state can figure out how to pay for it.

“A bunch of pieces have to fall together here. So far, it’s gone well,” Becker adds.

Sexton, of course, is upbeat about the proposal, saying the plan addresses legislators’ concerns, primarily with the “triggers” required to move to the second phase and the “circuit breakers” enabling Tennessee to pull the plug.

If TennCare isn’t meeting costs per year, lowering use of emergency rooms and increasing use of primary-care physicians, then it won’t proceed, he says.

“I think members, when they look at the plan, they’ll look at it as a financial conservative approach and not being on the hook for a lot of state dollars in the future and not knowing how many people it could be,” he says.

The House Health Committee chairman contends this is a more “conservative” approach than Insure Tennessee because it addresses a health-care need rather than determining a plan based on whether the feds would give the state a certain amount of money.

Going at it in a two-phase approach also “protects” taxpayers’ money through a “more methodical approach” instead of “immediate implementation of the full plan.”

The details

Designed to catch people in a coverage gap between TennCare and the Affordable Care Act’s market exchange, the plan’s first phase would target people with a diagnosis of mental illness or substance abuse or proof of honorable discharge from the military and an income up to 138 percent of the poverty level. People with behavioral health disorders also would be assessed to qualify.

“In this model we’re trying to create that physician relationship for these patients so that they feel comfortable with their primary care physician or the primary care practice that they go to,” Sexton says. “And secondly, what we’re really wanting to do is move people from government assistance to independence because that should be the goal.”

Those who meet the guidelines would receive a full TennCare benefit package through its managed care organizations. It would test innovations such as health savings accounts (also part of Insure Tennessee) to create patient incentives for healthy lifestyles and disincentives for poor use of health care.

Qualifiers would pay premiums and co-payments based on the federal poverty level, around $16,000 for an individual.

They would receive account credits for health behaviors and penalties for misuse of health care.

Credits and debits would vary across the state, based on insurance ratings, but would have the same actuarial value.

The plan would use TennCare’s Health Home to bolster access.

Medication-therapy-management fees would be set up for high-risk patient groups and medications.

Extended access would be provided to tele-health, tele-psych and other telephonic services as an alternative to emergency room care.

Patients who fail to pay premiums would be locked out after receiving written warnings but could be reinstated after paying those premiums.

In addition, enrollees would receive state assistance in finding jobs, getting job training or going to school for degrees. They would receive credits in their health savings accounts for participating in the job program, and failure to participate or follow through could lead to debits.

If approved by the Legislature in 2017, the first phase could commence next year, followed by phase two in 2018. For those interested in numbers, that’s four years later than Insure Tennessee.

Sticking points

Though the task force traveled across Tennessee and talked to hundreds of people since the Legislature let out in April, its plan has a number of holes.

First and foremost, the group doesn’t know how many people it will serve, how much it will cost or even if it has federal approval.

The Department of Mental Health and Substance Abuse projects an estimated uninsured 114,000 people could be served in phase one, but Sexton says a number between 60,000 and 100,000 is probably more likely.

In addition to CMS approval, potential patients will have to be diagnosed so the state can decide who qualifies, Sexton says.

Negotiations continue with the Tennessee Hospital Association, as well, and how much it could pay. Because while Insure Tennessee would have tapped the federal government for 90 percent of the costs and presumably THA for another chunk, the feds pay only 65 percent of TennCare.

Finding the other 35 percent could prove problematic, especially if the feds decide not to cover uncompensated care for hospitals.

In a General Assembly controlled by Republicans, Democrats didn’t have the numbers to pass Insure Tennessee. They’re still a little sore about it, but they are likely to vote for the 3-Star Healthy plan.

State Rep. Craig Fitzhugh says the plan is “positive” in that the task force is “trying to keep expansion alive.”

“At least the speaker (Harwell) does propose expansion, which she’s been against before, so maybe she’s changed her mind. She’s really the one that’s put the stop on this, so maybe that opens it up to some degree,” Fitzhugh explains.

On the other hand, he believes it will cost the state more than Insure Tennessee and will provide fewer people with coverage.

Clearly, veterans and the mentally ill should be part of health-care expansion, but the state might as well move ahead with full coverage of those in the gap, which is estimated at 280,000 but could be as many as 400,000, some officials have said.

“The negative is it’s not a very well thought out plan at all. I don’t know that CMS will approve, and it’s only a two-to-one match versus the complete thing that we had before with the hospitals. I can’t imagine the hospitals are going to pick up the tab for a third of this,” says Fitzhugh, a Democrat from Ripley in West Tennessee where hospitals are folding or struggling mightily to stay open.

State Rep. John Ray Clemmons, who serves on the House Health Committee, says he will support “well-intended and well-crafted” legislation designed to help working Tennesseans.

“But I question the Republican majority’s sincerity when they talk about those issues for several reasons,” he adds.

First, he says, the Legislature could have passed Insure Tennessee and covered veterans two years ago, then addressed any remaining coverage gaps with an emphasis on mental health.

Instead, the Health Committee spent much of the 2016 session debating “discriminatory counseling bills,” Clemmons says. The Legislature passed a measure allowing therapists to decline counsel for people if they disagreed with their lifestyle, presumably gay people.

“The second problem I have with this whole 3-Star healthy project is it’s being touted as an alternative to Insure Tennessee, and that’s patently offensive to the people out there across the state suffering and the hospitals that are continuing to close,” Clemmons explains.

The Nashville Democrat contends the task force is going about the whole thing backwards, trying to come up with something that will pass the General Assembly, rather than putting together a sound health-care policy and then seeking approval.

“We’ve already turned away billions of dollars in our own taxpayer money, and all they’re wanting to do is just push it further down the road to the point that it wouldn’t come into effect until we have a Democratic governor.

“And then they’re gonna turn around and try to blame it on whoever the Democratic governor is for doing that very thing we should have done two years ago,” Clemmons says.

Clemmons even questions the color paper of the presentation itself, a grey paper as opposed to a white paper, which is a persuasive, authoritative report presenting solutions for a specific topic.

“My guess is the only thing this grey paper had in common with a white paper was that it was on paper,” he points out. “And that gives me very little confidence CMS is going to approve whatever this committee has proposed to it.”

The analysis

The task force’s creation and effort should not be dismissed. Sexton and others have put in yeoman’s work.

Considering the Legislature could not bring itself to support a plan using billions of Tennessee tax dollars created through President Barack Obama’s Affordable Care Act, something had to be done to help people caught between TennCare and Obamacare, a situation caused by the state’s refusal to participate in the Affordable Care Act.

If nothing else, Sexton and the committee should be commended for sitting through these meetings for hours on end to discuss health-care policies. It’s sort of like going to the dentist’s office every day for a year to get your teeth drilled.

The question, though, is this: Why is this necessary? For the Legislature, 3-Star Healthy is sort of like walking from Memphis to Mountain City to find its way to Nashville.

And, if “circuit breakers” kick in at the end of 2017, rather than “triggers,” as the late Yogi Berra said, it’ll be “deja vu all over again.” They’ll have to come up with another study group and a new catchy name. By the time they agree to something, Tennessee could have four stars.

Sam Stockard can be reached at sstockard44@gmail.com.

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