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Tennessee has 30 community health centers across 249 sites serving 437,669 patients — the #22 FQHC state by patients outside California and Texas. As a non-expansion state, the uninsured are the biggest exposure, and the ACA premium-credit expiry is the dominant federal risk.
Tennessee never expanded Medicaid, so its safety net runs on two pillars: TennCare—operated under the long-running 'TennCare III' Section 1115 demonstration, a modified-aggregate-cap 'shared savings' waiver approved in 2021 for an unprecedented 10 years and due to rebase in 2026—and the ACA Marketplace, which ballooned to nearly 643,000 enrollees in 2025 (more than double 2020) on the back of enhanced premium tax credits. Because TN sits in the coverage gap with no expansion population, the expiration of those enhanced credits at the end of 2025 is the state's most urgent coverage threat: the Sycamore Institute projects 142,000–203,000 Tennesseans could drop coverage as premiums more than double, pushing uninsured demand onto FQHCs already absorbing rural hospital closures.
Patient-weighted across the 30 centers with UDS 2024 data.
Tennessee is a restricted-practice state: nurse practitioners must practice under a written collaborative/supervisory agreement with a physician, who must personally review at least 20% of the NP's charts and conduct an on-site visit at every remote site at least once every 30 days (Tenn. Comp. R. & Regs. 0880-06-.02).
Expiry of the enhanced ACA premium tax credits (end of 2025) is the dominant federal risk in this non-expansion state — it widens the coverage gap and raises uninsured/self-pay volume at FQHCs; Medicaid community-engagement (work) requirements (CMS-2454-IFC, full implementation Jan 1, 2027) compound the redetermination burden.
5 primary-sourced findings on Tennessee FQHC policy and financing.
NACHC reports the Community Health Center Fund—roughly 70% of federal grant dollars for health centers—is funded at $4.6 billion for FY2026 but only through short-term continuing resolutions, with the NHSC and Teaching Health Center GME programs riding the same cliff. Without long-term reauthorization, centers face hiring freezes, halted expansions, and service cuts. For Tennessee's ~30 FQHC organizations operating 200+ sites and serving the state's uninsured-heavy population, this base-funding instability compounds the looming ACA-credit and rural-hospital pressures.
NACHCThe Sycamore Institute reports nearly 643,000 Tennesseans enrolled in ACA Marketplace plans in 2025—more than double 2020—with enrollment among those at 100–150% of poverty up nearly 460% (49,000 to over 372,000), driven by enhanced premium tax credits. With those credits expiring at the end of 2025, Sycamore projects average premiums could more than double and 142,000–203,000 Tennesseans could forgo coverage. Because TN is a non-expansion state, the Marketplace—not Medicaid—is the channel where coverage losses land, sending uninsured demand to FQHCs.
The Sycamore InstitutePer Chartis's 2026 Rural Health State of the State, the share of vulnerable Tennessee rural hospitals jumped from 44% in 2025 to 61% in 2026, with 27 at risk and 14 at immediate risk of closing within 2–3 years; TN has lost inpatient care at 18 hospitals since 2010, second only to Texas. Non-expansion states like Tennessee underperform expansion-state hospitals financially, deepening the risk. As rural ERs and maternity/mental-health services disappear, the state's ~100 rural FQHCs and 326 rural health clinics become the fallback access point.
ChartisKFF's analysis of H.R. 1 (the 2025 reconciliation law signed July 4, 2025) confirms the new Medicaid work requirements—80 hours/month, effective January 1, 2027—apply to the ACA expansion population and partial-expansion waiver states (Georgia, Wisconsin). Because Tennessee never expanded, it is not directly subject to the work mandate, but H.R. 1's added eligibility red tape and its squeeze on ACA Marketplace subsidies still drive coverage losses in a state where 100,000+ residents already sit in the coverage gap—keeping FQHCs as the primary safety net for the newly uninsured.
KFFTennCare III, approved January 8, 2021 for an unprecedented 10 years (through 2030), is Tennessee's modified-aggregate-cap Section 1115 demonstration—often called a 'block grant' but structured as a budget-neutrality-with-shared-savings waiver. Tennessee keeps 45% of savings (up to 55% with quality improvement on 10 measures), and those freed-up state dollars can fund other priorities 'seemingly without restriction.' The funding cap rebases in 2026 to actual per-capita costs from 2021–2024, a pivotal recalculation for the dollars that flow to TennCare providers, including FQHCs.
The Sycamore InstituteBy patients (HRSA UDS 2024). Tap for the full profile.
| Organization | Patients | Sites | Uninsured | Revenue (990) | District |
|---|---|---|---|---|---|
| Cherokee Health Systems Knoxville | 66,766 | 42 | 24.91% | $81M | TN-02 |
| Christ Community Health Services Inc. Memphis | 62,583 | 15 | 40.14% | $62M | TN-09 |
| United Neighborhood Health Services, Inc. Nashville | 30,750 | 14 | 73.45% | $27M | TN-06 |
| Rural Health Services Consortium, Inc. Rogersville | 28,440 | 16 | 29.26% | $39M | TN-01 |
| Maury Regional Hospital Columbia | 21,895 | 6 | 8.15% | $291M | TN-05 |
| Memphis Health Center Inc. Memphis | 18,475 | 7 | 28.74% | $15M | TN-09 |
| Matthew Walker Comprehensive Health Center, Inc. Nashville | 18,311 | 4 | 38.64% | $19M | TN-07 |
| Hardin County Regional Health Center Savannah | 16,750 | 6 | 17.05% | $23M | TN-08 |
| Tennessee Department of Health Nashville | 15,030 | 17 | 64.2% | — | TN-06 |
| Rutherford County Primary Care Clinic Inc. Murfreesboro | 14,736 | 4 | 21.86% | — | TN-04 |
4 hospital/university/county-operated: 2 hospital, 1 university, 1 county.
| District | Representative | Sites |
|---|---|---|
| TN-01 | Diana Harshbarger | 55 |
| TN-06 | John W. Rose | 40 |
| TN-03 | Charles J. “Chuck” Fleischmann | 39 |
| TN-07 | Matt Van Epps | 25 |
| TN-09 | Steve Cohen | 22 |
| TN-08 | David Kustoff | 20 |
Tennessee ranks #22 by FQHC patients and #15 by organization count among the 57 national-breadth states/territories (excludes California and Texas, which have dedicated dashboards). All 30 centers depend on the federal Community Health Center Fund, authorized only through December 31, 2026.
FQHC data from the HRSA bulk-sites file + UDS 2024 + IRS 990. State policy profile via NACHC/KFF/AANP. Intelligence items cite primary sources. Federal items apply to all states; state items are Tennessee-only. Updated 2026-06-03.