Election 2018: How Tennessee’s Next Governor Will Tackle Medicaid, Marijuana and the Opioid Epidemic

Tennesseans will elect a new governor this year. In the coming months, opinion editors for the USA TODAY NETWORK - Tennessee will be asking the major Democratic and Republican candidates to share their views on vital state issues that will be facing the next governor.

Here are the views of Republican candidates Diane Black, Randy Boyd, Beth Harwell and Bill Lee, and Democratic candidates Karl Dean and Craig Fitzhugh on four of the state's most important health care issues: the closing of rural hospitals, Medicaid expansion, the opioid crisis and medical marijuana.

Rural hospitals

Q: Ten rural hospitals in Tennessee have closed in recent years, and 32 other hospitals (including 23 that are the only hospitals in their counties) have lost money three years in a row and are in danger of closing. As governor, what would you do about that?

BLACK: My understanding of how crippling hospital closures are for rural communities doesn’t come from working in Congress. It comes from working as an emergency room nurse. A heart attack doesn’t wait for a half an hour ambulance ride. I know it is critical for our rural communities to have access to care when every second counts. Across our state, rural communities are quite literally losing their lifelines. Eight of Tennessee’s rural hospitals have shut down since Obamacare was enacted, with several more on the verge of closing. Two ways to help rural hospitals is to address the lack of fairness in the area wage index and increase the Essential Access Hospital payments made to hospitals for uncompensated care. Both of these ideas would go along way toward stabilizing health care in rural Tennessee. As governor I will be an advocate for community health centers. The Lewis Health Center in Hohenwald and the Putnam County Health Department in Cookeville prove every day that we can think outside the box to solve health care access issues. Recently I sat down with the leaders of Ballad Health in East Tennessee and heard about all of the innovation that can take place when the government gets out of the way and accepts different models than the creation of a few national health care systems. It’s a challenging time for hospitals, and as governor, I will be an advocate and partner working towards a solution for rural hospitals.

BOYD: As commissioner of Economic and Community Development, I saw firsthand how devastating it is to rural communities when they lose access to health care services. As governor, I will do everything I can to protect and enhance health care access and quality care for Tennesseans in rural communities. The rural hospital represents much more than health care delivery. It’s a job creator, beacon of hope and often the place of last resort for the sick and vulnerable. As governor, I will tirelessly advocate for block grants to our state, so that Tennesseans can make decisions for Tennesseans, not Washington. By doing so, I believe we can find ways to provide better treatment for more people.

HARWELL: Health care and medical science have advanced so much over the last couple of decades that many of the procedures that once required a full hospital stay can now be done as an outpatient procedure in a clinic. Several of the hospitals that closed have been replaced with freestanding emergency departments or expanded urgent care facilities. Just last week federal officials were touring Lewis Health Center’s operations to see if it could work as a model for rural health care in counties that no longer have hospitals. I believe we need to look at the regulations on these types of facilities and make sure that our state policies are encouraging these innovative methods of increasing health care access. We should be encouraging more competition so that services remain accessible and affordable in our rural communities.

LEE: The existing health care model has become stagnant and is facing economic pressures in every direction, and it’s hurting our critical access hospitals. We need to make sure that the state, and TennCare in particular, are empowering providers to pursue new cost-effective ways to deliver care and we're reimbursing those efforts fairly.

We also have to look beyond the hospital to innovations that help improve the overall market for care. Our primary care physician shortage creates the condition for bad outcomes, but innovations like telemedicine or investing more in our residency pipeline can help. We also have to look at what government has done to make the problem worse. Regulations that prevent hospitals from cutting overhead or seeking new revenue streams are obstacles to their efforts to adapt the needs of the community. That means government is effectively pricing care out of our rural communities. It’s going to take fundamental reform to fix it, and simply spending more money is not a solution.

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DEAN: As governor, I would work to expand Medicaid to help keep our rural and safety-net hospitals open, patients treated, and our local economies in business. When Congress passed the Affordable Care Act in 2010, we had reason to believe that it would be a game-changer for rural and safety-net hospitals, which bear the brunt of uncompensated care in our country. Their indigent patients would finally have health care coverage and the hospitals would be reimbursed for the vital services they provide. But the reimbursements never came. In 2012, the Supreme Court ruled that states could choose not to expand Medicaid eligibility, and that’s exactly what our Tennessee legislature did. It was a terrible decision that cost the state roughly $3.5 billion in federal funds and left over 300,000 Tennesseans uninsured. And the hospitals serving them were left operating in the red rather than the black. We must expand Medicaid to reverse this trend and work to make access to preventative and emergency health care easier for all Tennesseans.

FITZHUGH: On my first day as governor, I would move to expand Medicaid and accept the federal funds that the legislature has rejected for many years. As the House Democratic Leader, my office keeps a daily tally of the expansion money Tennessee has forfeited: We have lost nearly $4 billion in tax money that instead has gone to other states. The blocking of these funds was a political move that had real world consequences for our hospitals. If the General Assembly had moved to expand Medicaid, our hospitals would still be open. Our rural hospitals are not only there for lifesaving care; they are economic engines in distressed areas, often as the largest employer. A closed hospital also affects future economic investment, as companies will not locate a new plant in a community that does not have a hospital.

An estimated 114,000 low-income uninsured residents in Tennessee would get access to care for mental illness and substance use disorder if the state accepted a federal offer of Medicaid expansion dollars

Medicaid funding and expansion

Q: After a 2014 law barred the governor from accepting Medicaid funds without the consent of the Tennessee General Assembly, legislators turned down opportunities to approve Gov. Haslam’s Insure Tennessee plan in 2015 and 2016. Some legislators say now is the time to seek funds to cover nearly half a million working poor Tennesseans. As governor, what would you do about that?

BLACK: Federal dollars used to fund Medicaid in states, especially those that expanded under a previous administration, will decrease over time. These states are not going to get the Medicaid funding they were promised. Our state has been in that position before, and we are not going down that road again. I first ran for office when I was an emergency room nurse watching TennCare bankrupt our state. I ran for Congress because I was determined to stop our federal government from making the same mistake our state had made years earlier. The answer to problems with Medicaid is block grants from the federal government to the states. The Founding Fathers included the 10th Amendment to the Constitution so states could find their own answers to difficult issues. Prior to Obamacare, Tennessee had programs such as CoverTN and AccessTN designed to provide coverage to different populations. Other solutions include the use of high-risk pools, reinsurance or invisible risk sharing, which was included in the American Health Care Act passed by the U.S. House of Representatives in 2017. Thirty-five states had similar programs prior to Obamacare.

BOYD: Washington and the professional politicians have failed us on health care. As governor, I would push the federal government to give us per capita block grant funding for our Medicaid program so that we can create innovative, common-sense, Tennessee-based solutions that are centered around a patients-first, consumer-driven health care system, not top-down federal mandates and bureaucracy.

HARWELL: I would continue to follow the will of the legislature. Until 2005, TennCare was an expanded Medicaid program. But it became unsustainable and costs continued to grow until we were forced to disenroll almost 200,000 people from the program. Even after those measures, TennCare has again reached the same percentage of the budget that it was in 2005, so taking the expansion funds would have just continued to see runaway costs. I would like to see more flexibility from the federal government over how we can spend Medicaid dollars, whether that’s through a block grant or a per capita grant. Once we have more control over how those dollars are spent and can design a program that saves money and contains costs, then we can discuss additional funding.

LEE: I’m opposed to Medicaid expansion. It locks Tennessee into an unsustainable spending program with the federal government. We tried it before in the 1990s and it failed. The discussion around Medicaid expansion is often politicized into whether you want to expand access or not. It’s not that simple. The question should be, how do you create an environment for access without giving up more and more of the state budget every year? So instead of a new spending program, I'd like to see a comprehensive reform to our health care system, one that gives patients affordable options, creates additional flexibility for providers to innovate, and establishes real incentives for controlling cost. That’s an effort that will need to be led at the state level, and we won’t advance it by placing almost half of Tennessee’s state revenues into the federal ACA bureaucracy.

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DEAN: I completely agree and would make Medicaid expansion a focus of my administration. We cannot afford to wait for Washington to get its act together. It is up to states and individual communities to figure out how to make the current structure of health care in our country work for our families. We need to bring our federal tax dollars back to Tennessee by expanding Medicaid. If elected governor, I will work with our state legislature to get this done. And if they once again refuse to do their job, my administration will spend our time working to give Tennessee voters the opportunity to decide by assisting in efforts to get Medicaid expansion on the ballot. We have to stop thinking about health care as just a policy debate and recognize the real people who are being hurt by our state's inaction. It's time for us to work together to implement smarter, more effective approaches to health care.

FITZHUGH: The 2014 law that tied the governor’s hands when it came to expanding Medicaid took time and effort that could have instead been used to make our state safer and healthier. I am glad that some of my colleagues now realize this delay has been a pox upon us. I have brought legislation to repeal the law that bars the governor from accepting Medicaid funds. As governor, I will work with the legislature to seek those funds and cover the working families who need insurance. The plight of working uninsured Tennesseans is a public health crisis. A governor — who represents every citizen in our state — must be able to negotiate with the federal government on behalf of Tennesseans.

The country is in the midst of an opioid epidemic. Did the FDA play a role in how we got here? Ayrika Whitney/USA TODAY NETWORK - Tennessee

Opioid epidemic

Q3: Across Tennessee, an average of three people die from opioid overdoses daily. Gov. Haslam has proposed devoting $30 million to address the crisis. His plan includes providing overdose-reversing drugs to all state troopers and ERs, and reducing sentences for prisoners who complete treatment programs. As governor, what would you do about the state's opioid crisis?

BLACK: The opioid epidemic is a scourge on our society and I firmly believe the next governor will be judged by how she handles this crisis. My plan attacks the root causes of the crisis. I believe we can significantly reduce the destructive impact of addiction on our state if we: 1) prosecute pill mills; 2) sue manufacturers who mislead providers about the addictive nature of their drugs; 3) provide more resources to district attorneys, local law enforcement and the TBI; 4) regulate prescriptions using a real-time Controlled Substance Monitoring Database without adding administrative burdens to providers and; 5) protect patients by encouraging pharmacies and manufacturers to include emetics in their formulas. The road to healing is a long and difficult one for our state, but I am confident that bold collaboration between government, health care providers and law enforcement will pave the way.

BOYD: I think Gov. Haslam's plan is a good first step to ending this crisis. However, I believe that we can do more. As governor, I will appoint a Chief Epidemic Officer who will be the point person for every level of government to end this epidemic. I will also declare a state of emergency to open up resources and coordination efforts. I have developed a comprehensive 10-point plan that builds on those two ideas, as well as calling for statewide education efforts to help prevent the problems before they begin, better training and prescription rules for our health care providers, and finally revamping our mental health and substance abuse system in Tennessee. To solve this crisis, we must also hold those who are responsible accountable. From pill mills to manufacturers, I will push for greater levels of accountability throughout Tennessee.

HARWELL: As Speaker of the House, I appointed a task force in early 2017 to take an in-depth look at the opioid crisis in our state and make recommendations as to what should be done. I appreciate Gov. Haslam incorporating several of the recommendations into the legislation he presented this year, and I am supportive of these efforts. As governor, I would continue the work we have started this year. We cannot incarcerate our way out of this crisis, so I would prioritize treatment and funding for treatment to ensure people have access to the help they so desperately need to get clean. I would also step up our prevention efforts, because educating the public about this issue is part of the battle as well. We can partner with faith-based and nonprofits to effectively ensure access to treatment programs. And finally, we have to support our law enforcement as they fight this, and keep these drugs off the streets.

LEE: There are many common-sense first steps our state is taking that we will need to build upon. For instance, restricting the use of addictive opioids in TennCare with limited exceptions for extraordinary cases is a good first step. Another is increasing funding for our law enforcement, which is critical to combat the flow of street drugs and the new threat of fentanyl into our state. One problem that will be a bigger challenge — but one we absolutely have to do — is to thoroughly re-evaluate our mental health support system. Until we acknowledge that the way we treat addiction is in need of improvement, and that at the root of a lot of addiction is trauma, then we’re going to lose more neighbors and family members to the disease of addiction.

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DEAN: I applaud Gov. Haslam and other state lawmakers, law enforcement officials, and health care providers who are working to address this crisis. The $30 million pledged is a good first step, but we need to do more, including expanding Medicaid to help support our hospitals who are treating patients and to give those patients better access to in-patient treatment facilities. As governor, I would take a three-pronged approach that includes a public education campaign to make people aware of the potential dangers of opioid use; increased support for patients through Medicaid expansion and other funding mechanisms to ensure they get the care they need; support law enforcement in their efforts to stop the illegal sale of these drugs. We must do all that we can now to save lives, limit the long-term impact to our communities, and work to address the deep-rooted reasons so many have turned to drug use in the first place.

FITZHUGH: While I applaud Gov. Haslam in his efforts, they do not nearly go far enough to make a dent in the crisis. Less than half of the $30 million comes from state funds, and we need to devote much more to this effort. Some hospitals alone are spending more. We have the funds to put more resources into the program in our rainy day fund, a fund that is set aside to deal with emergencies, and an immediate expansion of Medicaid would provide funding as well. The opioid crisis is an emergency like no other in our lifetime. With Tennessee’s booming construction industry, physical injury is a contributing factor to the prescription of opioids. We must work with the medical community, law enforcement and our safety-net resources to stop incidents of opioid abuse before they begin.

Four of the seven top-tier gubernatorial candidates won't say whether they've smoked marijuana recreationally, according to a USA TODAY NETWORK - Tennessee survey. (Photo: Getty Images / iStockphoto )

Medical marijuana

Q: Two Republican legislators have sponsored a bill to allow oil-based marijuana products for patients with certain health conditions. They insist it is not tied to any efforts to allow for legalize recreational use. As governor, what is your position on that?

BLACK: I am totally opposed to the idea of medical marijuana products which are not approved by the FDA. We do not want medical marijuana to be the next opioid crisis. Many doctors and patients believed the industry when it pushed opioids as non-addictive. That was how they were marketed to prescribers and patients. There is an industry push today for medical marijuana similar to the push for opioids a decade ago. Just as no one predicted that opioid prescriptions would lead to heroin overdoses, we don’t know what legalizing marijuana could lead to. No scientific research supports this marketing effort and neither does the National Institute of Health or the Food and Drug Administration. Finally, I would urge every parent to search "vape cannabis oil" and look at the results. Vaping cannabis oil is a dangerous trend that is growing in popularity among young people. As governor, I promise to fight this trend and those who peddle it to Tennesseans.

BOYD: First and foremost, I do not support any plan or movement to make Tennessee a recreational marijuana state. As it relates to potential medical uses, I believe that any marijuana or marijuana product should go through full FDA testing and approval showing any potential effectiveness and safety just as any other medicine would, and to date that has yet to happen.

HARWELL: I support the bill. I support regulated medical marijuana in pill or oil form and under the care of a physician. I am not for recreational use, but I do think there are Tennesseans who could benefit from having another option when it comes to treating serious and/or chronic pain.

LEE: I’m opposed to the use of marijuana for recreational purposes and I have deep concerns around legal medical use leading to recreational use. Despite that, I’m open to listening on how we can better improve the use of low-THC, non-psychoactive CBD oils to help patients with serious ailments.

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DEAN: I think we should be guided by medical professionals as it relates to medical marijuana use. If the medical profession says there is identifiable, concrete evidence why medical marijuana could help with a patient’s suffering, I think use should be permitted. I certainly would not want state government to stand in the way of someone receiving relief from their suffering if the medical community supports the treatment.

FITZHUGH: I am in favor of oil-based marijuana products for patients with certain health conditions. The majority of Tennesseans favor medical cannabis. The research shows that medical marijuana works for a host of ailments, from cancer to PTSD. We cannot turn our backs on any opportunity to improve the lives of our citizens who live with chronic and/or debilitating pain and illness. Medical cannabis and oil-based products may also provide an alternative for pain management instead of prescribing opioids. We cannot allow old notions of cannabis to stand in the way of lifesaving treatments.

https://www.commercialappeal.com/story/opinion/contributors/2018/03/02/tennessee-governors-race-candidates-health-care-issues-medicaid-marijuana-opioid/380428002/