Tennessee Medicaid Block Grant State Comment Period Analysis

November 4, 2019 // TJC Staff 

This past May, Tennessee’s legislature passed a bill directing Governor Lee to submit a proposal to amend Tennessee’s Medicaid waiver which was due within 180 days. Governor Lee’s administration unveiled the block grant on September 17, 2019 with seemingly no input from the public. This proposal is known as “Amendment 42” or the “Medicaid Block Grant.” On September 17th the state opened a public comment period, which is required under law. The state held public hearings in Nashville, Jackson and Knoxville. After public outcry, the state also held public hearings in Memphis and Chattanooga. The state comment period ended on October 18th.

Not including the verbal comments made at the public hearings, over 1,650 written comments were submitted by individuals and organizations. Less than 7% of these comments were submitted by organizations. The rest were submitted by Tennesseans across the state, representing at least 74 counties, with a handful of individuals from out of state expressing concern for loved ones in Tennessee. This includes individuals who are on TennCare, have experience with disability and serious medical needs, health care professionals, students, and advocates.

TJC staff read through and analyzed the 2272 pages of comments, and found that an overwhelming majority explicitly oppose this proposal and expressed serious concerns.

Only 10 comments of the over 1,650 comments explicitly supported or expressed positivity with little to no concerns about or suggestions to the proposal. The supporters consisted of 8 individuals and 2 organizations, Blue Cross Blue Shield of Tennessee, an in-state TennCare managed care contractor and Opportunity Solutions Project, an out-of-state, right-wing lobbying organization.

The state touts that this very brief proposal will lead to financial savings for the state and will not cut enrollment for eligible individuals or services for currently covered populations. However, many people who submitted comments noted the vagueness of the proposal in ensuring this pledge. TennCare is a multibillion-dollar program that encompasses many complex components of healthcare in the United States. The substantive parts of Amendment 42 that will upend the current structure of this program is just 20 pages.  Many commenters pointed out that these 20 pages  did not adequately explain how savings could be created while also ensuring no changes to “amount, duration and scope” of benefits.  What concerned most commenters is that Medicaid is meant to provide healthcare, not “savings”.

One comment from Gail Murray in Memphis, Tennessee, told her story of how important it is that we hold true to the real purpose of the Medicaid program.

I am the parent of a 43-year-old intellectually challenged but beautiful, generous, loving woman… She is dependent on TennCare for PT, OT, seizure medications, and general healthcare. She did not choose these disabilities. Our state should not choose to eliminate or restrict her access to healthcare professionals. Medicaid was created to help children, people with disabilities, pregnant women, and other vulnerable Americans get vital health coverage they need. This proposal goes against the objectives of Medicaid because it gives Tennessee new authority to cut services for these vulnerable populations. Please do NOT permit this to happen.

– Gail Murray, Memphis, TN

Even with the state’s declarations that this proposal will not cut services, 88% expressed concern about the possibility of TennCare cutting or limiting benefits for eligible or already covered populations. People have recognized that what the state proudly claims as newfound “flexibility” in the proposed program really means that there is no assurance or commitment to protecting the most medically needy in our communities.

A number of comments also expressed concerns about the – now estimated – over 630,000 of uninsured folks under 65 in Tennessee who do not have access to healthcare coverage. Most took this opportunity to request for Medicaid expansion in Tennessee. While the proposal states that it is possible that the state will eventually try to cover a new population, commenters recognized that without written commitments or assurances, this is an empty statement. If the state were truly interested in expanding access to healthcare, it would expand Medicaid. Expanding Medicaid would also resolve many of the state’s cost concerns.

Many health professionals weighed in and explained how beneficial Medicaid expansion would be for our state. As James Gurney from Germantown, Tennessee, wrote:

Dear Mr. Roberts,

I am a public health professional. With all respect, I am strongly opposed to the block grant proposal. I believe the block grant proposal provides far too much flexibility for the funds to be used for purposes other than direct health care for vulnerable persons in Tennessee, and it allows for far too little oversight by the federal government. The working poor have greatly benefited from Medicaid expansion in 37 other states in the US. Tennessee citizens are helping to pay for those services in the other states. All our citizens in TN deserve to have access to affordable health care – that will not be the case with the block grant experiment. Please reconsider this flawed proposal and instead adopt Medicaid expansion. Thank you for the opportunity to express my view.


 James Gurney, Germantown, TN

Some other concerns raised were the risks to the most vulnerable individuals in our community including children, the elderly, and the disabled. Many were worried about the impact on long term supports and services and dually eligible individuals for Medicaid and Medicare. Many were also worried about the impact of the block grant on supports for individuals with highly complex needs. Tennessee is waiting for approval on the Katie Beckett program, which will provide services to children who were not eligible for Medicaid yet have high medical costs because of their complex needs. Now, with the block grant, the effectiveness of this program is at risk.

Several comments also expressed serious concerns about the closed drug formularies. With many outside references and personal stories, people explained how a one-size-fits-all approach does not work for many patients. The current draft of the proposal does not mention allowing off-label drug use. Instead, the proposal would allow TennCare to supplant a doctor’s judgement. Closing individuals off from working with their physicians to find the best treatment for them will lead to serious consequences.

More than 99% of individual commenters agree that this proposal is too risky, and the state has not clearly mapped out why their calculations are appropriate. The state claims that this proposal is based on TennCare’s historical metrics. However, the state has historically underspent projected costs, and this has led Tennessee to rank at the bottom in almost every health outcome measure. Additionally, the state’s per member cost calculation is an average. This doesn’t appropriately capture the costs if more members that have significant healthcare needs join the program, such as those with disabilities and chronic conditions.

Of the over 130 organizations and service providers, some of whom co-authored a comment, about 98% explicitly opposed or had concerns or suggestions to modify the proposal. The organizations opposing this proposal covered those that work locally, state-wide, nationally and globally.

Many organizations and service providers, some of which have been assisting the underserved for over 100 years through advocacy work, policy work, and professional knowledge, supported their specific concerns with outside research and reports. The enormous impact of these organizations ranges from the Tennessee Public Transportation Association–which provided 633,823 NEMT trips in 2018 to Tennesseans on TennCare–to the National Heart Association organization–representing over 33 million people nationally.  Many of the comments broke down how, in fact, this proposal violates the law.

The written and verbal comments show an overwhelming opposition to this proposal. In four short weeks Tennesseans were asked what they thought about this proposal, and we responded. If Governor Lee turns his back on the voices of so many people expressing point blank that this proposal will hurt us, then we’re left to wonder: whose interests was he elected to serve?

Special thanks to TJC staff and volunteers: Charlotte Pate, Vanessa Zapata, Richard Chambers, Leezan Kittani, Patrick Jeon, Nora Hendricks, Austin Hollimon, and Thomas Bynum.