Adam Nickas, the new executive director of Tennesseans for a Responsible Future, is looking for a sweeping plan to catch some 280,000 people who fall into a health-care coverage gap across the state.

But based on what’s coming out of a 3-Star Healthy Task Force set up to find a politically safe alternative to Insure Tennessee, Nickas won’t get one – at least not for a while.

A phased-in approach is most likely, although the panel’s outcome is a mystery so far.

As the committee appointed by House Speaker Beth Harwell travels Tennessee gathering information from health-care providers, including state agencies, more or less learning on the run, Nickas is withholding comment, good or bad, about the proposal 3-Star Healthy might make to the federal government.

Instead Nickas, a veteran of political battles as former leader of the Tennessee Republican Party, is content to crisscross the state in a grass-roots effort to educate people about the problems Tennessee faces with people who are uninsured or fall through a crack between TennCare and the Affordable Care Act.

The nonprofit organization established by the Tennessee Hospital Association supported Gov. Bill Haslam’s Insure Tennessee plan. But understanding the politics of the day, it’s “glad the conversation is continuing,” Nickas says, and looks forward to a proposal state leaders will try to sell to the federal Center for Medicaid Services, most likely by the week of June 21.

“Our position is we believe any solution must be comprehensive in scope, that it must cover all those in that Medicaid gap that are eligible,” Nickas explains.

“Secondly, we think it needs to pass muster with the federal government, and the reason that’s important is we need federal approval to bring back Tennessee dollars to Tennessee so that it’s not going to states like California and New York, who are diverting our money because they have addressed the Medicaid gap in their states.”

Haslam’s plan called for tapping into the $1.2 billion annually Tennessee is sending the federal government to pay for the Affordable Care Act.

And while some opponents of Insure Tennessee, mostly Republican legislators who call it an extension of Obamacare, say the money is sitting in a leprechaun’s pot at the end of a rainbow, Nickas says there is no doubt the money is going to other states.

“We’re losing money by the day,” he says.

The genesis

When the governor introduced Insure Tennessee in early 2015, at the request of lawmakers, it barely saw the light of day, in spite of a special session he called for legislators to consider it.

Many legislators recalled the move by former Democratic Gov. Phil Bredesen to remove tens of thousands of people from the TennCare rolls a decade ago because the program grew too expensive.

They feared putting people into a costly health-care program because of the feds’ propensity for reneging on shared funds.

They also raised doubts about a federal agreement, even though the governor produced a verbal agreement in writing.

Nickas understands politics changes overnight, and many Republican leaders want to wait until a new president is elected, hoping the feds will send Medicaid block grants to the states and let them use them how they see fit.

No doubt, Hillary Clinton would keep Obamacare, while Donald Trump says he wants to repeal and replace it.

But Nickas says he has to work on the information at hand and can’t get into hypothetical fear.

Thus, Nickas is talking to people directly involved in the issue, whether they work at hospitals or fall into the Medicaid gap, meaning they don’t qualify for TennCare or federal tax credits.

“We think when Tennesseans are presented the substance of the problem and how to address it, they’re very receptive to it. And I think last year the debate happened so quickly, and that’s not a criticism, that’s how it played out,” Nickas adds.

Legislators had a short time frame to digest the Insure Tennessee proposal, he says, and the average Tennessean was put in the same position.

“They weren’t really afforded the opportunity to be told who was in the Medicaid gap, that they’re the working poor, what Insure Tennessee was all about,” Nickas explains.

Of course, polls done by Vanderbilt and MTSU show a majority of Tennesseans supported Insure Tennessee.

And legislators could have taken action on the governor’s proposal this past session. But Haslam chose not to push it because he saw no legislative support. And in the only vote dealing with it this year, a committee rejected legislation to put Insure Tennessee to a statewide referendum.

A big learning curve

As a result, the state is stuck with the 3-Star Healthy Task Force, which is hoping to do in a few months what Haslam’s administration did in a year and a half of study.

And, no offense to those serving on the committee or those in need of mental or physical treatment, but good Lord, those meetings are enough to drive anyone insane.

It took me three days to recuperate from two and a half hours of health-care discussion.

Seriously, though, legislators are still trying to figure out what the state of Tennessee and nonprofit agencies offer in terms of safety nets for mentally ill and drug-addicted people, indigents and so forth, all with a late-June deadline for submitting at least a “structural” plan to the federal government.

State Rep. Cameron Sexton, a Crossville Republican chairing the 3-Star Healthy Task Force, predicts the first phase of help will focus on behavioral health, involving mental health and substance abuse, two areas in dire need of attention. Nobody will argue with that.

But while Sexton says the 3-Star Healthy approach will differ from Insure Tennessee in that it won’t target 300,000 people immediately, instead using “triggers” and “circuit breakers” for other programs to start, he also says it’s likely to provide incentives for health-care providers and set up health savings accounts for individuals, a key part of Insure Tennessee.

“So I think we’re looking at a more comprehensive approach, which is, when I think of comprehensive, I don’t think of the number of people, I think of the benefits,” he points out.

Asked if he’s looking at Tennessee spending millions more to expand services, Sexton explains it depends on whether hospitals are willing to increase their assessments and to cover a portion of the 65-35 percent split paid through the Medicaid program.

“I think first and foremost what we’re concentrating on is improving access and having health care for people, and then looking at the funding level secondarily.

“If we look at the funding level first, I think a lot of times we’re not passing the best policy,” Sexton says.

Yet, asked if it sounds like legislators want to move people out of emergency rooms and into Health Department or nonprofit clinics, Sexton says if the state starts with a TennCare pilot program covering behavioral health, “we don’t need to lose sight that in that first phase there’s still other people who potentially won’t be on the program or in the pilot.

“And we don’t want to sacrifice their health care, so we were looking at other ways, and that’s the safety net and other things out there to hopefully enhance that coverage as we go along into this phased approach.”

If you’re confused, join the club.

For one thing, Sexton uses the term “comprehensive” at the same time he talks about a first phase focusing on mental health.

The second thing is lawmakers are trying to make this decision while going through a crash course on health-care treatment.

For instance, lawmakers apparently thought the state would be able to send uninsured residents to its Health Departments. But the Department of Health isn’t prepared for the influx.

Third, Sexton is saying he doesn’t want the health of Tennesseans to be sacrificed while saying he favors a phased-in approach. That means people who need treatment now could go without or that they’ll go to the emergency room and everyone else will pay for it – as they are now.

Fourth and foremost, it makes no sense to send Tennessee dollars to other states and then ask Tennessee hospitals and patients to pay more for a Medicaid expansion in which the state’s share would be bigger, simply because some legislators are more worried about getting linked to Obamacare – and then perhaps defeated in the Republican primary this August – than they are about making sure the working poor can get some sort of coverage.

Clearly the problem with health care lies with the high cost of treatment and the reluctance of insurance companies to pay for it.

Rates are going up as the Affordable Care Act kicks in because those who’ve never had health insurance are the most expensive to cover.

Although Sexton might not want to admit it, money and politics are the major sticking points here. Asking people who have little money to save money for health care only goes so far, and a $25 co-pay won’t do much either.

Somebody has to pay. And when $1.2 billion is sitting on the table, as Nickas says, failing to use it shows a failure to understand the problem.

As Nickas points out, Tennessee is hemorrhaging millions of dollars daily and other states are more than happy to scoop them up.

It shouldn’t take must ciphering for Tennesseans to figure that out. Then again, legislators are only good at math when they want to be.

Sam Stockard can be reached at [email protected].