NASHVILLE — Gov. Bill Haslam of Tennessee describes it as "trying to thread a needle from 80 yards."
Mr. Haslam is only the latest Republican tailor trying to figure out whether to expand the state's Medicaid rolls as prescribed by President Obama's Affordable Care Act. In his case, it involves trying — so far unsuccessfully — to balance some sharply conflicting concerns: struggling hospitals, local business groups, dwindling state resources and fierce conservative opposition to the new health care law.
And it has left him hanging out there, with no resolution in sight, while almost every other state has made a decision, and with many of his impatient constituents wondering how long it is going to take.
"Sometimes you've got to make a tough call," said Craig Fitzhugh, the State House Democratic minority leader, who is pushing for expansion. "It's time to say yes or no. I don't want to get morbid or dramatic about this thing, but it's lives we're talking about here. It's human beings."
Rick Perry of Texas and Bobby Jindal of Louisiana, among many other Republican governors, have flatly rejected the expansion, even though it would provide billions of federal dollars to their states. Gov. Jan Brewer of Arizona and Gov. Rick Snyder of Michigan are among a small number who decided to accept it, coming under intense criticism from conservatives as a result. Gov. John R. Kasich had to do an end run around his own Republican-controlled Legislature to make it happen in Ohio.
But Mr. Haslam, who had once promised a decision by summer's end, is still trying to negotiate a new plan of his own with federal officials, hoping it will satisfy the competing constituencies. It would involve using federal money to place many of the state's poor on the federal health care exchange created by the act, rather than on Medicaid. But so far he has not persuaded federal officials, who have asked for more details, and said he expected no quick resolution.
Although he is not required to do so, Mr. Haslam has also promised not to enact anything without the approval of the Legislature, whose Republican majority, he said, was dead set against an expansion of Medicaid. Support for his alternative plan seems uncertain at best.
"We don't want to expand a system that's not doing a good job controlling costs," the governor said, karate-chopping the air during an interview in his modest Statehouse office. "We want to end up with something that's not just Medicaid with lipstick on it."
Though Mr. Haslam has said he felt under no time pressure, the state faces a Jan. 1 deadline to qualify for the first $300 million in Medicaid money for the coming year. The Tennessee Hospital Association, the state Chamber of Commerce and Democrats say Mr. Haslam cannot afford to wait much longer.
The National Conference of State Legislatures says that as of this month, 21 states, all of them with Republican governors or Republican-dominated legislatures, have announced that they would not expand Medicaid, while 27 others, plus the District of Columbia, have already approved an expansion or indicated that they would do so. The election this month of Terry McAuliffe, a Democrat and a supporter of the health care act, as governor of Virginia makes it likely that the state will join the expanders.
That leaves just Tennessee and Pennsylvania, where Gov. Tom Corbett has also asked the Obama administration for permission to use federal funds to buy private health insurance for the uninsured poor, on the fence.
A son of the Knoxville, Tenn., founder of Pilot Flying J, the nation's largest chain of truck stops and travel centers, Mr. Haslam remains a popular figure in his state. A May poll by Vanderbilt University's Center for the Study of Democratic Institutions showed him with a 63 percent approval rating. The same poll, however, found that 60 percent of respondents favored the expansion of Medicaid in the state.
Mr. Haslam, 55, ran for mayor of Knoxville in 2003 as a pro-business conservative, and was re-elected in 2007 with 87 percent of the vote. In 2010, he ran for governor, winning with 65 percent of the vote. He is up for re-election next year and is a prohibitive favorite, with nary a primary challenger in sight and no strong Democratic challenger yet, either.
In Tennessee, opposition to expanding Medicaid has come largely from Republican officeholders and conservative groups. Arrayed on the other side are the Tennessee Hospital Association and other medical groups, the Tennessee Chamber of Commerce and Industry and local chambers across the state, several antipoverty organizations and the Democratic opposition.
Recent layoffs at a few Tennessee hospitals have focused attention on their plight — and complicated Mr. Haslam's decision.
David McClure, senior vice president for finance at the state hospital association, said that failing to expand Medicaid would have a devastating effect on the state's 165 hospitals, leading to layoffs and the closing of some facilities.
"In every community that has a hospital, we are typically the biggest or one of the biggest employers," Mr. McClure said. "I don't want to be Chicken Little and say the sky is falling, but there will be some hospitals that will close."
Since hospitals are required to treat patients who show up in their emergency rooms, whether or not they can pay, hospital officials had hoped that adding more poor people to Medicaid rolls would absorb some of those costs, Mr. McClure said.
Without an expansion of Medicaid, hundreds of thousands of Tennessee residents would fall into a gap, making too little money to get subsidized health coverage under the act and too much to qualify for Medicaid. The authors of the Affordable Care Act had assumed that states would expand their Medicaid rolls — which they had been required to do until the Supreme Court struck down that provision — providing coverage for these working poor families who fell into the gap.
The hospital association estimates that 400,000 Tennesseans fall into that gap. Other estimates are somewhat lower.
Deepening the angst over this decision is the state's own history with managed health care. Tennessee's homegrown health care system, TennCare, went through a wrenching downsizing in 2005, when the program was totally state sponsored. More than 170,000 people had to be thrown off the TennCare rolls.
Even though the federal government is promising to pay 100 percent of the new Medicaid costs for the first three years and most of the costs after that, Mr. Haslam said he was worried that later administrations might renege on that promise.
"If at some point we're going to have to cut people off the rolls," he said, "I'm not sure we'd want to go through that again. Our history makes us a little wary."
This article has been revised to reflect the following correction:
Correction: November 16, 2013
An earlier version of this article mischaracterized a health insurance gap in Tennessee that would occur without Medicaid expansion. The gap would include people who make too little money to get subsidized health coverage under the Affordable Care Act and too much to qualify for Medicaid, not too much for a subsidy and too little for Medicaid.
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