NASHVILLE—With the future of the Affordable Care Act secured, President Barack Obama returned to Nashville to praise the progress the country has made under the law. But he said more work is needed to make sure that the number of people without insurance continues to fall.
The public remarks came less than a week after the U.S. Supreme Court ruled in favor of the administration in King v. Burwell, preserving premium subsidies for millions of people purchasing insurance from a federal exchange.
"One thing I'm hoping is that with the Supreme Court case now behind us, we can focus on how to make it better," Obama said during a speech at Taylor Stratton Elementary School in the north Nashville neighborhood of Madison. The crowd included a who's who of healthcare leaders in a city where healthcare is the backbone of the economy. "There are still areas of improvement and there are still people who are uninsured."
Only one-third of the people who were previously uninsured have gained coverage, he said. But in other ways, the law has done exactly what it's supposed to do.
"It's made healthcare stronger, more secure and more reliable in America," Obama said, adding that the number of uninsured is the lowest it's been since formal tracking began. "It's actually ended up costing less than people expected. The inflation on healthcare costs have proved to be the lowest ... in the last 50 years."
The King v. Burwell outcome was a key victory for the administration in more ways than one. Although the ruling dealt with only a narrow facet of the Affordable Care Act, many observers saw the decision as a victory for keeping the law intact and argue that it makes it harder for opponents to chip away at it.
Attention is now turning toward Medicaid expansion as the next frontier to fully implement the law. Obama mentioned Medicaid expansion only obliquely in prepared remarks, noting that some states have refused to expand eligibility for the program because of politics. "Our hope is that more of them will."
But pressed by a member of the audience, Obama acknowledged that states that have taken full advantage of Medicaid expansion have had more success in lowering their number of uninsured.
"Understand that the way the law was set up, states have the option of expanding existing programs like Medicaid," Obama said. "Here in Tennessee, that's probably a couple hundred thousand people who could benefit. Given the strong history of innovation of healthcare in Tennessee ... y'all should be able to find a solution. The federal government is here and ready to work with the states that want to get going."
In Tennessee, that was certainly the expectation. Gov. Bill Haslam has twice failed to pass his alternative public-private approach to Medicaid expansion, known as Insure Tennessee. The Tennessee Legislature voted down the plan in both February and March. But now the political winds may be shifting.
"The timing of the Legislature might not have been the best," said Kim Looney, who specializes in healthcare regulatory compliance at Nashville-based law firm Waller. "Some people were hoping (the subsidies) would be overturned and they wouldn't have to do anything with Insure Tennessee."
In Middle Tennessee—the center of the country's for-profit healthcare corridor—the fight for Medicaid expansion has been particularly contentious. The state may be a strong Republican stronghold, but healthcare is a strong lobbying power in the capital city. Many local healthcare leaders have come out strongly in favor of expanding Medicaid eligibility in the state.
“We think Congress intended for Americans to have access to health insurance,” said Bill Carpenter, CEO of Brentwood, Tenn.-based LifePoint Health after the decision in King v. Burwell supporting the subsidies. “I hope this ruling will encourage state governments that the intent of Congress has to be validated and they'll expand their Medicaid programs.”
Carpenter was among the healthcare executives in the audience at the president's remarks.
Also in attendance was HCA CEO Milton Johnson. HCA, one of the largest hospital operating companies in the country, filed an amicus brief supporting the administration in the King case. The Nashville-based firm argued that the ACA is working as intended and using its own experience to highlight that the newly insured are taking greater control of their healthcare costs, including using the emergency room less frequently.
The Tennessee Justice Center rallied a group of supporters wearing purple "Insure Tennessee Now!" T-shirts in connection with the event. The wording is a nod to Haslam's public-private Medicaid expansion plan, an alternative approach that would provide vouchers for people in the Medicaid coverage gap to purchase coverage. Another prong of the plan would provide cost-sharing funds to people who make healthy choices.
The tax-neutral plan also is notable for requiring hospitals to pick up an increasing share of the cost as federal match dollars drop below 100%.
It's not the way the advocacy group would have written the plan, said Michele Johnson, executive director of the Tennessee Justice Center, but it's a fair compromise.
“Though (Haslam's) plan doesn't go far enough, we would be thrilled with it,” she said. “It's uniquely Tennessee. It's conservative; it's privatized; people have skin in the game.”
In community meetings across the state, supporters of the plan have come from three perspectives, she added. They include low-income Tennesseans who fall into the coverage gaps themselves, residents of rural communities who fear for the financial viability of their local hospitals and the employees of those hospitals on the brink of closure.
“The politics are changing,” she said. “People finally understand who it will help. We are absolutely overwhelmed with hope that this thing is going to pass.”