In 2015, Governor Bill Haslam presented his “Insure Tennessee,” Medicaid expansion to legislators, a plan that would have brought billions of dollars into the state and meant insurance coverage for up to 280,000 Tennesseans. Legislators rejected it.
Here we are six years later with the country still reeling from the far reaching impact of the Covid-19 pandemic, and legislators have once again refused to expand a program that would bring much needed dollars into a state that is among the bottom ten states for maternal and infant health, and pre-pandemic, had some of the highest increases in uninsured residents.
In rural areas of the state in 2019, 16.4% of the population aged 18-64 were uninsured and 5.1% of children under 18 were uninsured. In 2021, all rural counties in the state were in Health Professional Shortage Areas for Mental Health. There are only four Primary Care Physicians (PCP) per 100,000 people with some rural counties sharing only one PCP. With such dismal statistics that lead to poor health outcomes, now would be the ideal time to expand Medicaid since it is anticipated that 300,000 uninsured Tennesseans and approximately 86,000 additional Tennesseans will be in the coverage gap in the next 6 months. Individuals in the gap are not eligible for Medicaid under the state’s rules and their incomes are too low to qualify for subsidized health insurance in the Affordable Care Act marketplace.
You don’t need to be a sage or stare into a crystal ball to see that things are likely to get worse before they get better and Medicaid expansion could help turn the tides by increasing healthcare coverage gains and improving long-term health outcomes. It could be the difference between life and death for individuals with life threatening illnesses and no coverage for treatment and medications that control chronic conditions such as heart disease and diabetes. Research has shown that in states that accepted Medicaid expansion, it saved the lives of at approximately 19,000 adults aged 55 to 64 over a four-year period from 2014 to 2017. Conversely, 15,600 older adults died prematurely because of state decisions not to expand.
I recently spoke to a 60 year old who suffers with an autoimmune disease that literally eats away at the hands and feet. The patient needs hydrobaric oxygen therapy, a proven, effective form of treatment that is unfortunately not covered by Medicaid. Expansion could be the difference between this patient losing their hands and feet, subsequently landing them in a long term care facility that would cost Medicaid more in two months than it would cost to pay for the therapy.
It could be the difference between eviction and keeping a roof over the head of the person who has to choose between paying healthcare and/or medication costs or paying rent or mortgage; a choice that no Tennessean should have to make at a time when thousands are feeling the economic impact caused by the pandemic and they have no viable safety net to avoid pending homelessness.
Expansion could also mean that countless numbers of young disabled Tennesseans could regain their independence through expanded payment for medical procedures and assistive devices not currently covered by Medicaid. My daughter, a 42 year old nurse who suffered a massive stroke in 2017 is one such individual. The stroke left her with minimal to no functioning in her dominant right hand and arm. In early 2020, her physical and occupational therapists recommended an orthotic device that could restore functioning to her paralyzed right arm and hand, a device first used by veterans with remarkable success. After an evaluation by the company that makes the device and an order from her PCP, a request for approval was submitted to Medicaid. The request was denied. Three appeals were filed and they too were denied. The reason given for the denials was that the device was “experimental,” which made no sense since we had observed a patient in our home town that is using the device that was paid for by his private insurance company. We also submitted documentation of several federal appeals where judges ruled in favor of the patient. This obviously meant nothing to Medicaid who suggested that we continue with the same physical and occupational therapy that has proven to be ineffective, and the costs over the years would add up to more than the cost of the assistive device. This made no sense to us but after three appeals, we are moving on. Expansion could reverse decisions such as this one that deny the patient the opportunity that would lead to more independence and in my daughter’s case likely result in her returning to gainful employment.
And then there is the 40 year old I know who suffered a stroke and heart attack that left them totally paralyzed and unable to speak. This person was placed in a long term care facility after discharge from the hospital with a feeding tube, tracheotomy, and unable to walk. The scary part to this story is that the person never had an MRI because they were obese and unable to fit into the MRI machine. They were told that Medicaid would not pay for them to be transported to a facility that could accommodate them. So in reality, the diagnosis was never confirmed and their treatment plan was based on guess work by providers. Hard to imagine in 2021 in a country that prides itself on its medical advances. Expansion of services could have made a huge difference in this patient’s level of treatment and overall outcome.
There are countless others in this state with similar stories of poor health outcomes that could have been prevented. I understand that the wheels of justice turn ever so slowly but when it comes to justice in healthcare in Tennessee, we haven’t made strides in decades. In reality, one glance at any health statistic points out that things keep getting worse. In the middle of the “Bible Belt,” the good and right thing for legislators to do is to put personal and political agendas aside and take advantage of this opportunity to improve the health of all Tennesseans and make this a healthier state. If the pandemic didn’t point this out, perhaps the folks we chose to represent us are looking into a crystal ball and seeing things that I can’t see. Wonder what it will take to make them change their view.
Myrtle Russell is a retiree and caregiver. Contact her at firstname.lastname@example.org