Amanda Smith has been unable to qualify for TennCare, but she might if it were expanded to include more of the working poor. She recently turned to Partners for Healing in Tullahoma, Tenn. – a clinic for the working uninsured. Credit: Blake Farmer/WPLN

An expansion of Medicaid under the Affordable Care Act is supposed to cover more of the working poor and balance out cuts that were made to already-struggling hospitals. But Republican-led states like Tennessee have been opting out or at least holding out, and outlying areas may be the hardest hit.

Amanda Smith is just off the clock from her manufacturing job assembling car doors at the M-Tek factory in Manchester, Tenn.  Clear safety glasses are still perched on her head.

“What it boils down to is I’ve got problems as a woman,” she says. “I went to the hospital over and over, and they look at you just like you’re just there to get pain medicine and stuff like that these days.”

Smith says she has never had insurance – ever. And yet she’s always worked.

But making $9 an hour with an unemployed husband and two sons, Smith can’t even think of paying for the expensive coverage through her employer. And because she’s married and has a steady job, she doesn’t qualify for the state’s Medicaid program – known as TennCare. But she might if it were expanded.

“When you’ve already got medical [bills] coming in that you can’t even afford and you’ve got bill collectors coming after you over medical that you can’t afford, and you can’t get state help otherwise of your income, I mean, I don’t know what else to say,” Smith says, trailing off.

So like many people in her situation, Smith has turned to charity.

Partners for Healing requires that patients work at least 20 hours a week to qualify for free care. Credit: Blake Farmer/WPLN

Partners for Healing in Tullahoma, Tenn., offers care solely to the working uninsured, and there are plenty of them in this town of 18,000. There’s no shortage of studies showing rural Americans are more likely to have low-wage jobs, and thus have no insurance.

“You’ve got people trying, and they’re working hard. And they’re hard workers,” registered nurse Bell Royton says.

Royton helps run this clinic. She says many patients make barely enough to feed their families. When presented with a prescription for less than $10, patients say they won’t have the money for two weeks.

“It just might as well be a thousand dollars,” Royton says.

When a few dollars is too much, the uninsured often turn to the emergency room, where they can’t be turned away, even if they don’t have insurance.

Southern Tennessee Medical Center in Winchester, Tenn., is the largest hospital within an hour’s drive. Phil Young is the administrator there, and he says he’s facing tough decisions.

Like many hospitals, Young’s was banking on Medicaid expansion to bring in more paying customers. Health care reform has already taken a bite out of reimbursements. And the federal sequester is bringing more financial pain.

“Those two cuts to Southern Tennessee equal the salaries, wages and benefits of one third of our registered nurses in the hospital,” he says. “Those are not small numbers.”

A recent survey found that more than a third of Tennessee’s hospitals are already in such dire straights, they could close if the state doesn’t expand Medicaid to cover more poor people.

Southern Tennessee Medical Center in Winchester is the largest hospital within an hour’s drive. Administrator Phil Young says the facility will weather without expansion, but many others might not according to a recent survey. Credit: Blake Farmer/WPLN

For cities, a closed hospital could mean one or two fewer facilities. But in the country, that could mean losing the only hospital around.

“Frankly, the way things are going, it’s not looking good for a lot of our small, rural, high uncompensated care hospitals,” says Craig Becker of the Tennessee Hospital Association.

Tennessee is a Republican state that has kept the door to Medicaid expansion open. But so far the potential peril of hospitals and the state’s working poor haven’t convinced politicians to go along.

Governor Bill Haslam says he’s talking to federal officials all the time about a way to cover more people, but only if he can limit how much it will cost the state down the road.