The Future of Health Care in Tennessee Intro to TJC here, use clients in the background to tell our story Michele Johnson Tennessee Justice Center mjohnson@tnjustice.org www.tnjustice.org

The Threat: repeal the ACA without a replacement plan in place.

Repeal vs. Budget Reconciliation Takes away the entire law Need 60 votes to do it Budget Reconciliation: Can only take away parts that affect the federal budget Need 50 votes to do it Can be done within the next few weeks Will begin to break down the law before a replacement plan is in place

The ACA Pre-existing conditions clause Subsidies to buy insurance Kids stay on until age 26 Preventive services at no cost Eliminate lifetime caps

Congress’s Plan “Repeal and Delay” Begins the repeal process Pass the budget reconciliation bill to de-fund the ACA, but keep in place most aspects for 2-3 years. In the meantime, come up with a plan for the United States health care infrastructure. Begins the repeal process

Why this is scary Congress is putting a ticking time bomb on coming up with a solution that they haven’t come up with over the past 6 years.

Why this is scary 2. The immediate repeal of certain aspects – like the individual mandate – will put the health care system into chaos.

Why this is scary 3. Insurers are unlikely to stay in the Marketplace if it is set to dissolve.

What does this mean for Tennessee? 526,000 Tennesseans stand to lose health coverage. Uninsured rate will increase by 79% 203,000 received financial assistance at about $299 per month.

What does this mean for Tennessee? “Having the ACA has given me such peace of mind, because with my heart condition, my next open-heart surgery could be in the next couple of years or in ten years. With that broad range, I like knowing I’m covered, for surgery, and the tests needed leading up to surgery.” -Kristen Kristen Dunlap-Berg is a teacher at a preschool in Davidson County. The ACA changed Kristen’s life in 3 ways: In 2010, she was just about to lose her insurance, until the ACA went into effect and she was able to keep her parents’ insurance until age 26. She was born with a congenital heart disease, which would have made it nearly impossible for her to buy coverage if it weren’t for the ACA. When she turned 26, she got on the Marketplace and now has a plan that lets her see her cardiologist for regular check-ups and testing. “Really for me, having the ACA has given me such peace of mind, because with my heart condition, my next open-heart surgery could be in the next couple of years or in ten years. With that broad range, I like knowing I’m covered, for surgery, and the tests needed leading up to surgery.”

What does this mean for Tennessee? Tennessee’s economy stands to lose $27 billion over 9 years in federal funding.

What does this mean for Tennessee? 2.8 million Tennesseans with pre-existing conditions could be denied affordable, comprehensive coverage. Asthma, diabetes, cancer

What does this mean for Tennessee? “I have a pre-existing condition. And without that in the law, I would never get insurance coverage ever again. I had cancer.” -Christina Christina has insurance through the Marketplace for herself and her daughter. 3 years ago, she successfully battled breast cancer – and now, she has affordable insurance. But without the ACA, not only would she lose her insurance on the Marketplace, it would be nearly impossible for her to find insurance that would accept her pre-existing condition.

What does this mean for Tennessee? Premiums on the individual market will rise 20-25% in the first year, and will more than double eventually.

What does this mean for Tennessee? Even more hospitals are at risk of closing with reductions in federal funding, and the drastic drop of people with insurance. 4 rural counties have lost their only hospital Over 40 hospitals are at risk

What does this mean for Tennessee?

The threats don’t stop with the ACA . . .

The Threat 2.0: cut Medicaid funding by giving states block grants.

Medicaid/TennCare is BIG Covers 1.55 million Tennesseans $11.6 Billion total TennCare budget Provides over half of federal funds in state budget. 20¢ of every dollar state spends is federal Medicaid match.

Medicaid/TennCare 1.56 million enrollees in Tennessee ½ state’s children ½ babies born 61% nursing home care 2/3 of spending is for services for elderly and people with disabilities Bi-partisan cornerstone of health care infrastructure for over 50 years

TennCare is critical for behavioral health TennCare is the largest single payer for mental health and addiction services TennCare’s has major role in state efforts to combat opioid and meth addiction epidemics, which are among the worst in the nation

TennCare & People with Disabilities Covers a quarter million Tennesseans with disabling illnesses. Pays for 61% of nursing home care in TN. Two-thirds of all Medicaid spending for services is attributable to the elderly and persons with disabilities, who make up just one-quarter of enrollees

TennCare & Rural Health Plays an indispensable role in sustaining the health care infrastructure of rural Tennessee. TennCare enrollment is generally twice as high as in urban counties.

This is all on the table to be reduced, cut, and radically reformed.

What are the consequences? Immediate consequence of repealing individual mandate: We’re already seeing this happen with Humana.

What are the consequences? By 2019, we’d be worse than what we were pre-ACA.

What does this mean for Tennesseans?

Block Grants = Less Money Current structure Tennessee pays 1/3 Federal government pays 2/3 Block grant or per capita cap Federal government gives states a check States make up for the remainder Overall cuts are $1 trillion

Federal Medicaid Per Enrollee Spending Cuts to funding Federal Medicaid Per Enrollee Spending Sources: House Republican health plan, CBPP analysis of BLS and CBO data

Unanticipated increases not covered Current Medicaid Financing System vs. Capped Medicaid Funding $120 $120 $100 $100 FEDERAL CAP

10 million people with disabilities Medicaid Cuts Medicaid block grants or per capita caps would hurt: 33 million children 6 million seniors 10 million people with disabilities

TennCare is already lean People with disabilities Seniors Kids Neo-natal intensive care units

Nowhere to Safely Cut TN is 39th in per enrollee Medicaid expenditures TN’s eligibility criteria, provider payment rates and benefits are already among the lowest of any state. Therefore no way to respond to federal cuts without slashing coverage for the very vulnerable patients who account for most of the cost.

Nowhere to Safely Cut In addition to TennCare, 5 departments partially rely on federal Medicaid $$ to fund administration and/or direct services: Children’s Services Health Human Services Intellectual and Developmental Disabilities Mental Health and Addiction Services

Cuts would grow over time Percent Cut in Federal Medicaid Funds, Relative to Current Law

Limited ways for states to spend less in Medicaid States will need to figure out how to “do more with less” But, states really only have three ways to cut costs in Medicaid: 1. 2. 3. CUT BENEFITS CUT WHO IS ENROLLED CUT PAYMENTS TO PROVIDERS

Medicaid is Already Very Efficient

This is up to us. 52 Republican Senators. 50 needed for the budget reconciliation vote. There are 52 Republican Senators in the Senate. 50 of them need to vote yes on repealing the ACA without replacing it for the bill to go through. And nationally, there are 3 Senators who are widely seen as being moveable on the issue: Senators Alexander and Corker from Tennessee, and Senator Collins from Maine. That means that the health care infrastructure of the entire country falls on us.

TN’s U.S. Senators Play a Key Role Presently 52 GOP Senators, plus the Vice President who can break a tie. Need 3 GOP Senators to vote in defense of health and social programs.

Senator Alexander Chair of Health, Education, Labor & Pensions Committee Has expressed that he doesn’t want to see repeal without replace DC: (202) 224-4944 Nashville: (615) 736-5129 Senator Alexander is the most important person in this conversation. He is the head of the Health Committee, and has said that the repeal and replace should happen at the same time.

Senator Corker Took the lead in saying Congress needs to wait Also says doesn’t want to see repeal without replace DC: (202) 224-3344 Nashville: (615) 279-8125

mjohnson@tnjustice.org 615-846-4709 www.tnjustice.org/coverage-matters Questions? mjohnson@tnjustice.org 615-846-4709 www.tnjustice.org/coverage-matters

“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” -Martin Luther King, Jr. Thank you. mjohnson@tnjustice.org 615-846-4709 www.tnjustice.org www.facebook.com/tnjustice