Memphian Sarah Christine Bolton is one of about 20 percent of the Church Health Center's 60,000 patients who will likely be leaving their care after she purchases insurance through the new federal exchange.
"I'm self-employed, so I don't offer myself insurance," said Bolton, who does public relations and marketing.
But the majority of patients at the Church Health Center and Christ Community Health Services, both of which take uninsured patients, fall below 138 percent of the federal poverty guidelines and, thus, will not qualify for a federal subsidy to help them buy insurance, as required by the Affordable Care Act (ACA).
"If a single individual who makes less than $16,000 or a family of four with an income less than $32,000 goes to the exchange, they have to pay 100 percent of the cost. If you make $40,000 and you have a family of four, you may get most of it paid [through federal subsidies]. So the poorest people get nothing," said Dr. Scott Morris, CEO of the Church Health Center.
Those who fall between 138 and 400 percent ($45,960 for a single person or $94,200 for a family of four) of the federal poverty line will receive a subsidy to help pay for insurance.
The ACA was written with the assumption that all states would expand their Medicaid coverage for the poorest of the poor. But because Tennessee chose not to expand TennCare (the state's Medicaid program), the most vulnerable population won't be able to purchase insurance.
It isn't too late for Tennessee to expand its Medicaid program, however. Governor Bill Haslam has proposed a plan to ask the federal government if the state could leverage the federal dollars set aside by the health-care law to purchase private insurance for all uninsured Tennesseans. Morris doesn't expect that to be approved until after 2014.
Morris believes that about 80 percent of the Church Health Center's patients will remain enrolled for now because they won't be able to get insurance. The Church Health Center only offers medical care to the working uninsured. Shantelle Leatherwood, practice administrator for Christ Community Health Services, expects their clinics won't lose any patients.
"We accept all forms of insurance, but having insurance will still benefit our patients because it will give them access to specialty care if they need surgery," Leatherwood said.
Currently, the bulk of Christ Community's patients are on Medicaid or Medicare, but they also serve uninsured patients, as well as a small percentage with private insurance.
One downfall for those like Bolton who fall within an income bracket that requires them to purchase insurance and leave the Church Health Center's care is a lack of dental and eye coverage on insurance plans offered on healthcare.gov. The Church Health Center offers those services to its patients, but those who make enough money to afford insurance through the exchange will lose those benefits.
"In 2,500 pages of the bill, the words 'adult dentistry' do not appear," Morris said of the ACA. "We consider dentistry to be an economic issue. You can't go from a $7 an hour job to a $10 an hour job if your teeth are messed up."
Even though the Church Health Center may lose some patients to the private market, it won't be lacking patient numbers. There are around 1,000 people on its waiting list.
But Morris is quick to point out that, even if Tennessee expands TennCare eventually, there will still be a large number of patients who remain uninsured.
"No matter what happens, there will still be gaps," Morris said. "There were 26 million uninsured people in 1987 [when the Church Health Center was founded]. The most aggressive numbers I have seen is that in 2019, if the bill is fully implemented and there are no bumps in the road, we will still have roughly 26 million uninsured Americans."