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Key Takeaway
Blackburn voted repeatedly to repeal the Affordable Care Act without a replacement plan, threatening coverage for over 300,000 Tennesseans in the 1st Congressional District who gained protection for pre-existing conditions.
The 280,000 Tennesseans Stuck in the Medicaid Coverage Gap
Tennessee is one of 10 states that have not expanded Medicaid under the ACA. An estimated 150,000 or more Tennesseans fall into the “coverage gap” — they earn too much to qualify for TennCare (Tennessee’s Medicaid program) but too little to receive marketplace subsidies. Many of these individuals live in rural East Tennessee, where poverty rates exceed the state average and healthcare facilities are sparse.
Governor Bill Haslam attempted to expand Medicaid through a waiver program called Insure Tennessee in 2015. The proposal was killed in a state Senate committee before reaching a full vote, with opposition from conservative groups aligned with the same Tea Party movement Blackburn has championed throughout her career. Blackburn has consistently opposed Medicaid expansion at the federal level, aligning herself against the policy that health economists estimate would bring Tennessee over $1 billion in annual federal funding.
What ACA Repeal Would Have Meant for Patients With Pre-Existing Conditions
The AHCA bill Blackburn voted for included a provision allowing states to seek waivers from the ACA’s Essential Health Benefits requirements and its protections for people with pre-existing conditions. Under these waivers, insurers could have charged significantly higher premiums to people with conditions like diabetes, heart disease, cancer, and substance use disorders. East Tennessee has elevated rates of all of these conditions — a direct consequence of the region’s demographics, economic challenges, and the opioid crisis. The CBO estimated that in states pursuing waivers, premiums for people with serious health conditions could have increased by tens of thousands of dollars per year.
As governor, Blackburn would have direct authority over TennCare and the question of Medicaid expansion. Her record in Congress leaves little doubt about where she would stand: against expansion, against broader coverage, and against the federal funding that comes with it. For the estimated 150,000 Tennesseans in the coverage gap — and for rural hospitals struggling to stay open — this is not an abstract policy question. It is the difference between having healthcare and not having it.
Blackburn Voted Yes on the AHCA, Which the CBO Said Would Leave 23 Million More Americans Uninsured
In May 2017, Marsha Blackburn voted in favor of the American Health Care Act (AHCA), the House Republican plan to repeal and replace the Affordable Care Act. The Congressional Budget Office projected that the AHCA would result in 23 million more Americans losing health insurance by 2026. The bill would have allowed states to waive protections for pre-existing conditions and cut Medicaid funding dramatically—both devastating provisions for East Tennessee.
East Tennessee’s Healthcare Vulnerability
Tennessee’s 1st Congressional District has some of the highest rates of chronic disease in the nation. Diabetes, heart disease, COPD, and other conditions that qualify as pre-existing conditions are disproportionately prevalent across Appalachian Tennessee. The AHCA’s provision allowing states to waive community rating—which prevents insurers from charging sick people more—would have been catastrophic for families already struggling to afford care.
Many residents of the TN-1 region rely on Medicaid, the ACA’s marketplace subsidies, or community health centers that receive ACA funding. The AHCA’s cuts to these programs would have created a healthcare crisis in communities where the nearest hospital may already be an hour’s drive away.
Rural Hospital Closures Across Tennessee Since 2010
Tennessee is one of 10 states that never expanded Medicaid under the ACA, leaving hundreds of thousands of residents in the “coverage gap”—too poor to qualify for marketplace subsidies but not poor enough for traditional Medicaid. The AHCA would have made this problem worse by converting Medicaid to a per-capita cap system, reducing federal funding over time and leaving states with impossible budget choices. For rural hospitals in East Tennessee already operating on razor-thin margins, these cuts could have triggered additional closures.
Real Patients, Real Consequences: Pre-Existing Conditions in Tennessee
Under the AHCA, states could have applied for waivers allowing insurers to charge higher premiums based on health status. For a cancer survivor in Kingsport, a diabetic in Johnson City, or an asthma patient in Rogersville, this meant the return of a system where getting sick could make insurance unaffordable. Blackburn’s yes vote put the interests of insurance companies above the health security of her own constituents.
Tennessee Health Coverage at a Glance
Tennessee has experienced a wave of rural hospital closures over the past decade, with communities losing access to emergency rooms, maternity wards, and basic medical services. The state’s decision not to expand Medicaid under the ACA has been identified by healthcare policy experts as a major contributing factor to these closures, as hospitals in non-expansion states face higher rates of uncompensated care from uninsured patients.
In the 1st Congressional District specifically, communities have seen healthcare facilities reduce services or close entirely. When Blackburn voted for the “skinny repeal” of the ACA in 2017, the Congressional Budget Office estimated that the legislation would have resulted in 16 million more Americans losing health insurance coverage. For East Tennessee, where healthcare access is already precarious, the consequences would have been devastating.
ACA Protections Blackburn Voted to Eliminate
One of the ACA’s most popular provisions — the ban on insurance companies denying coverage or charging higher premiums based on pre-existing conditions — directly protects millions of Tennesseans. Common pre-existing conditions include diabetes, heart disease, cancer, asthma, and mental health conditions. Before the ACA, insurance companies could refuse to cover individuals with these conditions or charge them prohibitively high premiums.
Blackburn’s repeated votes to repeal the ACA put these protections at risk. While she has stated her support for maintaining pre-existing condition protections, the repeal bills she voted for did not include equivalent replacement protections. Healthcare advocacy organizations in Tennessee have pointed to this contradiction as evidence that Blackburn’s stated positions on healthcare do not always align with her actual votes.
What the Next Governor Can Do About Medicaid Expansion
The decision to expand Medicaid under the ACA rests with the governor and state legislature. Tennessee has not expanded Medicaid, leaving an estimated 300,000 residents in the “coverage gap” — they earn too much to qualify for traditional Medicaid but too little to qualify for ACA marketplace subsidies. As governor, Blackburn would have direct authority over this decision.
States that have expanded Medicaid have seen significant improvements in healthcare access, reductions in uncompensated care, and economic benefits from the influx of federal funding. Tennessee hospitals have been among the loudest advocates for expansion, arguing that it would help stabilize the financial situation of facilities struggling to serve uninsured populations. Blackburn’s record of opposing the ACA strongly suggests she would continue to block Medicaid expansion as governor.
Related: See also Blackburn’s role in weakening DEA opioid enforcement and her vote against Medicare drug price negotiation.
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Frequently Asked Questions
Did Blackburn vote to repeal the Affordable Care Act?
Yes. In 2017, Blackburn voted Yea on the AHCA, the House Republican bill to repeal the ACA. The CBO projected 23 million more uninsured Americans by 2026.
How would ACA repeal have affected East Tennessee?
East Tennessee has higher rates of chronic disease, poverty, and uninsured residents than the state average. Waivers could have led to higher premiums for people with pre-existing conditions.
Does Tennessee have Medicaid expansion?
No. Tennessee is one of 10 states that have not expanded Medicaid under the ACA. An estimated 150,000+ Tennesseans fall into the coverage gap.
Sources
- CBO: American Health Care Act Cost Estimate (May 2017)
- House Roll Call Vote 256: American Health Care Act
- Kaiser Family Foundation: Effects of ACA Medicaid Expansion
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