The Politics of Race, Administrative Appeals, and Medicaid Disenrollment in Tennessee

In 2004, Democratic Governor Philip Bredesen of Tennessee announced a plan to reform TennCare, the state’s Medicaid program. The reform package proposed to remove 323,000 adults from the program, which represented the most drastic cuts to Medicaid since its creation in 1965. The reform measure also allowed beneficiaries disenrolled from the program to appeal the decisions to the state Department of Human Services. This study examines how race and policy backlash—that is the backlash against Medicaid expansion—influenced the appellate process for beneficiaries removed from the program in Tennessee. The main argument is that race—especially the predisposition of African Americans—influenced the outcome of the appellate proceedings. The theoretical framework advanced in this study explains how procedural deliberations (legal decisions, policy disputes, administrative hearings) exacerbate disparities and produce differential outcomes that correspond with racial and other ascriptive hierarchies. The data for this research, comprising more than 60,000 former TennCare beneficiaries, were obtained through Open Records Requests in compliance with Tennessee state law. Using logistic regressions, the findings reveal a relationship between race and appellate proceedings. African Americans were treated unfairly in the early stage of the appellate process and those from racially polarized voting areas were less likely to receive fair rulings by hearing examiners. Additional findings identified age-related disparities between younger and older appellants, as well as a regional disadvantage between rural and urban beneficiaries.