NASHVILLE, Tenn. — To make the case that Obamacare is collapsing, Republicans point to Tennessee.

The most recent sign: Humana's decision to drop out of Obamacare markets for 2018 means residents of 16 counties around Knoxville could have zero options for purchasing individual coverage when the next open-enrollment period begins in November.


Another big player, Blue Cross Blue Shield, fled the state's biggest markets, triggering some of the sharpest premium spikes in the nation. Republicans warn that other states could look just as dire unless they get rid of Obamacare and replace it with a market-driven system.

“The Affordable Care Act is too expensive to afford,” Rep. Marsha Blackburn (R-Tenn.) said during a town hall meeting over the Presidents Day break in Fairview, about 30 miles southwest of Nashville. "Our goal is that health care is going to be more flexible, more usable and more affordable to everyone.”

But even here, despite all the turbulence, resistance is mounting to Congress scrapping the law without a credible replacement plan, because it could unleash even more chaos. Obamacare defenders believe their message is starting to resonate, especially with the state's Republican senators, Lamar Alexander and Bob Corker.

In deep red Tennessee — which did not create its own Obamacare exchange, expand Medicaid or embrace the 2010 health care law in any way — the problems began mounting in 2015, when a startup, nonprofit health plan called Community Health Alliance collapsed. That left 27,000 people scrambling for new coverage.

The challenge for insurers, then as now, is the struggle to get enough healthy people into the coverage pool to offset the cost of caring for older, sicker individuals. Some in the desirable cohort have flouted the health care law's mandate that most people be covered and instead have paid penalties, happy not to deal with rising premiums.

“What happened is the people who are healthy paid the penalty and moved on,” said state Rep. Cameron Sexton, a Republican who chairs the House Health Committee. “And then, the people who were really sick picked up the insurance because they needed it, and the risk to the insurance companies was far greater than they ever expected.”

But concern about proposed solutions is circulating in Washington.

“I think all of a sudden [there’s a] realization that if they don’t do something of significance, they’re going to destroy the individual market not just in Tennessee, but in other states as well,” said Tony Garr, former head of the Tennessee Health Care Campaign.

Michele Johnson, executive director of the Tennessee Justice Center, said the problems have been exacerbated by the state’s failure to expand Medicaid eligibility under the health care law. Johnson pointed to neighboring Kentucky, which opted in and dramatically lowered its uninsured rate, as evidence that such a move would have helped stabilize the individual market and reduce premiums.

“We chose not to do it and then they’re like ‘This thing is dying.’” Johnson said. “That’s because you have your hand around its neck killing it.”

Eric Jans has watched Obamacare go from boom to bust from his one-man insurance brokerage in Nashville that focuses on selling individual health plans. Jans had roughly 300 customers enrolled in Obamacare market plans in 2016. Then, about a month before the 2017 open-enrollment season, Jans received a notice from Blue Cross Blue Shield of Tennessee informing him that it would no longer be selling individual coverage in the Nashville market.

“That was about 85 percent of my income gone with that one email,” Jans said recently at Ugly Mugs, a coffee shop in his East Nashville neighborhood.

Jans initially shrugged off the bad news. Humana still offered a product that he thought would meet the needs of most of his clients. But then a couple of weeks later, Humana sent an email indicating it would no longer pay brokers commissions for individual plans. Cigna, Aetna and UnitedHealthCare also announced that they were either eliminating or significantly reducing commissions.

After seeing his livelihood virtually evaporate over a matter of weeks, Jans is regrouping by focusing on the small group market, but he is uncertain how that will work out financially.

“It’s definitely nerve-racking at the moment,” said Jans, who has two kids under the age of 6. “It’s not going to replace the income I lost, not right away.”

Even with all the problems plaguing the individual market in Tennessee, thousands of individuals have benefited from its coverage programs. Prior to Obamacare, Buddy Mondlock was frozen out of coverage because he had hepatitis C stemming from a car accident more than three decades ago.

“Luckily the hepatitis was not active at that time,” said Mondlock, who makes a living as a folk singer. “The thing about hepatitis C is it can lie dormant for 30 years and then just come back and kill you.”

Mondlock was able to get coverage through the ACA starting in 2014 for less than $100 a month. His Blue Cross Blue Shield plan covered a full course of treatment with Harvoni, which otherwise would have cost around $80,000, and he’s been virus-free for two years.

“I never, of course, would have been able to afford it,” Mondlock said of the breakthrough treatment. “I’m a folk singer. I don’t make that kind of money.”

This year, Mondlock had to switch to a Cigna plan after Blue Cross pulled out of the Nashville market. He’s concerned about having to rely on a limited network of providers while performing on the road.

“My network is only here,” he said. “I travel all the time, so it could be a problem.”

Obamacare supporters in Tennessee say the health care law’s tenuous future has triggered an unprecedented flurry of advocacy work aimed at protecting people who gained coverage. Protesters have become ubiquitous outside the Nashville offices of Alexander and Corker.

On a recent Wednesday at lunchtime, a couple of hundred people showed up for a rally in Centennial Park to greet the “Save My Care” bus, which is traveling around the country to build support for the law. Among the attendees was April Reed, a 49-year-old bartender, who held a sign that says, “ACA saved my husband’s life.”

Reed said that before the ACA, her husband, a musician and painter, had been unable to get coverage after breaking his back. Once Obamacare was enacted, the couple immediately enrolled in a Blue Cross Blue Shield plan. Within a year, Reed says, her husband was diagnosed with renal cancer. The bill for chemotherapy and other treatment if he hadn't been insured would have been $210,000.

Reed and her husband recently were forced to switch to Humana. She’s not thrilled with the $3,500 deductible, but worries whether some of the GOP Obamacare alternatives she’s read about would be an improvement.

“I realize the program needs some work,” Reed said. “It’s not perfect. But if we hadn’t had it I literally could have lost my husband.”