Is Tennessee aiding the ‘silent killer’?

Erica Williams, 38, didn’t know she had high blood pressure until doctors informed her when she was at Baptist Memorial Hospital for Women to give birth to her third child in 2019. 

Afterward, she didn’t treat it seriously — “I felt fine,” she said — until perhaps two years later when she started fainting.

“I didn’t know how serious it was until I started having blackouts and passing out at work,” she said.

High blood pressure is a major risk factor for heart disease, the leading killer in Memphis, the United States and around the world. Heart disease refers to several conditions, most commonly coronary artery disease, or the buildup of plaque in the arteries, which can lead to potentially fatal conditions such as a heart attack or stroke.

It is quite common for patients to come in for treatment for an unrelated condition and discover they have heart disease or a condition that leads to it, says Dr. Austin Dalgo. 

Co-medical director of the free Wellness and Stress Clinic of Memphis, in the Oakhaven neighborhood, he regularly sends patients from the clinic to the emergency room because of alarmingly high blood pressure.

A heart condition might mean visits to a primary care physician every few months, multiple daily medications, lab tests and scans and visits to a specialist, such as a cardiologist. Costs can mount quickly. So health insurance is important in ensuring continuous care — imperative for chronic conditions like heart disease, which need constant monitoring.

But Tennessee is one of 10 states that has not expanded Medicaid, which “impacts a significant number of our patients,” said Dr. Scott Morris, founder of the nonprofit Church Health at Crosstown Concourse.

Baltimore, which, like Memphis, has a majority-Black population, is in a state that implemented Medicaid expansion in 2014. Although several factors can influence mortality rates, the mortality rate for heart disease in Baltimore County is 180.7 per 100,000, according to the latest data from the Centers for Disease Control and Prevention. The rate for Shelby County is 204.6.

The nonprofit Robert Wood Johnson Foundation found in a study that if Tennessee expanded Medicaid, the number of insured people in the state would increase by about 151,000; the number of uninsured residents would decline by about 27%.

U.S. Rep. Steve Cohen (D-Memphis), a founder of the State Medicaid Expansion Caucus, is unequivocal about the benefits of expansion.

“We have a very poor state. We have a very unhealthy state. Cardiac illness is the largest killer in the state, and yet we haven’t expanded Medicaid,” he said. “It’s a billion dollars plus a year that we give away that the federal government would just be giving us. … It’s callous and it’s un-Christian, un-Judeo-Christian, un-Judeo-Muslim-Christian. It’s just bad.”

African Americans and the poor are hard-hit

Tennessee has the sixth-highest mortality rate due to heart disease in the nation, topped only by neighboring states Oklahoma, Mississippi, Alabama, Louisiana and Arkansas.

The disease strikes African American and low-income populations particularly hard. It is the leading cause of death in Shelby County. Memphis, a majority-Black city with a 21.4% poverty level (with the Black poverty rate nearly three times the white poverty rate), is especially vulnerable. African Americans have among the highest rates of hypertension in the world and are 30% more likely to die of heart disease than white Americans. Low-income populations, even controlling for other factors, are 52% more likely to have heart disease than their higher-income neighbors.

Besides hypertension, other risk factors include high cholesterol, diabetes, smoking and lack of exercise.

A poor person who is feeling fine — which is often the case for those who have cardiovascular disease — has little incentive to go to the doctor for preventive care, doctors point out. In addition, patients fear being hit with unforeseen costs if they venture across a physician’s doorway.

“If you go to the doctor, you’re not going to get paid. You don’t get paid, your kids don’t eat,” Morris said. “So going to the doctor is not a high priority.”

Pastor Dianne Young, who founded the Wellness and Stress Clinic with her late husband, Bishop William Young, put it even more starkly. 

“Many times, people have to choose between eating and getting their medicine,” she said. “And nine times out of 10, eating’s going to win.”

Dwight Dishmon is an interventional cardiologist with an office in Whitehaven who is affiliated with several local hospitals.

“I’m the one that’s called in the middle of the night when someone’s having a heart attack,” he explained. “My job is to relieve the obstruction that’s causing the heart attack as fast as I can.”

He points out that risk factors for heart disease are less well-controlled in the African-American community than other populations.

Williams now has her hypertension under control with the help of medication — and cutting out some of her favorite foods. Yet, if she doesn’t take it, she says, she develops blurred vision and slurred speech.

“High blood pressure tends to develop at an earlier age in African Americans,” Dishmon said. And yet, the discovery and treatment of the disease in the Black community is often delayed. “And unfortunately, hypertension — high blood pressure — is called the silent killer for a reason.” 

TennCare: limited and hard to access

The Affordable Care Act expanded Medicaid coverage to almost all adults with incomes up to 138% of the federal poverty level (currently $15,060 for an individual and $31,200 for a four-person household). The increased coverage has been shown to improve both people’s access to care and hospital finances.

Yet in 2014, the Tennessee legislature passed a bill that required legislative approval before the governor could negotiate Medicaid expansion. The current governor, Bill Lee, elected in 2018, has stated that Medicaid expansion “will not happen on my watch.”

Tennessee’s current, unexpanded Medicaid program, called TennCare, is limited largely to families with children; non-disabled adults with no children who are under 65 are ineligible.

And even to get on the books for Tennessee’s limited Medicaid program is no easy matter. A look at the numerous categories for eligibility and differing income requirements, depending on the age of children in the household, is enough to give even an accountant a headache.

“This is rocket science to figure out a basic human need,” said Peter Hossler, a Rhodes College urban studies professor and, until recently, director of the Wellness and Stress Clinic of Memphis. He also objected to the strict eligibility requirements. “If you are not pregnant, recently pregnant or disabled, you are not going to qualify for Medicaid in Tennessee. Outside of that, you are screwed.”

Solving inequities in health care

On a recent Saturday, the Rev. Earle Fisher, senior pastor of the Abyssinian Missionary Baptist Church in Whitehaven, invited Pastor Jason Mitchell of Oakhaven’s Perfecting Love Community Church to lead a 30-minute exercise session. 

It was part of Black Faith Fast, a program FIsher started several years ago. Recently, he began holding it in February as part of Black History Month.

Black Faith Fast recommends 30 minutes of exercise and five minutes of devotion daily; less salt, sugar and fried foods; and more water, fruits and vegetables.

In a cleared-out space at the center of the church, Mitchell led five congregants, aged 35 to 66, and Fisher in repeated rounds of calisthenics and stretching.

“Three, two, one, let’s get it!” Mitchell encouraged the participants.

Though quite fit today, Mitchell said that seven years ago he was 50 pounds overweight and out of shape. That’s when he set himself a personal challenge of 100 days of fitness without interruption. He went from 252 to 202 pounds during that first 100-day commitment.

“I just believe that God created us to be healthy beings,” he said.

For his part, though he initiated this community effort, Fisher believes that the government also must do its part to ensure people’s health. He went without health insurance for 15 years, until this month, because he couldn’t afford it. He is an outspoken supporter of Medicaid expansion in Tennessee.

Fisher lays the failure to expand Medicaid at the feet of the “radical right-wingers” of the Tennessee legislature, who “didn’t want to show Obama or the Democratic party in a favorable light.”

At the nearby Wellness and Stress Clinic, Dalgo says the way to address some inequities in care is indeed to have better insurance coverage, as Medicaid expansion would offer. 

Though he works at the free clinic, devoting his time and expertise, Dalgo is the first to admit that care there is not ideal. For one thing, it is open only on Monday evenings and does not have the equipment or manpower to handle certain situations.

The clinic provides free medication to its patients — a rarity — but must depend on an erratic supply of donated medications that are near their expiration date. Often, there are shortfalls. Through a partnership with a medical lab, the clinic offers some free testing, but the types of tests are circumscribed.

With Medicaid expansion, more people would have access to the care they need, he said.

“They wouldn’t have to come here as a safety net clinic, where we can’t do electrocardiograms on the heart,” he offered as an example. “We do our best to provide the best care we can, but we have limited resources.”

This story is part of “The Holdouts,” a reporting collaborative focused on the 10 states that have not expanded Medicaid, which the Affordable Care Act authorized in 2010. The collaborative is a project of Public Health Watch. 

Sono Motoyama is the science writer for MLK50: Justice Through Journalism. Contact her at sono.motoyama@mlk50.com.

---

This story is brought to you by MLK50: Justice Through Journalism, a nonprofit newsroom focused on poverty, power and policy in Memphis. Support independent journalism by making a tax-deductible donation today. MLK50 is also supported by these generous donors.

Got a story idea, a tip or feedback? Send an email to info@mlk50.com.