Improving Access to Health Care for Tennesseans

When Dana Henderson worked as a nurse practitioner at a rural health clinic in Macon County, she saw a patient who came in complaining of back pain. Within a year, the man died of prostate cancer that had spread to his bones.

What saddens Henderson the most is that his death may have been preventable. Lacking health insurance, the man didn’t undergo the regular screenings that can help doctors catch—and treat—prostate cancer in its early stages. It could have given him a far better chance of beating the cancer.

More than a decade later, Henderson is now quality manager for the nonprofit Tennessee Primary Care Association, where she hears similar stories from other providers of uninsured patients who put off care because they couldn’t afford it—until it was too late.

“They limp along ... until it is catastrophic,” she says.

An estimated 476,000 additional Tennesseans would be eligible for health coverage—including 72,000 uninsured people ages 50 to 64—if the state opted to expand Medicaid under the Affordable Care Act, according to AARP Public Policy Institute research.

The 2010 health care law required states to extend Medicaid—the joint federal-state health insurance program for low-income Americans—to include adults who make up to 138  percent of the federal poverty level ($20,783 for a single person in 2024). But a 2012 U.S. Supreme Court decision made that expansion optional.

Forty states and the District of Columbia have expanded Medicaid coverage, including North Carolina and South Dakota last year. Meanwhile, Tennessee is among 10 states that have not.

Mia McNeil, AARP Tennessee’s state director, says older Tennesseans have worked hard, paid taxes and shouldn’t be left without access to health coverage that could provide essential services.

Health care gaps

The Tennessee Hospital Association and numerous nonprofits support expansion. A 2018 Vanderbilt University poll of 1,004 registered voters in Tennessee found that 66 percent also favored expansion.

Still, the issue has remained politically divisive over the years in Tennessee and in some other states, with some lawmakers citing concerns such as expanding a program they say is inefficient and the cost to taxpayers.

But proponents point out that by rejecting expansion, Tennessee is turning down billions of dollars in federal funding that could boost the economy and help struggling rural hospitals. The federal government covers 90 percent of the cost of expansion enrollees—more than it typically pays for regular Medicaid recipients.

A 2023 AARP analysis estimated Tennessee would receive an additional $1.5 billion in federal funding during 2024 and 2025 if it expanded. That money would save the state nearly $337 million over those two years by helping to cover services it already pays for, such as mental health care.

Without expansion, tens of thousands of Tennesseans fall into what’s known as the “coverage gap.” They make too much money to qualify for Medicaid (known as TennCare in Tennessee), but their incomes are too low to qualify for financial assistance to buy affordable coverage on the federal health insurance marketplace.

These are mostly people in low-wage jobs—waitresses, home health aides, construction workers—notes Michele Johnson, executive director of the nonprofit Tennessee Justice Center, which advocates for expansion.

Choosing not to expand has also hit rural communities hard, Johnson says, with Tennessee among the states with the highest number of rural hospital closures.

Positive outcomes

Expansion has fueled economic growth and improved access to health care in other states. An analysis of 404 studies by the nonprofit KFF found that expansion had positive effects on access to and utilization of care, insurance coverage, health care affordability, self-reported health and other measures.

In Kentucky, the uninsured rate fell from 14.3 percent in 2013, before expansion, to 5.7 percent in 2021, federal data shows. Tennessee’s rate fell from 13.9 percent to 10 percent over that period.

More than a decade since the Affordable Care Act took effect, some states are reconsidering expansion. North Carolina lawmakers approved expansion last year. As of April 1, more than 400,000 residents had signed up.

In Tennessee this year, state Rep. Caleb Hemmer (D-Nashville) introduced a bill that would have reversed a state law requiring the governor to get legislative approval before expanding Medicaid. The measure didn’t make it out of committee, although Hemmer says he will be trying to drum up support to get the bill on next year’s agenda.

“We know it’s the right thing to do. We just haven’t had the political will to do it,” he says.

Lisa Bertagnoli, a Wisconsin-based journalist, writes about livable communities and other topics. She’s written for the Bulletin for 20 years.

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