Tennessee proudly calls Nashville our nation’s “health care capital” as we are home to some of the largest hospital systems in America and a hub that shapes care far beyond our borders. Yet for many Tennessee families, health care feels less like a source of pride and more like a source of anxiety.
More than three in four Tennesseans, an incredible 76 percent, say they worry about affording care, and medical debt remains one of the most common financial burdens in our state. How can the epicenter of American healthcare also be a place where so many fear the cost of getting sick?
At the center of that anxiety sits soaring hospital prices. Over the past two decades, the cost of hospital care has absolutely skyrocketed, squeezing family budgets and driving up insurance premiums.
In Tennessee alone, hospitals report nearly $5.7 billion in unreimbursed costs, including more than $1.1 billion in self-pay charges and $380 million in bad debt. Those bills either fall directly on patients or are shifted elsewhere in the system. Together, these figures highlight a system under strain, where rising charges and unpaid bills contribute to mounting financial pressure on families and providers alike.
High prices are only part of the problem. Many Tennesseans don’t know what they will owe until well after receiving care. Even with federal transparency requirements in place, patients often struggle to get clear, comparable information beforehand.
It is no surprise that nearly six in ten adults in our state report receiving an unexpected medical bill in the past year. When costs are unpredictable, families cannot plan, and patients are left with little ability to make informed choices about their care.
Across the country, as Americans wrestle with rising hospital bills and growing medical debt, there is an intensifying need to question if and how nonprofit hospitals are fulfilling the charitable missions they are bound to. Nationally, nonprofit hospitals receive tens of billions yearly in tax breaks for providing “community benefit,” including charity care for low-income patients.
However, reports indicate that the value of tax exemptions often exceeds the value of charity care and financial assistance hospitals provide. This imbalance should raise concerns about accountability at a time when hospital costs are the largest driver of healthcare spending in the United States.
As home to some of the country’s most prominent hospital systems – including nonprofit hospitals – Tennessee reflects many of these national pressures. Independent reviews found that many nonprofit systems devote a small portion of their expenses to free or discounted care for patients. Others, like Methodist Le Bonheur Healthcare – the largest nonprofit hospital system in Memphis – go so far as to aggressively pursue patients for outstanding medical debt, bringing lawsuits on patients who had little ability to pay.
When nonprofit hospitals fall short on meaningful charity care, the consequences have far-reaching impact. Patients often delay care or accumulate debt, placing families across Tennessee in precarious positions and facing financial instability. Local governments and taxpayers are left to absorb higher costs due to uncompensated care.
In consolidated markets, where there little choice due to the dominance of large systems, hospitals negotiate higher prices, which result in higher premiums for employers and workers alike. In Northeast Tennessee and Southwest Virginia, roughly 1.1 million residents now depend on a single provider for hospital care: Ballad Health. While the 2018 state-approved merger has kept facilities open, annual reports show the system has fallen short of multiple quality-of-care benchmarks, including measures related to infections, mortality, emergency room wait times, and patient satisfaction.
Limited hospital choices can shape outcomes in moments that matter most. In 2022, Jerry Qualls suffered a heart attack and was taken to Holston Valley Medical Center in Northeast Tennessee, a flagship of Ballad Health.
His wife says doctors told her he was unlikely to recover and would not qualify for a transplant, so she insisted on a transfer to another hospital. Within days, Jerry was awake, and he ultimately received a lifesaving transplant.
His story raises broader questions about oversight, performance standards, and how we measure success in consolidated health systems. Yet even amid cases like this and documented quality shortcomings in state reports, Tennessee’s renegotiated oversight agreement allows Ballad Health to qualify as a “clear and convincing” public benefit, despite performance that would earn a “D” on most A-to-F grading scales.
Tennessee families deserve a health care system that rewards quality, transparency, and fair competition. Stronger oversight of hospital consolidation and meaningful enforcement of transparency, including how nonprofit hospitals are providing charity care and meeting quality-of-care standards would help restore balance to a market that too often leaves patients in the dark.
Affordability, accountability, and quality of care must define the future of Tennessee’s health system and lawmakers must hold these hospital systems accountable. If Tennessee is going to lead in health care, it must lead for the families who depend on it, not just the consolidated systems that profit from it.
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Walter Blanks Jr serves as the Executive Director of the Legacy Society.
