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What you’ll read about: BirdDog sent seven questions to the Tennessee governor hopefuls to illuminate policy stances on a range of health care topics, including outpatient treatment for substance abuse, balance billing, whether Medicaid expansion would be a priority, and whether the state and/or employers have an obligation to help with access to coverage.

Updated at 6 p.m. on 4.19.2018 to reflect additional responses.

The next governor of Tennessee will inherit numerous health challenges that entwine with other factors shaping how the economy progresses in the coming decades.

Issues range from how to structure or expand Medicaid, whether to refashion the benefits covered in individually purchased insurance, what types of clinicians practice to what scope, and how to regulate the construction of new health care facilities.

Leaders from across the state say that businesses considering expanding or relocating to Tennessee make access and cost of care a top consideration.

And, time after time, employment with benefits has proven to be the easiest way to get coverage.

Surging deductibles — in both employer-sponsored and individually purchased insurance — are hitting families, as well as clinics that have traditionally served the uninsured but are treating more of those who are underinsured.

» Education, jobs, saving access to care: Governor candidates pitch strategies for sustaining rural Tennessee

Tennesseans who need outpatient treatment for substance abuse often find waiting lists at the places that do offer the service.

So far, topics at gubernatorial health care forums have focused on both the big picture of Tennessee’s poor health status and the candidates’ positions on traditionally partisan, and broad, topics, ranging from Medicaid expansion versus block grants to work requirements. Candidates have also talked about the scope and breadth of the opioid abuse epidemic, and how they want to work across the educational, criminal justice and health care sectors to stem the crisis.

The candidates speaking at those events often sound similar when articulating the importance of improving Tennesseans’ awareness of overall health, sustaining access to care in rural areas, and highlighting the interconnectedness of health with prosperity and education — an increasingly frequent talking point.

Some differences, however, are beginning to emerge.

At the Rural Tennessee Gubernatorial Forum in Jackson on April 17, Republican candidate Bill Lee said he’d make deregulation of health care in the state a priority — notably the certificate of need process around freestanding emergency departments — in addition to focusing on costs.

Karl Dean, former mayor of Nashville who is campaigning for the Democrats’ ticket, wants to look at how to cut or cap costs while focusing on preventative care, including creative tech-enabled alternatives, and expanding Medicaid.

State Rep. Craig Fitzhugh, D-Ripley, wants to expand Medicaid; and make sure people in rural areas aren’t finding that the only emergency care is in the back of an ambulance and that they have access to more types of care than just hospitals.

Meanwhile Randy Boyd, a Republican candidate and the former commissioner of the Tennessee Department of Economic and Community Development, didn’t get asked specifically about hospital closures. Boyd wants to focus on improving the health of the workforce, be “smarter about costs,” and that focusing on insurance is “missing the point” when talking about how to improve.

Neither Tennessee House Speaker Beth Harwell, R-Nashville, nor U.S. Rep. Diane Black, R-Tenn., attended.

BirdDog reached out to each of the top tier candidates on April 9 with seven questions to be answered in 200 words.

Two of the candidates, Black and Fitzhugh, responded to each. Dean sent answered one question while Boyd and Lee’s schedules prevented a response by publication. Harwell’s communication team did not respond to email inquiries.

Find the answers, in full, below. If more responses arrive, the post will be updated. (Updated to include responses from Lee on 4/19).

1. Eight years into the Affordable Care Act, please provide a synopsis for how you believe the federal law has affected and impacted Tennesseans: What do you think has worked and what has not worked? As governor, what you would like to change about implementation in Tennessee?

Black:

Obamacare has been an absolute disaster in Tennessee.

After expanding TennCare nearly bankrupted our state, Tennessee knew single payer health care was not going to work. It didn’t work at the state level, and it certainly didn’t work nationwide.

After the single-payer experiment, we instituted Cover TN and Access TN that gave Tennesseans options for a health care plan they wanted at a price they could afford. But our state-based solutions were eliminated under Obamacare, which mandated certain types of coverage.

This was especially true for the rural communities across our state. When Obamacare was signed into law, the federal government told our farmers that their existing plans they had through the Farm Bureau did not meet their standards. Thousands of farmers were immediately thrown off their insurance plans.

Under Obamacare, people are paying high premiums and high deductibles. And we have seen that even though they may have a card, they don’t actually have access to care.

Since Obamacare was enacted, Tennessee has seen nine hospitals close, the second-most closures in the nation, leaving many rural communities 45 minutes from the nearest emergency room.

As governor, I will push for a patient-centered solution to let patients choose the doctor they want and an insurance plan at a price they can afford. •

Fitzhugh:

The Affordable Care Act has provided insurance for a large population that may otherwise not have had healthcare coverage. When the ACA was implemented, it allowed for people to not be tied to their job for their coverage. But when the system was created, it was created as a system that would work hand-in-hand with Medicaid expansion.  In the states where expansion happened, the ACA has had better results. Options for plans have not been as plentiful in Tennessee because of this, and with our hospital closures— that can be directly tied to the failure of not expanding Medicaid — the system has not functioned as intended.  Insurers have changed their plans and coverage, and every county in Tennessee has different options.  Options for coverage have to be more uniform for the ACA to work in Tennessee. •

Lee:

The biggest impact the ACA has had on Tennessee has come in the form of rising insurance premiums.

As an employer who purchases healthcare for nearly 1200 employees, I’ve seen our rates rise 29% and 19% in the last two years. The rate increases in the group market are a reflection of failed government mandates, which has left many Tennesseans with fewer coverage options.

Unfortunately, the ACA in its current form fails to address many of the fundamental issues in our healthcare system: an outdated fee-for-service payment model, a lack of emphasis on health and healthy incentive, and an uncompetitive insurance market. I’d prefer to see a wholesale change that provides more choices for consumers, rewards innovation for providers, and address the question of rising costs. •

2. What qualifications are you looking for in future commissioners of the Tennessee Department of Health and Department of Commerce and Insurance? What approach will your TDCI commissioner have toward reviewing and approving premiums on the federally run marketplace?

Black:

With my healthcare background, I want commissioners of Health and Commerce and Insurance who will work with me to make sure that Tennesseans are getting the best deal possible. We need people in leadership positions who understand the industry, but also understand that more government is not the solution – in fact, government is often an impediment to the solution.

I have a relationship with President Trump and Vice President Pence and we will work with them to make sure that Tennesseans have more access to health care at a price they can afford. I know that the Trump Administration is looking at ways to increase transparency and provide states more flexibility in developing health care solutions and I will work with them to get that done for Tennessee. •

Fitzhugh:

The commissioners of the Tennessee Department of Health and the Tennessee Department of Commerce and Insurance (TDCI) would have to have the same goal: improving the lives and health of our citizens.  They would have to make sure that we are serving the working families of Tennessee — not insurance companies. Insurance companies have to partner with our administration — not be an entity that attempts to dictate policy through scarcity. The TDCI commissioner will have to approve plans that are affordable and flexible to the needs of consumers. Healthcare is a product that every person uses — it has to work for all. •

Lee:

Every insurance commissioner has a duty to ensure the solvency of the marketplace and to protect consumers. But under the current federal model, both are extremely challenging to achieve. Last year Cigna requested an average 42% rate increase. Blue Cross Blue Shield requested 21%. With a greater number of healthier people leaving the exchange, I think we can expect that these insurers will continue to seek significant rate increases in the future.

I will look for commissioners who share my vision for the ideal healthcare system: a marketplace where patients have choices and freedom, and preventative health and healthy behaviors are accessible and rewarded. •

3. The state’s uninsured population fell to 9 percent in 2016 – a record low. Working age adults are more likely to be uninsured than children or older adults; many have jobs that don’t offer plans or affordable coverage. Do employers and/or the state have a role to help provide access to coverage or care? Explain.

Black:

The best way to get good health insurance is to get a good job that provides good benefits. Our state’s economy is doing well, and I believe our record low uninsured population reflects of that. But we need to continue to build on our progress.

And for those who are purchasing insurance on the individual market, we can make sure that there are options for folks to buy an insurance plan that has the coverage they need at a price they can afford.

There should also be a strong safety net for those who need it. We can play a role in helping those who are down on their luck. But we need to make sure it doesn’t create a culture of dependency.  

The more people we can help lift out of poverty with a good job that include health benefits, the less are relying on government health care programs.

As governor, I will invest in bringing those high-quality jobs to Tennessee and the education they require. •

Fitzhugh:

Insure Tennessee — Governor Haslam’s version of Medicaid expansion — would have covered the population that is left most vulnerable by a lack of coverage. These are working people who work jobs that do not offer healthcare.

Employers and the state must work together to make sure our citizens have coverage. I cannot emphasize enough that these are working men and women. They are doing everything they are supposed to do. In the legislature the debate on healthcare coverage focuses on individuals.  Healthcare is a collective good. Healthy Tennesseans create a healthy Tennessee. •

Lee:

I believe government has a role in creating the environment where private business has options and capacity for providing health coverage.

Whether it’s from our tax code or regulation at the federal level, there are several challenges for our employers. As governor, I’d be committed to working with our employers to address these challenges and make it easier and more cost-effective to provide access to health care.

4. As governor, would you consider expanding Medicaid? What are the advantages and disadvantages of expansion for the state?

Black:

I would not consider expanding Medicaid.

The federal dollars that are used to fund Medicaid in the states, especially to those who expanded under the previous administration, will be decreasing over the current administration. The states that opted to expand are not going to get the Medicaid funding they were once promised.

Expanding Medicaid would bankrupt our state. We have been in that position before, and we are not going down that road again.

I first ran for office when I was an emergency room nurse sick of watching TennCare wreck out health care system. I ran for Congress because I was determined to stop our federal government from making the same mistake our state had made years earlier.

We know that something must be done, but we can’t accept big government as the solution.

As governor, I will work with the Trump Administration to get a block grant for Medicaid, that will allow us to create a TennCare system that actually meets the needs of our state. It would allow us to institute work requirements and create a high-risk pool to lower costs overall.  I believe Tennesseans can do a better job of designing a Medicaid system than bureaucrats in Washington. I will work with President Trump and Vice President Pence to make that happen. •

Dean:

Fitzhugh:

As governor I will move to expand Medicaid on my first day.  I have fought for expansion from the first day our state was allowed to do so some years ago. In my legislative office we have kept a daily tally of lost dollars from not expanding Medicaid, and today we are north of $4 billion.

I can’t see a disadvantage of expansion. Tennessee leads the nation in per capita hospital closures, especially in our rural areas. Expansion would keep the doors of these hospitals open. It would help with preventative care and keep our emergency rooms open for emergencies, instead of first line care for individuals without insurance. •  

Lee:

Tennesseans should have access to quality healthcare, but growing government by expanding Medicaid is not the best way to do it. •

5. Tennesseans have some of the highest rates of chronic disease and risk factors, such as obesity, smoking and low levels of physical activity, in the nation. How will your administration tackle this problem?

Black:

Tennessee has higher rates of obesity, smoking, and poverty and lower rates of exercise and post-secondary education than the rest of the nation.

Diabetes, hypertension and cardiovascular disease alone cost the state nearly $5.3 billion in direct medical care, lost productivity and early death.

Statistics show that populations with less income and education are at greater risk for chronic disease.

At the state level, we have to prioritize the improvements that have the greatest impact on these communities. We have to invest in bringing high-quality jobs and education to all communities in our state, not just the big cities.

And we have to invest in better access to health care for those suffering from chronic disease in our rural communities.

As governor, I will propose making our county health departments the hub of care for rural Tennessee and the access point to telehealth. Our county health departments should function as a primary care provider with a system that provides health care based on ability to pay.

During this election season, we’re hearing a lot of talk of all the different areas where we need to make Tennessee more competitive with the rest of the nations, and lowering chronic disease should be no exception. •

Fitzhugh:

We are in a public health crisis when it comes to healthy options for Tennesseans. We face food deserts in all areas of Tennessee. Access to fresh fruits and vegetables are the best start to healthier families. We also need walkable neighborhoods and parks for our urban residents. Smoking cessation programs are not only good for individuals who are looking to quit using tobacco, but also benefit our communities as well. Healthy individuals have lower rates of absenteeism from work and school. I would make sure our health commissioner works with local entities to make better choices more accessible. •

Lee:

When it comes to healthy behaviors, we’re talking primarily about personal responsibility, which is determined more by the culture in a community than it is by any government program.

We should continue to address these issues by engaging and partnering with community organizations to accomplish this goal. I chaired the YMCA of Middle Tennessee, and they are part of a national effort to intervene with pre-diabetic populations to prevent diabetes through healthy lifestyles. Healthy Tennessee is one of many other examples of community and non-profit leadership in Tennessee helping to drive the conversation around health. •

6. Surprise billing practices hit people all around the state but aren’t often publicly debated. Physicians and other service providers don’t have to accept the same insurance plans as the hospitals within which they provide services, meaning insured patients may receive surprisingly large out-of-network bills despite receiving service at an in-network facility.

The onus is on the patient to call ahead of services to confirm that each clinician who could see them or their file is in-network, or request a different provider. Even then, there is no guarantee the provider will accept the insurance. The state legislature convened a task force on the issue in 2017, but no action was taken in this session.

As governor, will so-called surprise bills, or balance bills, be a priority? If so, what actions will you consider?

Black:

Finding a solution to balance bills would be a victory for patients and providers alike, and I will make it a priority of my administration.

For too long the patient has been the loser when it comes to balance billing. They receive a surprise medical bill after getting treatment from an out-of-network provider they saw in an in-network facility.

And providers certainly aren’t winning either. It’s been estimated that more than half of the bills owed do not get paid.  

We can all agree that these mandates have not been fair to providers or patients and they deserve better. As governor, I will be committed to bringing everyone to the table, from physicians to managed care organizations to insurers, to figure out how to take care of this issue so no one is surprised at the end of the day and patients feel comfortable about going to a provider that’s within their insurance plan. •

Fitzhugh:

Balance billing is a problem for consumers of healthcare. People are not only being billed for out-of-network services, but they are receiving bills months after a procedure, for amounts that they have no way to cover. This is an area where the industry must work with customers. It serves no purpose for providers to exist within a web of out-of-network systems. In every other area of our lives, consumers are able to find the price of the products they will use. In healthcare, we have created a system that can keep a person caught up paying for procedures years after they have been completed. We have to have a simpler, more direct billing system. •

Lee:

Surprise bills are a symptom of a larger problem: a lack of transparency and a growing bureaucracy in third-party payment.

It is troubling that many patients have little or no ability to find out ahead of time the status of who will be treating them and efforts to make good consumer decisions are not always rewarded. Placing all the responsibility onto the provider doesn’t solve the problem either, and there’s no guarantee it still won’t have any adverse effect on patients in the form of higher prices or limited choices. I’d like to work with our payers and providers to improve network education and information, and ultimately encourage behaviors that lead to good healthy decisions. •

7. The opioid abuse problem continues to rage across the state, and there are waiting lists for out-patient treatment. Please provide a framework for how you would tackle the opioid abuse and overdose problem in Tennessee. Do you think increasing capacity of outpatient treatment for opioid and substance abuse will help? How do you anticipate financing treatment, and how will people pay for out-patient services?

Black:

As a nurse for 45 years, I’ve been trained to think about the root causes, how to diagnose a problem and how to build a treatment strategy from the bottom up.

That’s the attitude that brought me to leaders in both the law enforcement and health care communities to create my plan to end the opioid epidemic.

My plan:

• Shut down and prosecute pill mills, which are knowingly over-prescribing opioids and support lawsuits against drug manufacturers who are knowingly misleading providers and patients.
• Hire more TBI agents and empower them to search already-collected data for evidence of overprescribing.
• Increase the penalty for the manufacturing, sale, and/or delivery of fentanyl greater than 0.5 grams from a C felony to a B felony, and greater than 150 grams to an A felony.
• Broaden the 2nd degree murder statute to include the killing of another, which results from the unlawful distribution, or dispensing of any scheduled substance on the Tennessee Drug Control Act of 1989.
• Recognize that the opioid crisis is a very personal one. We need to treat those who are addicted to opioids as patients who can recover. My plan calls for a pilot program to rehab patients in prisons so we can break the cycle of addiction and stop wasting money constantly re-arresting addicts.
• Incentivize pharmacies and drug manufacturers to include emetics in their formulations to protect against overdose and remove obstacles for clinics that offer non-pharmaceutical solutions to pain. •

Fitzhugh:

The opioid crisis is devastating our communities, our state and our nation. Entire families are being destroyed by this scourge. Again, to help stem the tide, we must expand Medicaid. Closed hospitals make the opioid crisis worse. We need to ensure law enforcement has the tools they need — such as arming officers with Narcan — but we must make sure hospitals are open and accessible for acute cases of overdose.

Outpatient care could be financed through the rainy day fund. While Gov. Haslam’s efforts for the opioid crisis should be applauded, the money dedicated to opioid legislation this year just isn’t enough. There are individual hospitals that spend more money for opioid addiction than Tennessee allocated. Spending serious money will show that we are serious about battling this problem. •

Lee:

Outpatient treatment has to be a part of the solution, and while the medical community continues to improve best practices for treatment, we have to be committed to supporting those options.

As governor, I’d work to improve the capacity of the Department of Mental Health and Substance Abuse Services as well as TennCare to ensure more effective treatment for Tennesseans. •

Photo by Hush Naidoo