In the time since the Supreme Court decided in June 2012 that each state could decide whether or not to expand Medicaid for its residents, the majority of states have taken a decisive stance on the highly contested issue. This provision of the Affordable Care Act applies to those individuals with incomes up to 138 percent of the federal poverty line, consequently expanding coverage for Americans that were previously ineligible for Medicaid.

Despite the length of time given to states to choose to opt out or not, Governor Bill Haslam has yet to take action, leaving Tennessee as one of only two states still left undecided over the expansion that would affect an estimated 180,000 Tennessee citizens currently left uninsured. Thus far, 21 states have decided not to expand Medicaid while 27 states and the District of Columbia have decided to proceed with expansion. The states that decided against it either have governors belonging to the GOP or a legislature with a Republican majority.

The main source of Gov. Haslam’s hesitancy appears to stem from his aim to please the conflicting interests of those with a vested stake in the outcome of the decision. This has Tennessee at a continued standstill after the Governor already pushed back a deadline to have a decision made by summer’s end. With 300 million dollars from the federal government on the line and the effects of uncertainty beginning to materialize, reaching a decision by the looming January 1 deadline is going to be imperative.

In the eyes of the state’s conservative opponents of expansion, accepting a provision of the Affordable Care Act, a piece of legislation so politically charged that it is synonymous with Democratic interests, would be nothing short of treason. Those Republican Governors that have expanded Medicaid in their states have faced harsh criticism from their fellow GOP members across the nation. Most recently, Senator Rand Paul accused Governor Chris Christie of “embracing Obamacare” when he chose to expand Medicaid in New Jersey. In a state as strongly conservative as Tennessee, choosing to expand Medicaid under the terms of “Obamacare” could be a risky move. Gov. Haslam is a popular figure in Tennessee, receiving a 63% approval rating according to a Vanderbilt University poll conducted in May. However with re-election looming in the coming year and Medicaid expansion itself becoming a popular topic in Republican primaries, the stance that Gov. Haslam takes on the issue could have significant implications for his political future.

This indecisiveness is beginning to have a substantive impact on Tennesseans, which is especially evident through threats of layoffs and closing hospitals in the state that has left the Tennessee Hospital Association, the Tennessee Chamber of Commerce, and state Democrats urging the Governor not to put off the decision any more. When considering the status of local hospitals and the insufficient funds the state has to offer, expanding Medicaid and consequently receiving billions of dollars from the federal government would do nothing but benefit these stakeholders. Both the president of the Tennessee Medical Association and the former president of the Tennessee Nurses Association are urging Gov. Haslam to expand Medicaid in the state, stating that the outcome of choosing not to expand the program will have negative effects to the extent that it will provide the conditions for a “health care crisis.”

Attempting to appease these parties at odds has left Gov. Haslam working with the federal government and the state legislature to construct a different plan. Called the “Tennessee Plan,” Gov. Haslam has advertised this plan as his alternative to expanding Medicaid in the state. However, there are still no specific details for the delineation of the plan and support from the legislature is questionable. Further, seeking approval of the plan from both the Obama administration and the state legislature is looking to stand as a considerable hurdle in the way of the Governor’s strategy. What Gov. Haslam has disclosed about his plan thus far is that it would involve using the funds for Medicaid expansion towards purchasing those eligible individuals private insurance through the online exchanges. These individuals would then have higher co-pays for services utilized and also have limits on their visits to their doctors, provisions that may not be accepted by federal officials.

Clearly, there are high stakes for whichever route Gov. Haslam chooses to pursue. The vague terms and low likelihood of a successful compromise indicates that it may be in the best interests of Tennesseans for Gov. Haslam to choose a side and stick with it, no matter what the cost may be. Each decision will inevitably have its drawbacks, however the increasing costs of indecision appear to be too heavy for the Tennessee to bear in the position it occupies in an already tenuous national health care scheme. The Affordable Care Act has ushered in an era of innovation, and with it an era of uncertainty. The only viable option at a time like this is to make a decision and be prepared to defend it to the unavoidable opposition that will occur.

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