KEJC Comment Opposing Approval of Tennessee’s Medicaid Block Grant Proposal

Secretary Alex M. Azar, II

United States Department of Health & Human Services

Washington, DC

via electronic submission


RE: Comment Opposing TennCare Waiver Amendment 42


Dear Secretary Azar,


Kentucky Equal Justice Center (KEJC) submits these comments in response to Tennessee’s recent block grant proposal referenced above. KEJC is a 501(c)(3) advocacy center dedicated to addressing issues that affect low-income Kentuckians. As the Health Law Fellow at KEJC, I’m usually focused in on Kentucky’s Medicaid program, but when we heard about Tennessee’s proposed changes to their Medicaid program, we couldn’t stay silent about how those changes might affect our neighbors to the south. We’re also concerned about the long-term effects that approval of Tennessee’s proposal could have on other states.


According to Tennessee’s proposal, the state wants to “reimagine[] the Medicaid financing structure” with an eye to saving the state money. Essentially, Tennessee is asking CMS if it will ignore the financing structure that Congress established in the Medicaid statute and just allow the state to use federal Medicaid dollars however the state pleases.


The proposal is very short on details, so it’s hard to tell (and therefore difficult to comment on) what exactly the state has in mind besides saving money. The proposal says that this new financing structure “emphasize[s] state accountability for effective program management,” but the content of the proposal suggests otherwise. According to the proposal, the state can “modify enrollment processes, the service delivery system, and comparable program elements” without federal approval.


But the Medicaid program is not (and should not be) a blank check for states with no accountability. Imagine going to a hospital where the hospital’s highest objective was saving the hospital money. (Maybe you have been to such a hospital.) Imagine further that the hospital says it will be even easier to save money if it’s accountable to no one. That might be true; it will probably be easier to save money if patients and government agencies can’t hold the hospital accountable for the services it provides. But here’s the catch – no one would want to go to that hospital or take a relative or friend to that hospital (at least not any relative or friend you liked). No one would say to a friend, “You should go to that hospital because I’ve heard it ‘routinely underspend[s]’ what it budgets.”


Tennessee is very near and dear to me. A lot of my family lives in East Tennessee; I visit there regularly. I graduated from Union University in Jackson, Tennessee, and many of my friends are spread throughout the state. I’m deeply troubled by the fact that many of my friends and family members might need healthcare from a state system devoted to budget savings over quality care for its citizens.


If Tennessee’s primary concern was providing quality care to as many of its residents as possible, Tennessee would expand Medicaid instead of proposing this block grant. States like Kentucky that have expanded Medicaid have experienced higher rates of early-stage cancer diagnosis, an uptick in smoking cessation, improvements to behavior health and substance use disorder treatment, and lower emergency department utilization. And ironically, expanding Medicaid is also a proven (not experimental) way to boost local economies. While rural hospitals in Tennessee struggle to stay open, Medicaid expansion has saved many rural hospitals in Kentucky.


But instead of exercising the Medicaid options Congress has specifically crafted for states, Tennessee is asking to implement a payment scheme not authorized by Congress that will undoubtedly invite legal challenges. Kentucky can also attest to the costs of defending Medicaid experiments that favor state savings over Medicaid beneficiaries.


We at KEJC strongly and unequivocally oppose approval of Tennessee’s block grant proposal. The Medicaid Act’s purpose is to pay for medical services for the neediest among us, and we want to ensure that the program stays that way for Tennessee and every other state.


Thank you for this opportunity to comment,

Betsy Davis Stone

Health Law Fellow

Kentucky Equal Justice Center


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