MADISONVILLE, Tenn. - Since his heart failure last August, since the insertion of a defibrillator and pacemaker to monitor each beat of his heart, doctors tell Dann Osborn to avoid stress.

Stress can trigger another episode, setting off the defibrillator to try to keep him alive.

But at 7 p.m. Thursday, Dann punches a number -- 1-866-358-3230 -- into his wife's cellphone. He gets a busy signal. He calls again, this time reaching only silence.

Dann, 57, gets up from a black metal chair and paces the small patio in his backyard. He tries the number again. Another busy signal from the Tennessee Department of Human Services. Another chance lost to get a coveted application to apply for TennCare's standard spend-down program, which would cover his monthly medication and hospital bills.

In 55 minutes, the line will close for thousands of people trying to make the call. It won't be open again for another six months.

Hold still, his wife, Debbie Osborn, tells him. You'll lose the signal.

His bearded face furrows.

The spend-down program once covered about 100,000 people in Tennessee, but it was closed in 2005. In 2009, the state agreed to reopen the program, with potential coverage for up to 7,000 people. Today -- though the program has funding for about 3,500 -- only about 1,000 are enrolled, TennCare officials say, but there is no way to know how many people may be eligible.

And as Gov. Bill Haslam and state lawmakers consider whether they will expand the TennCare program under guidelines of the federal Affordable Care Act, critics say the phone-in system exemplifies why Tennessee needs to provide coverage to people who face a mountain of medical debt.

Michele Johnson with the Tennessee Justice Center, an advocacy group that focuses on family issues, compares the system to the Oklahoma land rush.

"It might be a good way to give away concert tickets, but it's not the way to decide who gets health coverage," Johnson said. "No other state does it this way."

TennCare officials say the system is necessary to allow them to process all the applicants under required federal guidelines. Georgia's similar program accepts applications throughout the year.

• • •

Dann was in the library, typing on a computer on Aug. 2, 2011, tired from working swing shift as a security guard in Loudon, Tenn.

He thought he was in perfect health. He didn't have health insurance.

Suddenly he felt strange. And the next thing he knew he was waking up, still in the library, with people asking him what had happened.

Doctors later told him his heart had quit for nearly five minutes before restarting on its own.

"It's a miracle he's alive," Debbie says.

Over the next months, the Osborns plummeted from a middle-class existence to medical-bill nightmare.

After Dann couldn't go back to work, the security company let him go. Two weeks after his heart failed, Debbie lost her part-time job.

The bills -- nearly $200,000 from more than a dozen doctors and hospitals and lab tests -- stacked up. They couldn't pay their rent for four months; they ate food from the food bank.

They sold Debbie's car and Dann's guitars from his home recording studio. They canceled their cable.

"We were almost on the street," Dann said.

• • •

Dann tried to call the hotline in February, the last open enrollment period for the spend-down program. By then, Debbie had found another job, and the hospitals agreed to write off some of the debt. But they still owed more than $15,000.

Dann called and called the number for more than an hour, then threw the cellphone down in frustration.

He picked it up and called again, but the lines closed before he heard anything but a busy signal.

"It shouldn't be this difficult," Debbie said.

And it was back to slowly paying the bills each month and answering calls from creditors, trying to dig their way out of the debt chasm.

Dann isn't eligible for Debbie's insurance because he has a pre-existing condition. Each new bill and each hospital visit -- the last was in August -- is another one on the stack, another number in Debbie's Excel spreadsheet.

He still loses his breath when he walks across the lawn behind their small brick home that overlooks the rolling foothills of the Smoky Mountains. He struggles to accept that he can't work or pay their bills.

"I feel like less of a human being," he says, his 6-foot-5 frame sprawled in a chair.

• • •

The standard spend-down program -- for people who have too much income to meet regular TennCare standards but have large medical bills -- is only a small segment of TennCare.

During the open enrollment, the state accepts about 2,500 calls and mails those people an application. Of those, about 400 to 500 are usually found eligible.

But for three years, critics have argued the program should have an enrollment process like other TennCare programs. At the very least, phone calls during the phone enrollment period should be screened to determine eligibility so more eligible people have a chance to get an application, Johnson said.

The toll-free number system is to ensure equal access to everyone interested in the program, TennCare spokeswoman Alyssa Lewis said in an email.

Since the Department of Human Services can only process 2,500 applications for each enrollment period, they can't take more calls than that, Lewis said.

By the time six months rolls around, Johnson said, the people who didn't make it through the phone lines are sicker than ever and have more bills.

Most of the people trying to get coverage under the spend-down program would be eligible under the Medicaid expansion that's part of the Affordable Care Act. That would mean coverage for people with incomes up to 138 percent of the poverty level. But the U.S. Supreme Court, in the ruling that upheld the constitutionality of the health reform law, said the federal government can't force states to expand their Medicaid programs.

Tennessee can't afford not to expand its program, Johnson said, especially since the first three years would be fully funded by federal dollars.

Haslam has said he plans to wait until after the November presidential election to decide whether to expand Medicaid.

• • •

On Thursday evening, Dann makes more than a dozen phone calls in 17 minutes. Suddenly, the busy signal gives way to a recorded voice.

"Thank you for calling ..."

"I'm in," Dann says jubilantly, quietly.

After waiting five more minutes, he talks to a person and gives his name, date of birth and address. He jots down a confirmation number.

He will get an application within two weeks.

He hopes he will be eligible.

Staff writer Andy Sher contributed to this article.