Nashville resident Jennifer Murray is caught in the snare of uncertainty looming over Tennessee health insurance coverage. Self-employed as a health care consultant, the single 48-year-old bought individual coverage through BlueCross BlueShield Tennessee’s marketplace plans each year since the Affordable Care Act took effect in 2014. The company offered the widest range of physicians, and its insurance was accepted in most places.

For Murray and about 112,000 Tennesseans, though, the plans offered by BlueCross BlueShield are vanishing at the end of 2016 after the company opted to drop individual marketplace coverage in the Nashville, Knoxville and Memphis regions – only a month before enrollment periods open.

“It was distressing enough when we got the letter saying your premium was going to go up 62 percent, because that meant mine was going to go from $450 to $730 (monthly), a big difference and a big chunk of my income,” she says.

Murray, after hearing rumblings of trouble, was even more horrified when she went to a local BlueCross BlueShield office and found out the company was dumping her because of the high cost of insuring marketplace customers, many of whom qualify for tax credits.

“I was shocked, and they had this canned speech about they have lost $500 million because more people used it than they had anticipated,” she says. “And when I finally got my letter, that’s what it says in the letter, that they have been out $500 million and blah, blah, blah.”

Murray understands the company line.

“But that doesn’t help me when there’s a law that says I have to have insurance but I can’t afford it, and then they’re not even gonna offer it,” she adds.

Like most conscientious people, Murray wanted to do something as soon as possible to figure out how she can replace BlueCross BlueShield.

Cigna and Humana are expected to offer plans in Nashville, though they also received state approval to raise their rates by more than 40 percent.

But other insurance companies aren’t quoting their rates until Nov. 1, Murray says. And with premiums expected to be much higher next year, she’s not sure if she should find a cheap insurance plan that doesn’t meet federal guidelines and then pay the tax penalty on top of that, while also facing the consequences of deductibles in the $5,000 to $10,000 range. She wonders, though, whether those would cover mammograms and pap smears.

Murray might even opt for the Faith Family Medical Center, a nonprofit provider that traditionally cares for low-income residents but started accepting people with insurance, she explains.

“I’m really mad at BlueCross for waiting this late to tell us. I just think that’s so unfair. I know they’re a business, but it just really impacts me,” Murray says.

She’s not sure, either, if the state of Tennessee or the Legislature has the authority to do anything about it. More than likely, they don’t.

BlueCross BlueShield will continue offering individual/marketplace plans in five regions where other insurance plans are readily available. The company says losses approaching $500 million by the end of the year are “unsustainable.”

“We have tried to make the ACA Marketplace model work for Tennessee, but we believe there are too many uncertainties to continue participating on a statewide level as we have before,” the company says in a statement.

“We’ve made this difficult decision carefully, with the intention Tennesseans in every marketplace region will still have an option for individual coverage under the ACA.”

The company isn’t ruling out a return to all regions in 2017. Its decision next year could depend on what the Legislature and federal government do, mainly based on the presidential election. Hillary Clinton is likely to tweak the Affordable Care Act while Donald Trump says he’ll dismantle it.

Legislative reaction

Predictably, reaction in the General Assembly is split between controlling Republicans and minority Democrats, their pronouncements coming not long after Commerce and Insurance Commissioner Julie McPeak approved sizable premium increases and told lawmakers the system is on the verge of “collapse.”

McPeak

“BlueCross’s decision is the latest canary in the coal mine. This is the collapse of coverage Commissioner McPeak warned about (in August),” Senate Majority Leader Mark Norris says.

Norris, a Collierville Republican, contends a precursor to this failure of Obamacare came early in 2016 when several Consumer-Oriented and Operated Plan, or CO-OOPs, collapsed because the federal government failed to keep its commitments.

Those were set up as an alternative to a government-run insurance plan or public option, and their failure cost taxpayers an estimated $1 billion, according to Congressman Phil Roe.

“Now others see more clearly why Medicaid expansion in Tennessee was always an intolerable risk,” Norris says. “The uncertainty of an unreliable government puts Tennesseans unreasonably at risk. This is just the next chapter.”

Norris, who is mulling a gubernatorial run, says his biggest worry lies with people “who must find coverage where it may cost too much or may not exist at all.”

Sen. Mark Green, a physician also considering a run for governor, called on Gov. Bill Haslam to petition the Obama Administration for permission to fund a TennCare Opt Out program he sponsored this year.

The pilot program would enable low-income Tennesseans to set up a health care expense account and shop for lower health care and wellness prices instead of using traditional government allotments for a federally set menu.

“We’ve talked about it. We’ve predicted it. Now, it’s time to act with a free-market solution for not just TennCare patients but all low-income citizens who seek some type of insurance coverage,” Green says in a statement. “Folks, government-run health care does not work.”

One wonders, though, just how much control the government has over the marketplace, since the private market provides the insurance.

While Republicans spent more time criticizing Obamacare than BlueCross BlueShield, House Minority Leader Craig Fitzhugh says he was “extremely disappointed” in the company’s decision.

“After receiving permission to increase premiums an unprecedented 62 percent for the coming year, the company decided that they no longer would participate in the Affordable Care Act Marketplace Exchange. This is unacceptable,” Fitzhugh says via a statement.

He points out House and Senate Democrats asked for hearings in August to figure out why Tennessee is hitting hard times on the marketplace while half the country’s states are doing better.

The vocal proponent of Medicaid expansion calls the pullout an “unnecessary hurdle” for health care in Tennessee and says approval of Gov. Haslam’s Insure Tennessee initiative could have averted many of the problems. It would have helped some 290,000 working Tennesseans caught in a gap between TennCare and Obamacare.

State Rep. John Ray Clemmons, a Nashville Democrat who questioned the transparency of McPeak’s decision, is planning informal hearings on the matter after his request for formal hearings was rebuffed by Republicans and the administration.

Lack of public information from “credible sources” is his biggest worry.

“My constituents and those with whom I have spoken across the state are seriously concerned about what is going on with the health insurance market in Tennessee and rightfully so,” he says. “Their concerns are warranted, and they are only exacerbated by the unknown.”

Most Tennesseans’ knowledge is limited to Medicaid expansion, Insure Tennessee, rising marketplace premiums and the BlueCross BlueShield withdrawal, he says, adding the state has a responsibility to provide basic information to families on “complicated and nuanced” issues such as health insurance markets and health policy.

Lack of information or, worse, the spread of “misinformation” creates “panic” among people and destabilizes markets, Clemmons says.

With that in mind, he and Sen. Jeff Yarbro, a Nashville Democrat, are inviting key administrators, health care providers, insurance carriers and others affected by recent decisions to participate in roundtable-type discussions.

More questions

While BlueCross BlueShield is skating away from Republican criticism, the Tennessee Health Care Campaign isn’t letting it get by without leveling some shots.

“How do you fix problems with health care access that impact tens of thousands of Tennesseans? By walking away and creating barriers to care, or by working for solutions?” Walter Davis, executive director, asks in a statement.

The organization uses a network of volunteers and marketplace navigators called Get Covered Tennessee to help people enroll in plans.

Davis calls the BlueCross BlueShield move “shameful” for a nonprofit company with assets of some $2 billion and points out they did it “without warning” and only a month before open enrollment starts for the exchange. The pullout also raises fears for the 80,000 people left in rural areas who use BlueCross BlueShield, he says.

He points out the Affordable Care Act depends on the private market to provide coverage and manage its business risk.

“But if the private insurers cannot, Congress and the states will have to revisit public options,” he says. “If private insurers instead continue to make net income or executive salaries the bottom line, it becomes imperative to create an effective consumer voice within (Tennessee Department of Commerce and Insurance), as exists in many other states, to prevent disruptive events like BCBST’s actions.”

Tennessee Hospital Association Executive Director Craig Becker isn’t quite as sharp-tongued but says the BlueCross BlueShield decision “will continue to have an impact on hospitals,” especially those run by Ascension, the ownership company for St. Thomas hospitals.

The number of people without insurance could increase, which affects the amount of uncompensated care hospitals put on their books each year, he notes, adding that number has been improving because of the marketplace exchanges.

Separately, the hospital association supports efforts for House Speaker Beth Harwell’s 3-Star Healthy proposal, seen as an alternative to Insure Tennessee, dealing first with veterans and behavioral health problems before expanding to catch a segment of the population caught in a coverage gap between TennCare and the Affordable Care Act. It has not been approved by the Center for Medicaid and Medicare Services.

Meanwhile, Murray, who volunteers as president of the Tennessee Cancer Consortium, says the group has been told Vanderbilt University Medical Center is set to stop accepting marketplace policies or BlueCross BlueShield for cancer patients.

People could find themselves midway through chemotherapy treatments when all of a sudden they’re told to go somewhere else, required to pay out of pocket or to see if their physician can practice at another hospital.

“It’s really left a lot of people in limbo,” she says.

Three months before the 110th General Assembly convenes, that seems to be where much of Tennessee’s health care system lies, barred from heaven and likely headed for hell.

Sam Stockard can be reached at [email protected].