Post by Moses on Nov 20, 2004 10:01:04 GMT -5
November 20, 2004
Once a Model, a Health Plan Is Endangered
By RICK LYMAN
NASHVILLE, Nov. 19 - A decade after Tennessee inaugurated a health care plan for the state's most vulnerable residents that was hailed as a model for the nation, the program is once more being held up as a model - of failure in an era of soaring medical costs and voters' aversion to higher taxes.
Today the plan, TennCare, which sought to improve health care for Medicaid recipients while covering those who fall through the federal program's cracks, is on the ropes.
[New Democrat] Gov. Phil Bredesen, a conservative Democrat and former health maintenance organization entrepreneur, has threatened the program with extinction, saying that rising costs and generous benefits - TennCare consumes nearly a third of the state's $25 billion budget - make it unaffordable unless it can be radically restructured to save money and limit benefits.
In the coming year alone, the program faces a potential deficit of $650 million.
After more than a week of tense negotiations between the governor and advocates for TennCare's 1.3 million users - nearly a quarter of the state's population, including an estimated 430,000 who would not be covered by Medicaid if TennCare disappeared - the two sides decided to "step back from the brink," as Mr. Bredesen put it.
"Before I go down the road of taking 430,000 people off the rolls - more specifically, before I can face even one of them, individually, and tell them that it is over, that I can no longer help - I need to be clear in my own heart that I've done everything that I know how to do to solve this," the governor said.
Rather than immediately kill TennCare, as he was poised to do, the governor agreed on Wednesday to one more round of talks after Thanksgiving, though he said saving the program was still a long shot.
In the meantime, TennCare's precarious future leaves those who depend on the program in a state of vigilance and dread.
"In this country, rich as it is, people shouldn't have to choose whether their child will live or die," said Angela Ray, the mother of a severely ill 12-year-old girl in Lawrenceburg. "It's amazing to me that it's come down to this."
Her daughter, Jasmine, must take 20 extremely expensive medications every day to control the rare stew of chronic diseases, including Elephant Man Syndrome, that make it impossible for her to run and play. There are no doctors in Tennessee who can treat her, so her parents must frequently drive her to Birmingham, Ala., for care.
Soon, she may lose that care - out-of-state trips are covered by TennCare, but not by Medicaid - and possibly, her life.
Anita Hyche, 35, a suburban Nashville homemaker who suffers from a rare and agonizing disorder that causes her bone joints to dislocate easily, takes a battery of painkillers that make it possible for her to live a normal active life. Her disease makes her uninsurable, and she would not qualify for Medicaid, so if TennCare ends she will no longer receive $1,200 a month worth of pills.
Ever since she heard that TennCare might be killed, Ms. Hyche said, she has been hoarding her medication - taking seven pills a day instead of a dozen or more - and she thinks she has squirreled away enough to last for several months. After that, she does not know what will happen
"The thing that scares me the most isn't thinking about coming up with the money, it's thinking about going back to the way my life was before I had this medicine," she said. "I don't want to feel that bad again."
The fate of TennCare has profound national as well as personal implications. Other governors, also under pressure to stem rising health insurance costs, are watching to see whether Tennessee will provide a model for how to trim their own programs.
And there are fears that Republicans in Washington, flush with their recent election victories, will try to cut away at federal medical benefits, further squeezing the states.
"There's no question it's going to be a tough year ahead for Medicaid," said Victoria Wachino, director of health policy for the Center on Budget and Policy Priorities, a liberal Washington research group. "But there are ways to reduce the deficit without further shifting additional health care costs to the states."
Created by former Gov. Ned McWherter, TennCare replaced Medicaid for those Tennessee residents not covered by other health insurance on Jan. 1, 1994. As costs for health care and prescription drugs rose steadily in subsequent years, TennCare became a larger and larger portion of the state's budget and a frequent political flashpoint.
In 1995, TennCare cost $2.5 billion. In this fiscal year, it will cost $8 billion out of the state's $25 billion budget. The money comes from the federal government (nearly $5 billion), state tax revenue (about $2.5 billion) and sources like premiums from those who can afford to pay for their care (just under $500,000).
Tennessee is one of the few states without an income tax. When proponents of establishing one argued several years ago that it was needed, in part, to pay for TennCare, conservative politicians and talk-show hosts increased their criticism of what they called a socialist program, and legions of "horn honkers" drove past the state capitol and TennCare offices.
By the time Mr. Bredesen, a former Nashville mayor, ran for governor in 2002, TennCare had become the state's sharpest political thorn, and he won partly by promising to overhaul it. In 2003, the state began phasing in a preferred drug list to cut the cost of prescriptions.
On Feb. 17, citing a recent report that TennCare would be $650 million in the hole in 2005, Mr. Bredesen offered what he called a "last chance" to save the program. "We need to face the facts," he said. "We have too many people with too many benefits for the money we have."
He said he could come up with a new, permanent TennCare fix that was affordable and fraud-free without cutting benefits for children, pregnant women and the disabled.
In May, the Legislature approved the broad outlines of his plan, including a limit of 10 doctor visits per year (later raised to 12) and six prescriptions per month (recently, the governor said that might have to be lowered to four).
"What began as a grand vision had become a political scramble to cut the program as fast as possible," said Gordon Bonnyman, head of the Tennessee Justice Center and the leading legal advocate for TennCare recipients.
The program's advocates fought back. In June, Mr. Bonnyman went to federal court to argue that the changes violated four consent decrees he had won over the years that forced TennCare to abide by federal standards in certain crucial areas, like eligibility, home health visits and medical screening for children.
Particularly troubling to advocates was that access to TennCare services would be dictated by "medical necessity" - which would be determined by the state or its medical contractor, rather than a patient's doctor - and that the state would be required to provide only the least expensive "adequate" care. Also, the governor asked federal officials for "pre-approval" of moves he might make later, without spelling out what those cuts might entail.
The lines were firmly drawn. On one side was the governor, the Legislature and representatives for doctors, hospitals and drug companies. On the other side were Mr. Bonnyman and other advocates for TennCare's users, like AARP, the Children's Defense Fund and dozens of charities and associations like the Alzheimer's Foundation and the National Mental Health Foundation.
In September, Mr. Bredesen officially requested federal approval of some of the changes he had sought, providing fresh specifics that further troubled the program's advocates.
Meanwhile, the governor has grown increasingly vocal about what he calls the advocates' intransigence, and ratcheted up his rhetoric, comparing the health care program favored by Mr. Bonnyman to "a dictator in a glass coffin" and declaring the program he was proposing as "more American."
The advocates have also shown a willingness to appeal to emotions.
"Certainly, some people will die who would not otherwise have died," if the program is killed, Mr. Bonnyman said.
On Nov. 10, attacking the advocacy groups for their persistent lawsuits, Mr. Bredesen said he was ready to give up his overhaul efforts and pull the plug on TennCare.
Mr. Bonnyman asked for more time and the governor said he would continue talking.
On Wednesday, just when it appeared that negotiations were stalled for good, Mr. Bredesen invited Mr. Bonnyman to his office for their first one-on-one meeting and, that evening, made his unexpected announcement.
"These talks have not gone well, and we are at an impasse," the governor said. "By any reasonable measure, I should say, 'it's over,' and move on."
Instead, the governor promised to give it one more try after a vacation and a Thanksgiving holiday.
"It's good news," Mr. Bonnyman said. "We have really pulled back from the brink."
The governor agreed.
"I need to try again," he said.
At a hearing on Friday, Judge John T. Nixon of Federal District Court suggested that former Governor McWherter, whose administration created TennCare, be summoned as a mediator. Both sides said they would consider the idea.
Meanwhile, TennCare's enrollees, especially those who depend on the program to keep them alive and well, wait and wonder and continue to hoard their pills.
....Ms. Hyche said, staring at the array of prescription bottles spread across the coffee table in her living room. "It's just so cruel."
www.nytimes.com/2004/11/20/national/20tennessee.html?th=&pagewanted=print&position=
Once a Model, a Health Plan Is Endangered
By RICK LYMAN
NASHVILLE, Nov. 19 - A decade after Tennessee inaugurated a health care plan for the state's most vulnerable residents that was hailed as a model for the nation, the program is once more being held up as a model - of failure in an era of soaring medical costs and voters' aversion to higher taxes.
Today the plan, TennCare, which sought to improve health care for Medicaid recipients while covering those who fall through the federal program's cracks, is on the ropes.
[New Democrat] Gov. Phil Bredesen, a conservative Democrat and former health maintenance organization entrepreneur, has threatened the program with extinction, saying that rising costs and generous benefits - TennCare consumes nearly a third of the state's $25 billion budget - make it unaffordable unless it can be radically restructured to save money and limit benefits.
In the coming year alone, the program faces a potential deficit of $650 million.
After more than a week of tense negotiations between the governor and advocates for TennCare's 1.3 million users - nearly a quarter of the state's population, including an estimated 430,000 who would not be covered by Medicaid if TennCare disappeared - the two sides decided to "step back from the brink," as Mr. Bredesen put it.
"Before I go down the road of taking 430,000 people off the rolls - more specifically, before I can face even one of them, individually, and tell them that it is over, that I can no longer help - I need to be clear in my own heart that I've done everything that I know how to do to solve this," the governor said.
Rather than immediately kill TennCare, as he was poised to do, the governor agreed on Wednesday to one more round of talks after Thanksgiving, though he said saving the program was still a long shot.
In the meantime, TennCare's precarious future leaves those who depend on the program in a state of vigilance and dread.
"In this country, rich as it is, people shouldn't have to choose whether their child will live or die," said Angela Ray, the mother of a severely ill 12-year-old girl in Lawrenceburg. "It's amazing to me that it's come down to this."
Her daughter, Jasmine, must take 20 extremely expensive medications every day to control the rare stew of chronic diseases, including Elephant Man Syndrome, that make it impossible for her to run and play. There are no doctors in Tennessee who can treat her, so her parents must frequently drive her to Birmingham, Ala., for care.
Soon, she may lose that care - out-of-state trips are covered by TennCare, but not by Medicaid - and possibly, her life.
Anita Hyche, 35, a suburban Nashville homemaker who suffers from a rare and agonizing disorder that causes her bone joints to dislocate easily, takes a battery of painkillers that make it possible for her to live a normal active life. Her disease makes her uninsurable, and she would not qualify for Medicaid, so if TennCare ends she will no longer receive $1,200 a month worth of pills.
Ever since she heard that TennCare might be killed, Ms. Hyche said, she has been hoarding her medication - taking seven pills a day instead of a dozen or more - and she thinks she has squirreled away enough to last for several months. After that, she does not know what will happen
"The thing that scares me the most isn't thinking about coming up with the money, it's thinking about going back to the way my life was before I had this medicine," she said. "I don't want to feel that bad again."
The fate of TennCare has profound national as well as personal implications. Other governors, also under pressure to stem rising health insurance costs, are watching to see whether Tennessee will provide a model for how to trim their own programs.
And there are fears that Republicans in Washington, flush with their recent election victories, will try to cut away at federal medical benefits, further squeezing the states.
"There's no question it's going to be a tough year ahead for Medicaid," said Victoria Wachino, director of health policy for the Center on Budget and Policy Priorities, a liberal Washington research group. "But there are ways to reduce the deficit without further shifting additional health care costs to the states."
Created by former Gov. Ned McWherter, TennCare replaced Medicaid for those Tennessee residents not covered by other health insurance on Jan. 1, 1994. As costs for health care and prescription drugs rose steadily in subsequent years, TennCare became a larger and larger portion of the state's budget and a frequent political flashpoint.
In 1995, TennCare cost $2.5 billion. In this fiscal year, it will cost $8 billion out of the state's $25 billion budget. The money comes from the federal government (nearly $5 billion), state tax revenue (about $2.5 billion) and sources like premiums from those who can afford to pay for their care (just under $500,000).
Tennessee is one of the few states without an income tax. When proponents of establishing one argued several years ago that it was needed, in part, to pay for TennCare, conservative politicians and talk-show hosts increased their criticism of what they called a socialist program, and legions of "horn honkers" drove past the state capitol and TennCare offices.
By the time Mr. Bredesen, a former Nashville mayor, ran for governor in 2002, TennCare had become the state's sharpest political thorn, and he won partly by promising to overhaul it. In 2003, the state began phasing in a preferred drug list to cut the cost of prescriptions.
On Feb. 17, citing a recent report that TennCare would be $650 million in the hole in 2005, Mr. Bredesen offered what he called a "last chance" to save the program. "We need to face the facts," he said. "We have too many people with too many benefits for the money we have."
He said he could come up with a new, permanent TennCare fix that was affordable and fraud-free without cutting benefits for children, pregnant women and the disabled.
In May, the Legislature approved the broad outlines of his plan, including a limit of 10 doctor visits per year (later raised to 12) and six prescriptions per month (recently, the governor said that might have to be lowered to four).
"What began as a grand vision had become a political scramble to cut the program as fast as possible," said Gordon Bonnyman, head of the Tennessee Justice Center and the leading legal advocate for TennCare recipients.
The program's advocates fought back. In June, Mr. Bonnyman went to federal court to argue that the changes violated four consent decrees he had won over the years that forced TennCare to abide by federal standards in certain crucial areas, like eligibility, home health visits and medical screening for children.
Particularly troubling to advocates was that access to TennCare services would be dictated by "medical necessity" - which would be determined by the state or its medical contractor, rather than a patient's doctor - and that the state would be required to provide only the least expensive "adequate" care. Also, the governor asked federal officials for "pre-approval" of moves he might make later, without spelling out what those cuts might entail.
The lines were firmly drawn. On one side was the governor, the Legislature and representatives for doctors, hospitals and drug companies. On the other side were Mr. Bonnyman and other advocates for TennCare's users, like AARP, the Children's Defense Fund and dozens of charities and associations like the Alzheimer's Foundation and the National Mental Health Foundation.
In September, Mr. Bredesen officially requested federal approval of some of the changes he had sought, providing fresh specifics that further troubled the program's advocates.
Meanwhile, the governor has grown increasingly vocal about what he calls the advocates' intransigence, and ratcheted up his rhetoric, comparing the health care program favored by Mr. Bonnyman to "a dictator in a glass coffin" and declaring the program he was proposing as "more American."
The advocates have also shown a willingness to appeal to emotions.
"Certainly, some people will die who would not otherwise have died," if the program is killed, Mr. Bonnyman said.
On Nov. 10, attacking the advocacy groups for their persistent lawsuits, Mr. Bredesen said he was ready to give up his overhaul efforts and pull the plug on TennCare.
Mr. Bonnyman asked for more time and the governor said he would continue talking.
On Wednesday, just when it appeared that negotiations were stalled for good, Mr. Bredesen invited Mr. Bonnyman to his office for their first one-on-one meeting and, that evening, made his unexpected announcement.
"These talks have not gone well, and we are at an impasse," the governor said. "By any reasonable measure, I should say, 'it's over,' and move on."
Instead, the governor promised to give it one more try after a vacation and a Thanksgiving holiday.
"It's good news," Mr. Bonnyman said. "We have really pulled back from the brink."
The governor agreed.
"I need to try again," he said.
At a hearing on Friday, Judge John T. Nixon of Federal District Court suggested that former Governor McWherter, whose administration created TennCare, be summoned as a mediator. Both sides said they would consider the idea.
Meanwhile, TennCare's enrollees, especially those who depend on the program to keep them alive and well, wait and wonder and continue to hoard their pills.
....Ms. Hyche said, staring at the array of prescription bottles spread across the coffee table in her living room. "It's just so cruel."
www.nytimes.com/2004/11/20/national/20tennessee.html?th=&pagewanted=print&position=