Mind the gap: Thousands of Tennesseans fall in government health insurance gap

Oct 02 2019
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Mind the gap: Thousands of Tennesseans fall in government health insurance gap

By: Hannah Herner


This story is part of a series about homelessness and health care. Read more about Neighborhood Health Clinics and Centerstone's Keys to Recovery program.


When it comes to health insurance coverage, there’s a gap. There are about 280,000 Tenneseeans in it, including many of our neighbors who are homeless, according to Tennessee Justice Center (TJC).

Tennessee is one of 14 states that hasn’t expanded Medicaid. 

TennCare, Tennessee’s state Medicaid program, only covers children under 18 and their parents, people with severe disabilities, and women who are pregnant or have breast or cervical cancer. On the other side of the gap is an Affordable Care Act marketplace premium tax credit, which subsidizes health insurance costs, but a single person has to make $12,000 to get it. 

“For many of the homeless, they’re working and they can’t afford private coverage without some subsidies, but they don’t qualify for subsidies because they’re too poor for subsidies and they don’t qualify for Medicaid because they don’t fit in the pigeonholes,” says Michele Johnson, executive director of TJC. 

That said, Johnson says TJC has worked with Contributor vendors who use their proof of income through selling the paper to qualify for the tax credit. 

When people don’t have health insurance they turn to church-based clinics and federally qualified health centers that offer sliding scale fees, but another problem remains. 

Many of these clinics only offer primary care, which still excludes things like dental care, vision care, chemotherapy, dialysis and physical therapy. Specialists sometimes donate their time, often at yearly events like Saint Thomas’ Day of Health Hope and Healing, which fills Nashville Municipal Auditorium with queues. 

 “That’s the real challenge. If you’re homeless and in the coverage gap and need specialty care — that’s why we need expansion,” Johnson says. 

For those that do have Medicaid, signing up for and recertifying it has been challenging in two different ways. Participants used to recertify via a 98-page packet that arrived (or didn’t arrive) in the mail — which makes things difficult for those who do not have a reliable permanent address. Now that process has been moved online, which Johnson says is a great improvement, but puts those who aren’t tech-savvy at a disadvantage. 

The thing that makes Medicaid incredibly complicated is that there are 28 different qualifying categories. Depending on the category, you might have to show different paperwork, identification — things that people experiencing homelessness often don’t have a place to safely store. Johnson says there used to be regional offices and social workers to set an appointment with to sort all of this out, and those people don’t exist anymore. 


The open enrollment for the (Affordable Care Act) coverage is Nov. 1 until Dec. 15. Johnson says the main skill needed in getting people signed up for health insurance is comfortability with a computer, and TJC can train organizations who are interested in helping.  

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