NASHVILLE, Tenn. — Tennessee’s four leading gubernatorial candidates outlined competing approaches to rural hospital closures and maternal health care on Oct. 12, with Medicaid expansion emerging as a central dividing line in a state where 12 rural hospitals are at immediate risk of closure. The proposals ranged from expanding Medicaid to improve hospital finances, to directing new federal money toward rural services and opening stand-alone emergency rooms. Candidates also highlighted the difficulty of ensuring prenatal and emergency care in communities where residents may face long drives for treatment. Democratic candidate Jerri Green said Tennessee should accept federal Medicaid expansion funding, arguing that the money could help keep rural hospitals open and support local economies. She said many rural hospitals lack obstetric services and described families facing long ambulance trips and costly airlifts for premature infants. Green said emergency departments on their own cannot replace the full range of services a hospital provides. She also pointed to Medicaid expansion in other states as a way to strengthen rural health care, while warning that hospital losses affect local jobs and businesses as well as patients. Republican candidate Marsha Blackburn, a U.S. senator, pointed instead to a federal Rural Health Transformation Fund. She said Tennessee is set to receive $1 billion over five years, with investment planned for technology, maternal and child health, and rural health-care staffing. Blackburn also cited a stand-alone emergency facility in Fentress County, developed after the county lost its hospital, as a model for bringing services closer to residents. Blackburn said those facilities can offer services including imaging, lab work, telehealth and behavioral health care. For pregnancy care, she proposed connecting residents with nearby health centers and expanding access to midwives, doulas and prenatal education. Independent candidate Lauren Pinkston said low TennCare reimbursements and the number of uninsured patients put rural hospitals under financial strain. She emphasized preventive care, including placing family doctors and nurse practitioners at large workplaces, and called for stronger investigations into alleged fraud involving medical supplies billed to public programs. Pinkston said she would move the state office responsible for investigating that fraud under the attorney general or the Tennessee Bureau of Investigation. She argued that hospitals’ reliance on TennCare patients and people without insurance can undermine their finances, but did not offer a specific replacement for the federal funds Tennessee has forgone by rejecting Medicaid expansion. Independent candidate David Hatley said the state should work with rural hospitals to determine what would keep them open, while ensuring communities have emergency services even when a full hospital is not viable. He cited Fentress County’s emergency facility as an example and said residents should not have to travel an hour during a heart attack. Hatley acknowledged he did not have a plan to replace the federal funding rural hospitals have lost. He proposed reviewing the state budget to find money for rural health care, arguing that lawmakers should identify waste and prepare for declining federal support. Tennessee has rejected Medicaid expansion, leaving billions of dollars in federal funding unclaimed, and has been ordered to repay hundreds of millions in federal matching funds following compliance audits. The state’s rural hospital closures have left some communities with limited access to emergency and pregnancy-related care. Candidates also offered different estimates of the state’s standing nationally for rural hospital closures. The debate leaves voters weighing whether the state should expand Medicaid, rely on targeted funding and alternative facilities, or redirect existing state spending. The candidates’ proposals carry particular significance for rural residents who may have to travel long distances for care and for pregnant patients in communities without local obstetric services.