In His Own Words 

Gordon Bonnyman on what's wrong with TennCare and how to save it

Gordon Bonnyman on what's wrong with TennCare and how to save it

Remember those old yellow-and-black Civil Defense signs on public buildings that proclaimed that they would shelter us if the Russians ever nuked Music City? What wishful thinking. And now state officials offer the same false sense of security as we face the demise of TennCare.

Gov. Bredesen's proposals will remove 323,000 people from the program—nearly half of all adults on TennCare—and drastically cut services for those who remain. Altogether, TennCare patients will suffer the withdrawal of $1.7 billion in medical services. Not to worry though, state officials say, because they are looking into ways that church clinics, county health departments, emergency rooms and private insurers might care for the 1.3 million Tennesseans who will feel the cuts. The notion that volunteerism and emergency rooms can respond to medical cuts of that magnitude suggests officials are in deep denial, like the Civil Defense bureaucracy that asked us to believe that a yellow placard on a building made it an effective shelter from nuclear attack.

It is time for a reality check, time to face the real causes of the problem and come up with real solutions to the looming crisis.

TennCare is the largest conduit of federal dollars—$6.5 billion worth—into the state budget. The federal government matches every dollar the state spends with two dollars. When the governor says that he will cut medical services by $575 million, that translates into a loss of federal dollars of $1.15 billion and total cuts in medical care of over $1.7 billion.

The governor and his consultants approach TennCare as if it were a private HMO. It's not. TennCare is a complex, critically important public health program that provides a safety net for those whom commercial insurers wouldn't touch with a 10-foot pole. Like Medicaid programs in other states, TennCare provides care to the sickest, poorest, most vulnerable—and politically powerless—people in our community. These include most of Tennessee's medically fragile infants and children. It includes adults whom insurers shun because of a history of cancer or heart disease.

Three-fourths of elderly Tennesseans who are in nursing homes rely on TennCare. The program provides a lifeline for 100,000 children and adults with severe mental illness. TennCare funding keeps the doors open at Meharry General and many rural hospitals. TennCare underwrites most communicable disease control efforts. It defrays local schools' special education costs and pays the salaries of social workers who investigate suspected child abuse. TennCare does all of that because of federal money. That's reality.

The governor needs to shed his preoccupation with the consent decrees that he helped draft in 2003, but now regards as a scourge. Consent decrees are out-of-court settlements, based in this instance on the state's promise to comply with federal laws that govern all Medicaid programs. When he announced the agreements, Gov. Bredesen said they would put the state "back in the driver's seat" so that he could save $150 million a year and move forward with other reforms. Eighteen months later, he blames the same agreements for a $650 million state deficit. That's incorrect. In November, my colleagues and I offered to modify the consent decrees, as the governor had demanded, to enable him to implement his reform proposals. He rejected those offers. His finance commissioner conceded that officials had realized, with or without the decrees, the "reforms" couldn't save the budget. That's reality.

The harshest reality is which TennCare patients will take the hit. The cuts will extract their biggest savings from the relatively small percentage of the TennCare population, most of them elderly, who are the costliest to treat. This includes 1,500 elderly who will be booted from nursing homes, and 30,000 severely mentally ill who will lose their coverage. The first to feel the cuts will be retirees whose medicines often exceed their entire Social Security checks, and who had been praying they could hang on until next year, when the Medicare drug benefit takes effect. Widows with half a dozen serious illnesses and twice that number of legitimate prescriptions will now be cast adrift.

With apologies to those who consider it in poor taste to say aloud, some people will die. UT's Center for Health Services Research did an analysis of the effect on the state's death rate of moving people from the TennCare rolls to the ranks of the uninsured. The conclusion: cutting 323,000 people off of TennCare can be expected to raise the death rate by as much as 440 deaths per year, or the equivalent of an additional, preventable death every 20 hours. And that's only among the people who are going to lose their coverage altogether. As doctors, and common sense, tell us, denying lifesaving drugs and medical care to thousands who remain on the program will take an additional toll.

There is no getting around the reality that taking over $1.1 billion in federal funding out of the health care system will damage its capacity to respond to the needs of all Tennesseans, not only those on TennCare. When the state made Medicaid cuts 20 years ago, it had to reverse them within two years, because even those comparatively small cuts had put key hospitals at risk. It is naive to expect that pre-K, or any other public programs, will benefit from spurning over $1 billion of federal aid for medical services that, to a great extent, state or local governments will have to provide anyway.

Is there any hope? Yes, but only if we get past name-calling to address the real roots of the crisis, which lie in the previous administration. For years, TennCare had the lowest per-patient cost of any Medicaid program in the nation, saving the state hundreds of millions of dollars while covering many otherwise uninsured Tennesseans. But in a series of missteps culminating in 2002, former Gov. Don Sundquist unwittingly undermined the program. He relieved the HMOs of their financial responsibilities, eliminating incentives to effectively manage care. He also renegotiated a deal with Washington that cost TennCare hundreds of millions in federal funding. Those two moves effectively made TennCare unsustainable.

We need to recover the federal funding if there is to be any hope for TennCare's immediate survival. Real reforms, as distinct from the meat-axe cuts now planned, cannot save $575 million by next year. Only restoration of federal funds will buy the time needed to implement reforms—such as disease management and reform of drug prescribing patterns—while enabling Tennessee to avoid a health care catastrophe on a scale that no other state has ever experienced.

The governor has dismissed the notion of federal aid as unrealistic. To prevent Medicaid meltdowns less extreme than the one facing Tennessee, Louisiana last spring received a $774 million bailout, and Alabama is poised to receive $1 billion in federal concessions. The Senate majority leader is from our state. We can make a good case that the present crisis is at least partially a result of the federal government taking advantage of our former governor. However difficult it may be to negotiate federal relief, the alternative—like planning to ride out an atomic attack in a building with a Civil Defense sign—is no plan at all. The sooner everyone faces that reality, the sooner energies can be devoted to averting disaster, rather than trying to pretend it won't really be so bad.

Gordon Bonnyman has worked as a legal aid lawyer since 1973 and is presently the executive director of the Tennessee Justice Center, a nonprofit public interest law firm that serves low-income families across the state. He has been an advocate for TennCare patients since the program was established in 1994.

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