Building on a Strong Partnership – Expanding and Protecting Access to Care in Tennessee

Building on a Strong Partnership – Expanding and Protecting Access to Care in Tennessee

This blog is part of our Working Better Together series and was authored by Michele Johnson and Gordon Bonnyman, Executive Director, Co-Founder and Staff Attorney, Co-Founder, respectively at Tennessee Justice Center. This blog series is intended to provide our Health Law Partnerships with a platform to highlight successes, challenges, and innovative approaches to furthering health access and health equity in the states where they work.

Forging a Lasting Partnership

The Tennessee Justice Center‘s partnership with NHeLP has been a vital source of strength since the first day of TJC’s existence. In 1996, when Congress barred federally funded Legal Services organizations from handling a host of legal matters, Tennessee bar leaders and Legal Services directors created TJC to take on those low-income clients and cases that were suddenly without legal representation. Started on a shoestring, the little non-profit public interest law firm opened with a staff of two working from a musty attic above the offices of a Nashville civil rights firm. TJC’s grandiose mission was to address the most urgent legal needs of low-income Tennesseans across all 95 counties of the state.

On the day TJC opened, a bucket brigade of friends passed scores of boxes of legal papers, case documents, exhibits and client files from hand-to-hand two blocks from Legal Services to our attic cubby. The cases and clients who were part of that transfer included several Medicaid class actions that were now the responsibility of the fledgling organization. Arrayed against us were the state government, a national nursing home chain, and the state’s entire managed care industry.

Fortunately, we had a lifeline. With a copy of NHeLP’s Advocates’ Guide to Medicaid Program, connections through NHeLP to counterparts who had handled similar cases in other states and – most importantly – Jane Perkins’ phone number, we were good to go! Over the next several years, TJC achieved success in the cases it had inherited, prompting state officials to complain that TJC had compelled Tennessee to provide over $2 billion in Medicaid services it would not have otherwise provided.

Identifying the Most Pressing Problems Facing Low-Income Families

TJC advocates on matters involving nutrition, income supports and access to civil justice, but health advocacy remains a priority. TJC’s focus on health advocacy was informed by actual client needs surveys, conducted for the Tennessee Supreme Court, that identify health care and medical debt as low income families’ most pressing legal problems. TJC also recognizes Medicaid’s massive impact across all counties: covering half of all Tennessee children and over half of all long term care; serving as the principal source of services for people with disabilities; and providing critical funding for health care in underserved rural and minority communities.

With NHeLP’s crucial guidance, TJC brought a sweeping case enforcing Medicaid children’s access to early and periodic screening, diagnosis and treatment (EPSDT). We ventured into litigation involving Medicare home health and Medicaid home and community-based services and supports. With Tennessee’s entire Medicaid population enrolled in mandatory managed care, TJC spent years battling managed care contractors’ abusive denials of care and debunking inflated performance measures. That gave us an opportunity to look behind the managed care curtain, inspecting HMOs’ call centers and gaining access to their proprietary utilization review criteria. (Disclosure: it didn’t make us feel better about how managed care gets managed.) We learned from NHeLP and its national network of advocates and shared what we learned with them.

TJC also advocated in the state legislature before administrative agencies, leading a successful campaign that won the belated establishment of a Children’s Health Insurance Program, which has been a lifeline for immigrant mothers and children.

Evolving Litigation Strategies

Litigation remains an important tool, but we find ourselves more often playing defense. Our advocacy strategies have evolved, along with NHeLP’s, in response to an increasingly challenging legal and political environment. Many of our clients’ present problems accessing health care have no effective litigation solution and ultimately require us to make their case to political leaders and in the court of public opinion. Storybanking has become an important part of our work, curating our clients’ experiences and helping them share their experiences with the news media. Often in concert with NHeLP, our clients’ stories have been used by state and national media outlets, including the New York Times, NPR and all major television networks, to give meaning and emotional impact to large policy issues. Our story bank contributed to the public relations battle against repeal of the Affordable Care Act and the attempt to cap federal funding for Medicaid.

As it has evolved, TJC has not only gone public but has gone nerdy. Frustration with lack of data to identify and address racial inequities in health care has led us to engage in highly technical advocacy for the inclusion of race and ethnicity identifiers in electronic billing forms. TJC has played a central role in Tennessee’s development of complex financing arrangements to fund its Medicaid program, pioneering methods that all states have used to prevent budget cuts. Some states have used those arrangements to finance Medicaid expansion.

Tragically, Tennessee is not among those Medicaid expansion states. For ten years, since the Supreme Court ruled in NFIB v. Sebelius that state’s could choose whether to expand Medicaid, TJC has led political efforts to win expansion in our state. We came tantalizingly close in 2015, only to see the partisan political opposition harden. TJC has mobilized several campaigns focused on the importance of expansion for the viability of rural communities, the health and financial security of working families, the vitality of the state economy and the strength of a health care infrastructure upon which all Tennesseans rely. Polling shows that most Tennesseans support expansion, but internal politics in the legislature’s Republican super majority have blocked legislative consideration of Medicaid expansion for several years.  

Black Health Matters and the Fight for Health Equity

Current Medicaid expansion efforts are built around our Black Health Matters campaign. In this time of national reckoning, we decided that it was time to name the racial bias that is behind the rejection of Medicaid expansion. Inspired by the successful campaign to force Mississippi to remove the Confederate emblem from its state flag, the BHM campaign seeks to make the shame of the state’s racially motivated denial of Medicaid equally embarrassing, so that national corporations, celebrities and organizations feel pressure to disassociate themselves from the state. The BHM team is creatively engaging Black fraternities, sororities, health care providers and faith communities, with a goal of elevating their voices to demand change.

Twenty-six years on, TJC’s partnership with NHeLP remains as vital today as it was the day our doors opened.  

Working Better Together Blog Series

The Working Better Together blog series gives our Health Law Partners a platform to highlight successes, challenges, and innovative approaches to furthering health access and health equity in the states where they work. Find other blogs in the series here.

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