Calls are growing among Democrats to expand Medicare. They view opening up the government insurance program for seniors as a way to achieve universal health coverage. But Nashville's health care industry roundly rejects "Medicare for All," despite vocally supporting efforts to expand insurance coverage.
Medicare is incredibly popular. So expanding it from mostly seniors to everybody else is appealing, according to recent polls, especially to those with pre-existing conditions.
Mindy Bates of Nashville has been fighting an aggressive form of leukemia since before the Affordable Care Act took effect. And now the ACA is in legal jeopardy.
"This could go away, and I would become one of hundreds of thousands of people who would be in the same boat."
Bates supports expanding Medicare to non-seniors. But such Medicare for All bills vary, and at the most extreme, such as a plan put together by Vermont Sen. Bernie Sanders, they would get rid of private insurance altogether and establish a single-payer system.
That's a non-starter for many.
"One of the concerns we have about Medicare for All proposals is it dismisses the progress we have made," says Lauren Crawford Shaver, spokesperson for the Partnership for America's Healthcare Future.
The lobbying group represents hospitals, insurance plans and doctors. They joined forces in mid-2018 in response to the Medicare for All push, with the goal of influencing messaging among Democrats.
Citing polling data, Shaver says those who have coverage through their employer are generally happy. Medicare for All would upend a system that works for most people, she says.
"The current system we have totally goes away and we start all over."
Shaver contends it would be much easier to improve what's in place, starting with making sure states like Tennessee expand Medicaid — the program that insures low-income people.
Few individual health care companies want to comment on Medicaid for All. They're leaving it up to their collective lobbying groups to do the talking. Those groups frame their concerns in terms of protecting patients.
But they're also defending their business model. Medicare pays far less than commercial insurance.
"If providers and doctors received only Medicare payment for all their patients, frankly many hospitals wouldn't be able to keep their doors open," says Chip Kahn of the Federation of American Hospitals, which speaks for the for-profit hospital industry, largely headquartered in Nashville.
The group representing nonprofit, academic and government-owned hospitals also says Medicare for All can't work.
Rick Pollack, CEO of the American Hospital Association, calls the government "a very unreliable business partner." Between Medicaid and Medicare, the government already has a hand in paying more than one-third of all hospital bills.
"Very often, what we see are reductions in payments and reductions or changes in benefit design to the Medicare program to save money in that program that is then used for other purposes," Pollack says. "That's what happens when you have a government-funded program."
But there is one struggling sector that sees some potential upside — rural hospitals.
"We find it intriguing," says Rebecca Jolley of the Rural Health Association of Tennessee.
Jolley says rural providers are more likely to embrace the idea of working with a single payer since they have very little leverage to negotiate with insurance companies and limited administrative staff to handle the complicated billing.
Outlying areas also have a disproportionate share of people without insurance. And Jolley says they would welcome a guarantee that all medical bills would get paid — even at a discounted rate.
"I think having dependability in reimbursement is attractive to a rural community, for sure."
But Jolley acknowledges that rural hospitals could still stand to lose in many scenarios if they're not given special consideration.
Nashville's Democratic congressman is not yet taking sides. Rep. Jim Cooper, who has taught health policy at Vanderbilt University's business school, concedes the cost of care is growing unsustainably, without improving public health. So he believes the system has to change. But he says a simple slogan like Medicare for All may overlook the necessary nuance.
"This is not like cheering for Clemson over Alabama," Cooper says. "This is something that has to be figured out because policy makers have screwed this up so much in the past. Everybody comes at it with good intentions, but this is not a pep rally."
Medicare for All is far from coming to a vote even in the Democratic-led U.S. House. But debate is expected to intensify during the 2020 presidential campaign.