By MICHELE JOHNSON, Executive Director, Tennessee Justice Center 

According to the most recent Vanderbilt poll, healthcare is a top concern of Tennessee voters and is therefore certain to be a major issue in this year’s elections. In the wake of Washington’s inability last year to substantially address the public’s healthcare concerns, voters will look to gubernatorial and state legislative candidates for answers. When they do, a single over-arching question is likely to be foremost: Should Tennessee finally accept the billions in federal healthcare funds it has spurned for four years?

In 2014, state Rep. Jeremy Durham (R – Franklin) and state Sen. Brian Kelsey (R – Germantown) won passage of a law that prohibits the governor from using federal funds allocated by the Affordable Care Act to extend Medicaid coverage to uninsured, low-income Tennesseans. The following year, Gov. Bill Haslam offered his Insure Tennessee proposal to use those funds to cover an estimated 280,000 uninsured working Tennesseans. The plan enjoyed nearly universal support in the business community, and it consistently polled well among voters of both political parties. The Tennessee Medical Association, Tennessee Hospital Association and Tennessee Nurses Association were among its strong supporters.

Two days into a special legislative session, however, a handful of state senators killed the proposal in committee, and it has never been reconsidered. Legislators cited their opposition to President Obama and the Affordable Care Act (“Obamacare”), which they expected to soon be repealed.

Building grassroots pressure led to the appointment in 2016 of a legislative task force to study the issue. The task force’s plan would have made full use of the federal funds, but legislative leaders peremptorily shelved it without a vote. Rep. Durham, author of the law blocking use of the federal funds, was subsequently expelled from the Tennessee State Legislature amid allegations of misconduct, but his law remains in effect.

The majority of states, including many with Republican majorities, have been making full use of their federal health funding for four years. That has created a natural experiment enabling researchers to compare Medicaid expansion states with non-expansion states and assess the impact of the federal funding. As the prestigious Kaiser Family Foundation summarizes the research literature:

As a whole, the large body of research on the effects of Medicaid expansion under the ACA suggests that expansion has had largely positive impacts on coverage; access to care, utilization, and affordability; and economic outcomes, including impacts on state budgets, uncompensated care costs for hospitals and clinics, and employment and the labor market.

Among specific results are findings that in expansion states, insurance markets are more stable and premiums are lower for those with private insurance; the risk of a rural hospital closing is six times lower; there is a 6 percent decrease in all-cause mortality, and a greater decline in infant mortality.

By contrast, Tennessee’s refusal to use the federal funds has been costly in numerous ways. The official estimate is that the law has cost $5.4 billion over four years, or $3.8 million every day, in federal funding, while 280,000 Tennesseans have gone without the financial security and access to affordable care that only insurance can provide. Tennessee has lost more rural hospitals for its size than any other state. Durham’s law denies urgently needed prevention and treatment resources to families and communities ravaged by the opioid epidemic. U.T.’s Center for Business and Economic Research estimates that the unused funds would have created 15,000 jobs.

Time moves on, and many legislators feel it is time to turn the page. Obama’s presidency is long over. The ACA seems to be here for the foreseeable future. Tennesseans’ health costs continue to grow, the overdose death toll is climbing, and the rural health crisis deepens.

In what seasoned observers see as an effort to change the subject, legislators are pushing “work requirements” that would strip unemployed TennCare enrollees of their health coverage. This would require an enormous bureaucracy to administer and, if a recent Tennessee Comptroller report is any indication, result in the erroneous termination of coverage for tens or hundreds of thousands of eligible patients. Healthcare providers are so likely to become collateral damage that Fitch Ratings just issued a warning about the potential impact of Medicaid work requirements on several major hospital chains headquartered in Tennessee.

Voters are not likely to be distracted, however, by such proposals, which solve none of their pressing concerns. Legislative candidates should be prepared to answer the central healthcare question on voters’ minds: “Will the legislature allow us to bring our federal healthcare dollars home to address Tennessee’s health and economic needs?”


Feb Blog.OpEd TJC.Michele JohnsonMichele Johnson is co-founder and executive director of the Tennessee Justice Center. The focus of her nationally recognized legal work has been children with special healthcare needs. A graduate of the University of Tennessee College of Law, she spent several years with Legal Services before leaving in 1996 to found the Tennessee Justice Center alongside Gordon Bonnyman with a grant from the National Association of Public Interest Law (now Equal Justice Works). She was named executive director of TJC in 2014.



Tennessee Justice Center