Despite overall aversion to the Affordable Care Act, Tennessee’s population continues to see improved health insurance coverage under the health reform law. How, if at all, has this impacted the overall health of the state’s population?
Tennessee health ratings
In The Commonwealth Fund’s Scorecard on State Health System Performance 2015, The Volunteer State placed 43rd out of the 50 states and the District of Columbia on – a loss of three spots from 2014. The score was based on several health indicators related to Access, Prevention & Treatment, Avoidable Hospital Use & Costs, Healthy Lives, and Equity, but The Volunteer state failed to crack the top 10 for any of them. At 13th, its uninsured rate for children ages 0–18 came close and was just below the U.S. average.
The uninsured rate for adults ages 19–64, however, came in 32nd and slightly above the U.S. average. Were the state to insure 467,758 more adults, it would improve to the level of the best-performing state. Tennessee’s Scorecard includes specific details that further explain how the rating was calculated.
The most recent edition of America’s Health Rankings (2015) placed Tennessee 43th among the 50 states and rated toward the middle for most measures that helped calculate the ranking – 31st for lack of health insurance, 25th for immunization (children), 21st public health funding, 18th for primary care physicians.
Trust for America’s Health has compiled 2016 Key Health Data about Tennessee, which includes the incidence of specific diseases and a variety of health factors and outcomes. You can also use this interactive map created by the Robert Wood Johnson Foundation to see how the individual counties in Tennessee compare with one another.
Has Obamacare helped Tennessee?
Tennessee can be counted among the states with higher uninsured rates and a bit more resistance to the Affordable Care Act. As such, it opted for a more hands-off approach with a federally facilitated exchange and has not yet expanded Medicaid.
Nonetheless, more Tennesseans have become insured since the ACA took effect. Prior to its implementation, Gallup Well-Being estimates an uninsured rate of 16.8 percent for Tennessee. By 2015, that number had decreased to 13 percent – still higher than the national average of 11.7 percent.
It is likely that expanding Medicaid would help many Tennessee residents move from uninsured to covered. Right now, about 118,000 of them are in the coverage gap, meaning they are ineligible for Medicaid based on the state’s eligibility criteria and also ineligible for Obamacare subsidies because their incomes are below the federal poverty level.
2017 Tennessee rates and carriers
- Blue Cross Blue Shield of Tennessee – 68.9 percent
- Cigna – 8.6 percent
- Humana – 6.7 percent
These percentages will likely shift. UnitedHealthcare had the remaining 15.7 percent of the exchange market share for 2016, but they are exiting Tennessee’s individual market at year-end.
Furthermore, rate requests have been filed and approved, and premium changes may encourage enrollees to shop around. On average, BCBS of Tennesee’s rates will increase 62 percent, Cigna’s 46 percent, and Humana’s 44.3 percent. The weighted average increase for Tennessee exchange plans is 59 percent. However, the state has typically had lower rates than most of the country. In 2016, a relatively steep weighted average rate increase brought Tennessee premiums to the level of the rest of the country, and the average pre-subsidy premium was $400 per month – it was $396 per month across all HealthCare.gov states.
Enrollment in qualified health plans
At the start of the first open enrollment period, the Kaiser Family Foundation estimated that 645,000 residents in Tennessee could potentially utilize the exchange to purchase qualified health plans, and that 387,000 of them would be eligible for premium subsidies.
By mid-April 2014, when the first open enrollment period ended, 151,352 people had finalized their plan selections in the Tennessee exchange, and 78 percent of them received subsidies to lower their premiums.
Does TN have an Obamacare CO-OP?
The ACA included a provision to fund Consumer Oriented and Operated Plans (CO-OPs), and 22 states participated in the program, receiving a total of more than $2 billion in federal funding.
In Tennessee, Community Health Alliance Mutual Insurance Company received $73,306,700. The CO-Op had been one of Tennessee’s five exchange carriers in 2015, but on Oct. 14 the Tennessee Department of Commerce and Insurance announced that Community Health Alliance would discontinue operation at the end of the year.
Tennessee and the Affordable Care Act
In 2010, Tennessee’s U.S. Sens., Lamar Alexander and Bob Corker (both Republicans), voted against the ACA. In the House, four Republican representatives voted no while five Democratic representatives voted yes. Alexander and Corker are both still in the Senate, and the U.S. House now has just two Democratic representatives from Tennessee, and seven Republicans.
The current congressional delegation from Tennessee is largely opposed to the ACA. This includes Rep. Marsha Blackburn, who has been very vocal in her opposition to the law.
Governor Bill Haslam has not been as outspoken against the ACA as many other Republican governors. The state opted to let HHS run the exchange and has not yet expanded Medicaid. Haslam has been working with HHS to try to gain approval for his modified version of Medicaid expansion, and he met with Secretary Burwell in July 2014 to continue the discussions he had been having with Secretary Sebelius.
Haslam has said he would like to expand Medicaid to cover another 161,000 low-income Tennessee residents, but he wants higher co-payments than HHS will allow, and no compromise has been reached yet.
The ACA called for Medicaid for all Tennessee residents with incomes up to 138 percent of poverty. In 2012 however, the Supreme Court ruled that states could opt out of Medicaid expansion, which Tennessee has done so far.
Tennessee is currently one of 19 states that has not expanded Medicaid; although, Governor Haslam is trying to reach a compromise with HHS that would allow the state to expand Medicaid the “Tennessee Way.” But for now, the state has 118,00 individuals in the coverage gap, with no realistic access to health insurance.
Exchange subsidies for private plans are not available for those who earn less than poverty level, and non-disabled childless adults are not eligible for Medicaid in Tennessee, regardless of income (although parents with dependent children can get Medicaid in Tennessee if their household income is up to 105 percent of poverty – a more generous threshold than many of the other non-expansion states use).
The residents in Tennessee’s coverage gap would be eligible for Medicaid if the state accepted federal funds to expand coverage. The federal government would pay the full cost of expansion through 2016, and then the state would gradually take on a small share of the cost, eventually paying 10 percent of the cost of Medicaid expansion by 2020.
The federal government will always cover at least 90 percent of the additional expense. But for now, there is no financial assistance available for people with incomes below the poverty level who do not qualify for Medicaid under the state’s existing guidelines.
During the first open enrollment period, which ran Oct. 2013 through April 2014, 83,591 Tennessee residents were still able to enroll in Medicaid under the existing guidelines, and the state’s Medicaid enrollment grew 8.1 percent from fall 2013 to July 2014. From 2013 to June 2016, Tennessee’s Medicaid enrollment increased 30 percent; nationwide, enrollment had increased 27 percent. Medicaid enrollment runs year round.
As of 2015, there were 1,235,157 Tennesseans enrolled in Medicare – 19 percent of the state’s total population. Nationwide, Medicare enrollees account for 17 percent of the population.
The state falls below the average for recipients eligible based on age alone – 79 percent vs. 84 percent. The remaining 21 percent of Tennessee Medicare enrollees qualify due to disability.
Medicare Advantage plans are available in Tennessee for those who want additional benefits beyond what Original Medicare offers. In 2015, a total of 34 percent of Tennessee Medicare recipients selected a Medicare Advantage Plan. About 42 percent of all Tennessee Medicare beneficiaries enrolled in Medicare Part D, compared with an average of 45 percent enrolled in stand-alone prescription drug plans nationwide.
State-based health reform legislation
Tennessee’s legislature has been quite active in the arenas of healthcare and healthcare reform, but not all of their legislation has been beneficial to the state’s residents. They passed a law prohibiting the governor from implementing Medicaid expansion, and another that allows a new mother to be charged with criminal assault if she used narcotics while pregnant (critics point out that this can be discriminatory towards low income women in areas where health care and addiction treatment isn’t readily available).
The legislature even tried to pass a law that would have banned schools from notifying parents about TennCare (Medicaid) and CHIP availability.
Several of the state’s lawmakers supported banning subsidies in states with HHS-run exchanges, which include Tennessee. However, as a result of the King v. Burwell ruling on June 25, 2015, subsidies are safe and legal in every state, regardless of how their exchange is run.
Here’s a list of recent state-level health reform bills: