The health of low-income people declined more in Southern states that didn't expand Medicaid than in those Southern states that did, with Tennessee, Georgia and Alabama ranking worst, respectively, according to a new study.

The study, published this month in the journal Health Affairs, found that in Southern states that expanded their Medicaid programs under the Affordable Care Act, adults experienced lower rates of decline in both physical and mental health.

"The effect is sizable and would amount to the worst-ranked Southern state [Tennessee] rising about halfway up the rankings in state population health if it expanded Medicaid," Dr. Michael McWilliams, senior author and Harvard Medical School Professor of Health Care Policy, said in a news release. "Unlike many other studies, we were able to focus on some of the most vulnerable populations who stand to gain the most from insurance coverage."

The ACA gave states the option to use federal funding to expand their Medicaid programs — which Tennessee calls TennCare — to cover a wider range of low-income individuals. Of the 14 states that have not yet expanded Medicaid, nine are in the South and two border the region.

The study categorized the four Southern states that expanded Medicaid before 2017 — Kentucky, West Virginia, Arkansas, Louisiana — as expansion states. Researchers then compared the health status of study participants in those states before and after Medicaid expansion to the before and after health status of those in the eight Southern states that didn't expand Medicaid: South Carolina, North Carolina, Virginia, Mississippi, Florida, Georgia, Alabama, Tennessee.

Changes in health status in non-expansion states when expansion took effect elsewhere

State  —  Rank  —  No Change  —  Improvement  —  Decline

South Carolina  —  1  —  43.3%.  —  23.3%  —  33.4%

North Carolina  —  2  —  42.4%  —  22.9%  —  34.7%

Virginia  —  3  —  42.1%  —  23.3%  —  34.7%

Mississippi  —  4  —  40.8%  —  23.4%  —  35.2%

Florida  —  5  —  40.5%  —  23.4%  —  36.1%

Georgia   —  6  —  40.6%  —  22.6%  —  36.8%

Alabama   —  7  —  38.3%  —  24.3%  —  37.3%

Tennessee  —  8  —  39.4%  —  23.1%  —  37.5%

Data: Vanderbilt University School of Medicine Department of Health Policy

John Graves, lead author and associate professor of Health Policy at Vanderbilt University School of Medicine, said an objective of the study was to understand the implications of expansion versus non-expansion in the Southeastern U.S. In addition, the study fills a gap in existing Medicaid expansion research, which has produced conflicting results.

"What we're finding is that Medicaid doesn't necessarily move people to better health," Graves said. "Really what it does is keep people in their current state of health — stemming off health declines."

The 15,536 low-income participants in the study were recruited from throughout the Southeast at predominantly safety-net and community health centers — primary care delivery sites that treat a large portion of chronically ill, non-Medicaid-insured minority and low-income people. Graves said the study indicates that for every 1,000 insured people, 337 fewer would experience a health decline over time. It also shows that safety-net programs aren't an adequate substitute for health insurance coverage, he said.

One reason Medicaid expansion may improve health is by increasing access to specialty care, which is often conditional on uninsured people's ability to pay for care up front, the study states.

Graves acknowledged that while Medicaid "isn't a silver bullet in terms of curing people," the study adds substance to state-level debates over the merits of expansion and bolsters the argument that expansion will yield improvements to the health of the state's population.

"Our goal is to inform policy making," Graves said. "It's important to understand the role that types of insurance play in terms of shaping health."

Dr. Kelly Rodney Arnold, founder and medical director at Clinica Medicos — a medical clinic serving Chattanooga's Latino community regardless of insurance status — said in an email that small statistical significance does not always equate to clinical relevance or broad impact.

"My opinion is that the focus on expansion versus no-expansion avoids a host of real pains and problems that patients face daily — even with Medicaid — and it's an empty assumption that the health of our nation actually hinges on this issue," Arnold said, adding that health care innovators hold an "underrecognized power" in addressing health care system challenges.

"Clinica Medicos represents the power of a local community taking action in ways that state and federal government officials rarely understand, let alone feel," Arnold said. "Our successful actions include real access to care 7 days a week (this doesn't mean one waits 6 weeks for an appointment), affordability and flexible charity, bilingualism, community-based social programs, and defragmented family care under one roof."

Contact Elizabeth Fite at or 423-757-6673.