The city of Fulton is split by the Kentucky-Tennessee border. On one side – in Fulton, Kentucky – working families have access to health care through a provision that was intended to benefit nearly all low-income Americans through the Affordable Care Act. Just blocks away, across the state line in the “twin city” of South Fulton, Tennessee, however, similar families are left out, forced to face the financial and emotional stress of a life without health insurance.

The difference: Tennessee is one of 23 states that has opted out of the provision of the Affordable Care Act, often known as “Obamacare,” that would have given more than 160,000 people throughout Tennessee access to health care through an expansion of Medicaid.

That expansion would have provided health care for more than one in four of the uninsured adults under age 65 in Tennessee. Nationally, more than 4 million people have been left out of the Medicaid expansion for no reason except for the misguided ideological stance of Republican governors and legislatures dominated by right-wing politicians. The failure of states to expand Medicaid through Obamacare is estimated by some experts to contribute to more than 7,000 deaths a year, as people without health insurance delay needed care.

In a series of interviews conducted by the office of Sen. Bernie Sanders, who chairs the Senate Subcommittee on Primary Health and Aging, a clear picture emerged.  People struggling to make ends meet on the Kentucky side of the border have now breathed a sigh of relief as health care – one of their major and most unpredictable expenses – is being addressed through the Affordable Care Act’s expansion of Medicaid. On the other side of the border, Tennesseans living in the same circumstances are being barred from health care coverage and the financial and emotional relief that comes with it.

Jackie Eubanks is the program manager for West Kentucky Allied Services and works with Kynect providing support to individuals, families, and small businesses with a simple way to select health coverage. “In Kentucky,” Eubanks said, “we have had a lot of people that have not had insurance – ever. And now they are just thrilled.”

Pam Rockwell, 58, of Murray, Kentucky says she is “so delighted with what has come about.”

“It is a huge relief to have some coverage after nearly a decade,” Rockwell said. Initially, she recalls, she had some trouble signing up, “Then, bam! I had health insurance. I can’t tell you what a huge relief it was. When you’re in that situation, you try to do a lot of ignoring things and trusting that they will go away. Now I no longer have to worry if I become sick or injured. I can’t tell you how worried I was without it.”

People living on the Tennessee side of the border haven’t had the same experience. “There has been a lot of confusion about this for people who live right on the line where news coverage and word of mouth crosses the state border. A lot of them work in Kentucky and they have heard that people have got Medicaid and they want to know how they can sign up,” Eubanks said, adding they must redirect them to Tennessee’s Medicaid program, TennCare, since they live in South Fulton, Tennessee. Unfortunately, since Tennessee failed to expand Medicaid through the Affordable Care Act, many seek out information, learn that they do not qualify, and are uninsured 

Many Tennesseans are not aware that the health care coverage they can get is dependent on what state they live in. “Some people really don’t know that Tennessee is different from Kentucky,” Eubanks said. “They have a hard time understanding the difference.”

The U.S. Supreme Court decision in June 2012 allowed states to opt out of the Medicaid expansion, creating an illogical and unjust situation where the state you live in determines whether you can have health insurance or not.

The Affordable Care Act called for states to expand eligibility of Medicaid to all low-income individuals under 138 percent of the poverty level, or about $32,500 for a family of four. Because the Supreme Court allowed states to opt out of the Medicaid expansion, Tennessee has decided to leave 160,000 people without the coverage the Affordable Care Act was crafted to provide.  They are also ineligible for subsidies available to people with incomes up to four times the federal poverty line to reduce the cost of health insurance available on the exchange.

A HARD HIT REGION

The inability for people on the Tennessee side of the border to obtain health care is exacerbated by the economic struggles of the region.

“All of the factories in this area have just about closed down,” said Carolyn Stares, who runs the Twin Cities Cares Mission store which sells donated goods in South Fulton, Tennessee. “So many factories have gone and people are left with nothing.”

With fewer employers in the region, there are fewer opportunities for jobs that come with good benefits. “There is just not a lot of jobs,” said Jenny Rushing, a social worker in Fulton, Kentucky. She noted some of the biggest employers left are Walmart, Kayser Automotive Systems, and Letica Corp., which makes plastic buckets.

The per capita income in Kentucky’s Fulton County is just over $19,000, several thousand dollars less than the statewide average of more than $23,000. About one in four people, 24 percent, live below the poverty line in the county.  In Tennessee’s Obion County, where South Fulton, Tennessee sits, one in six live in poverty. The per capita income is $22,000, about $2,000 below the statewide average. Nationally, 14.5 percent  of Americans live in poverty and the national per capita income was about $29,000 in 2013, according to the Census, so both counties face greater economic challenges than the nation overall.

‘A HUGE RELIEF’

Rockwell said she wasn’t surprised local politicians blocked thousands of Tennessee families from obtaining health care. “I’m just glad I am where I am. There are so many people like me, working people. It’s a huge relief to have some care.”

“It should be a given that if you get sick, you can get medical care,” Rockwell said. She is hopeful that the continuing debate on Obamacare will ultimately shift people’s views of who is entitled to medical care. “If you are an American citizen, you should have access to health care just like you have access to education.”

Eubanks shared a story of a Tennessee man who considered moving to Kentucky to obtain health care. In Tennessee, he can’t obtain coverage since Medicaid has not been expanded. He worries that if something happens to him his two-year-old son will end up in foster care. He looked into getting TennCare and makes too much – but would get Medicaid if he lived in Kentucky. 

Rushing, a social worker in Fulton, Kentucky, does as much as she can to help people who live in Tennessee, but adds “I can’t go over the state line.”  In other words, although her job is to help people in her community gain health insurance coverage, people living just blocks away in South Fulton, Tennessee can’t obtain Medicaid through the Affordable Care Act. As much as she wants to help them, there is nothing she can do.

Tony Dowdy, deputy executive director of West Kentucky Allied Services, a community action agency covering eight counties in southwestern Kentucky, sees a more promising future now that the ACA is in effect.  Since the passage of Obamacare, he said, health care opportunities have been created that didn’t exist before. That’s good news for a region that has struggled economically.

With health care insurance in place, it’s one less unexpected expense that must be accounted for, Dowdy explained, leaving more money for food, utilities, and other household expenses. This is particularly important at a time when other vital programs, such as food stamps, have been cut.

“A lot of people who have not been able to afford medical insurance in the past, can now get Medicaid,” Dowdy said. “Affordable health care has made it better for these individuals to live.” 

MAP: Millions excluded from Obamacare