

Tennessee state Sens. Becky Duncan Massey (R) and Jeff Yarbro (D) await a Feb. 4 Health Committee vote on GOP Gov. Bill Haslam’s Medicaid expansion proposal. They both voted in favor of the measure that ultimately failed. (Associated Press/Erik Schelzig)

Just when you thought there was some hope for the nearly 4 million people Republican leaders are denying access to health coverage across the country, the “hell no” caucus struck back. Conservative Indiana Gov. Mike Pence (R) concluded negotiations with the Obama administration last week to expand Medicaid in his state. “Indiana Medicaid Expansion May Tempt Other GOP-Led States,” declared one headline. “Will Mike Pence tip the GOP scales on Medicaid expansion?” asked another.

Not in Tennessee, where the state legislature on Wednesday repudiated an expansion plan that its GOP governor, Bill Haslam, has been pressing forward for months. This isn’t just bad for the people who will continue going without Medicaid in Tennessee. It also exposes how deeply irrational the anti-Obamacare frenzy is in certain sectors of the GOP, with staunch opposition remaining even when popular conservative leaders try to push in a more reasonable direction. And it’s a bad sign for what might happen if the Supreme Court rules against the Obama administration in its latest Affordable Care Act case.

Medicaid expansion has proceeded under a piece of the ACA meant to cover one class of low-income people. Though the federal government has committed to paying nearly all of the cost in perpetuity, the Supreme Court in 2012 made expansion optional for each state. Some states expanded gladly. Others used the opportunity to make a bizarre, counterproductive anti-ACA stand, totally refusing to expand. And then there were those like Indiana, not quite ready to jump headlong into an ACA-related program but also tempted by the obvious good expansion would do their states.

Over the past few years, GOP leaders in the third category of state have been hashing out compromise plans with the Department of Health and Human Services that offer their people coverage — but on terms very different from those of traditional Medicaid. Pence’s plan is by far the most conservative yet. Among other things, participants will have to put “skin in the game” — co-payments will be required and will rise for people with unhealthy habits such as smoking.

Republicans should be the most satisfied with this outcome. Instead of accepting a typical Medicaid plan, Pence forced the Obama administration to bend far, even though he was doing something decidedly in the state’s interest — taking expansion money, part of which came from Indiana taxpayers, out of Washington.

Pence is a strong, recognized conservative who insists he is trying to reform a Great Society entitlement program, not expand the ACA. So, following last week’s deal, there was room for hope that some Republicans would adopt Pence’s Medicaid model, or at least feel less pressure to stick with the hell-no crowd.

But the one-two attraction of simultaneously taking federal money to cover more people and pioneering conservative public coverage models was still not enough to convince the Tennessee Senate’s Health and Welfare Committee to approve a voucher-based expansion plan on Wednesday. It’s clearer than ever that convincing GOP governors to expand Medicaid is not enough. State legislatures stand as major obstacles. The big losers this time are the 142,000 low-income Tennesseans who have no option but Medicaid to obtain an affordable health plan — but who will continue to be denied access.

The no-Obamacare-at-all-costs attitude could result in many more losers soon. The Supreme Court made Medicaid expansion optional two and a half years ago. This year, the justices might make the core of the ACA — state insurance marketplaces — dependent on state cooperation, too. A court ruling hostile to the Obama administration this time around would wreck marketplaces in states that haven’t cooperated in establishing them. The low- and middle-income people relying on those marketplaces would lose coverage or pay a lot more for it. Any chance of preventing this outcome would disappear if state leaders refused to respond with policies meant to repair the damage. Given the record on Medicaid, it seems many would cheer as the system burns.