Despite overall aversion to the Affordable Care Act, Tennessee’s population continues to see improved health insurance coverage under the healthcare reform law. One demographic has reached the point at which almost 100 percent are insured: children. A Georgetown University Center for Children and Families report found that 23,000 Tennessee children have gained coverage since 2013 and now almost 96 percent of the state’s children have health insurance. The same report showed that nearly half of the nation’s uninsured children live in the south.
And while 85 percent of Tennessee exchange enrollees receive financial assistance, those who pay full price for their coverage saw costs rise dramatically in 2017. In August 2016, Tennessee’s insurance regulator called the state’s exchange “very near collapse” after she approved health insurance rate increases averaging 44 percent, 46 percent and 62 percent for Humana, Cigna and Blue Cross Blue Shield, respectively. An HHS spokeswoman in a statement reminded Tennessee consumers to shop around and reiterated the fact that the “vast majority” of Tennessee’s exchange enrollees qualify for premium tax credits (under the ACA, premium tax credits increase to keep pace with premiums, which means that people who receive premium tax credits — and are willing to shop around if necessary — often experience little or no rate increase from one year to the next).
Options in the individual health insurance market in Tennessee dwindled for 2017. BlueCross BlueShield of Tennessee left the state’s three major metro areas where it covered a majority of individual enrollees, although they’re re-entering the exchange in the Knoxville area for 2018, because Humana’s impending departure in that area would otherwise have left 14 counties with no insurance options at all. The Tennessean reported that Nashville General Hospital at Meharry, Saint Thomas Health, and Vanderbilt University Medical Center would not be in-network for in plans sold through the state’s exchange in 2017, thereby placing those who were unaware of the change at risk for “hefty out-of-network bills.”
Donald Trump, who campaigned on a promise to repeal and replace the ACA, easily won Tennessee in the 2016 election. In the ensuing months, House Republicans passed the American Health Care Act (AHCA) and Senate Republicans have introduced their own version of the bill, titled the Better Care Reconciliation Act (BCRA). Both would result in a dramatic increase in the number of uninsured residents in Tennessee. The Center for American Progress estimates that 637,000 additional people would be uninsured in Tennessee by 2026 under the AHCA (based on the CBO analysis of the legislation), and that 634,600 additional people in Tennessee would be uninsured by 2026 if the BCRA were to be enacted (based on the CBO analysis of that legislation, which was later supplemented by an additional analysis indicating that enrollment in traditional Medicaid would continue to fall after 2026 under the BCRA, relative to where it would otherwise be if current law were to remain in effect).
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. In the 2017 Scorecard, Tennessee dropped again, to 44th. Tennessee’s Scorecard includes specific details that further explain how the rating was calculated. 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 11th, 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 43rd — if Tennessee had accepted federal funding to expand Medicaid, it’s estimated that as many as half a million people would be newly eligible for Medicaid, but the state has thus far rejected the money. Both the BCRA and the AHCA prevent states from opting to expand Medicaid after March 1, 2017, although the legislation has not yet passed and it’s unclear whether it will.
The most recent edition of America’s Health Rankings (2016) also placed Tennessee 44th among the 50 states and rated toward the middle for most measures that helped calculate the ranking — lack of health insurance, immunization rates, public health funding, and number of primary care physicians. But the state had the lowest prevalence of excessive drinking, at 11.2 percent.
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, according to US Census data, 13.9 percent of Tennessee residents were uninsured. By 2015, that had fallen to 10.3 percent (for reference, the US average was 9.4 percent uninsured at that point).
It is likely that expanding Medicaid would help many Tennessee residents move from uninsured to covered. Right now, about 93,000 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. The number of people who would gain coverage under Medicaid expansion is much higher than this, because people with income between 100 and 138 percent of the poverty level are currently eligible for subsidized coverage in the exchange (not all are enrolled, however), and they would switch to Medicaid eligibility if it were to be expanded.
2018 Tennessee rates and carriers
Three carriers offer health insurance plans through the Tennessee exchange in 2017. The carriers and their share of the exchange market in 2016 are as follows:
- Blue Cross Blue Shield of Tennessee – 68.9 percent
- Cigna – 8.6 percent
- Humana – 6.7 percent
UnitedHealthcare had the remaining 15.7 percent of the exchange market share for 2016, but they left Tennessee’s individual market at the end of 2016.
For 2018, Humana is leaving the individual market nationwide, but Oscar Health is joining the Tennessee exchange in the Nashville area. Cigna and Blue Cross Blue Shield of Tennessee have both filed plans to remain in the exchange.
Blue Cross Blue Shield of Tennessee issued a press release on June 30, explaining their proposed rate increase for 2018. Their actuarial memo in their rate filing lists their average proposed rate increase at 21.4 percent, but notes that nearly all of the proposed increase is due to concerns that the Trump Administration won’t enforce the individual mandate, and the uncertainty surrounding ongoing funding for cost-sharing subsidies.
Of the 21.4 percent rate increase they’ve proposed, 14 percentage points are due to the uncertainty surrounding cost-sharing subsidy funding, and 7 percentage points are due to concerns that the individual mandate won’t be well enforced, resulting in a less healthy risk pool. So the rate increase would only be 0.4 percent if it weren’t for the Trump Administration’s refusal to commit to funding cost-sharing reductions and enforcing the individual mandate.
Cigna has filed an average rate increase of 42.1 percent (with increases that range from 12.2 percent to 182.2 percent). Their filing notes that 14.1 percentage points of this are due to the fact that the Trump Administration has not committed to funding cost-sharing subsidies. Their proposed rate increase would be 28 percent otherwise.
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.
268,867 people enrolled during the 2016 open enrollment period. Effectuated enrollment for 2016 had dropped to 231,705 by March 31. At the end of 2016 open enrollment, 85 percent of individuals who purchased Tennessee marketplace plans were receiving financial assistance.
234,125 people enrolled in private plans through the Tennessee exchange during the 2017 open enrollment period. This was about 13 percent lower than the total enrollment the year before.
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, and who shepherded the AHCA through the House as part of her Budget Chair duties.
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 wanted higher co-payments than the Obama Aministration HHS would allow, and no compromise was reached.
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 has been trying to reach a compromise with HHS that would allow the state to expand Medicaid the “Tennessee Way.” But for now, the state has 93,000 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).
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. The BCRA would provide premium subsidies for people with income below the poverty level, although it’s worth noting that the available plans would likely have out-of-pocket exposure far above the means of low-income families, making the coverage all but unusable.
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 April 2017, Tennessee’s Medicaid enrollment increased 23 percent; nationwide, enrollment had increased 29 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: