insights (2006-03)

Making TennCare’s Disenrolled Go Poof

hen TennCare lopped 191,000 needy Tennesseans from its rolls last summer, Governor Phil Bredesen heralded the creation of a safety net to keep them from falling through the cracks. While the $104 million in state funding for safety-net programs pales by comparison with the annual cost of TennCare coverage for the disenrolled, several health-care providers who were contacted believe the safety net is affording at least a modicum of care for those who lost their coverage.

“In terms of providing basic primary care services, we’ve been able to do that,” reports Dennis Freeman, CEO of Cherokee Health Systems, which serves more than 40,000 patients at clinics in 13 outlying East Tennessee counties. “There are obviously some gaps,” he adds—of which access to specialists heads the list. But even here he credits an initiative on the part of the Knoxville Academy of Medicine with beginning to put in place a network of volunteer specialists who will systematically offer donated services to those who can’t afford them.

Where the severely and persistently mentally ill (SPMI’s) are concerned, the president of the Helen Ross McNabb center, Andy Black, says, “The situation continues to improve in terms of broadened opportunity for people to have access to case management. We’d like to see a broader set of psychotropic drugs covered, but no one is being deprived of medication.”

Last month, Bredesen proclaimed that, “Because of careful management and an outpouring of support from healthcare providers and community leaders across Tennessee, we believe we’ll be able to extend many of the safety-net’s services for those coming off TennCare to further ease the transition to alternative healthcare sources.” The extension consists primarily of continuing to provide a limited list of generic drugs to all disenrollees without charge until June 30 whereas their provision had been due to terminate on Dec.  31. Diabetics, cancer victims and recipients of organ transplants will continue to get more extensive and expensive treatment for this same extended period.

But Bredesen’s heralding of the transitional extensions begs the question: Transition to what? And state officials don’t have clear answers to that question at this point. What appears to be emerging is a strategy of making the disenrollees disappear as a class of people and subsuming them in programs that would attempt to address the needs of all 800,000 Tennesseans who don’t have health insurance alike.

These mostly lower-income uninsured are, of course, part of a national population of more than 40 million for whom not even the federal government has been able to make a meaningful address. (Remember Bill and Hillary Clinton’s last failed attempt?) To think that a perpetuation of the $104 million in state safety-net funding could make much a dent in the problem seems wishful to the point of being specious. And it’s not even clear whether the $104 million will be perpetuated, let alone augmented.

An office of health planning in the state’s Department of Finance and Administration is in the process of promulgating a Request for Information that sounds like a call for help. “We’re looking for innovative ideas on how to stretch our dollars and determining what approach allows us to serve the most people,” says the director of health planning, Laurie Lee.

Some encouragement can be drawn from the fact that the $12 million in safety-net funding that’s going for primary-care coverage is already aimed at reaching the uninsured population at large—with some apparent success. With its projected $600,000 share of these funds, Cherokee Health Systems has been able to augment its staff sufficiently to see nearly twice as many uninsured patients this past fall compared to the year before. “We’re able to see everyone who presents themselves to us regardless of their ability to pay,” says Freeman.

The $11 million earmarked for community mental-health centers also appears adequate to their staffing needs. And while the medications menu is limited, the same probably can be said for the $37 million that’s covering drug costs for uninsured SPMI’s without regard to whether they were disenrolled from TennCare. Moreover, all these funds are in the state’s budget on what’s known as a recurring basis, which means that their perpetuation won’t necessitate eating into the state’s revenue growth in the fiscal year ahead.

The biggest bugaboo for safety-net extension, as it has been for TennCare, is prescription-drug costs. It seems amazing that the $12 million allocated last summer for a program known as RX Outreach has proven sufficient to allow for its continuation through June when a December cutoff was anticipated. Under RX Outreach, the list of 55 generic drugs available to disenrollees at no charge is only a tiny subset of the medications of the formulary for those who remain on TennCare. While low-cost drugs for a variety of disorders are covered, there’s nothing on the list at all for many chronic diseases such as multiple sclerosis and Parkinson’s disease that call for high-cost treatment.

Yet making even this limited menu affordable to all 800,000 uninsured is remindful of the challenge facing Jesus Christ when called upon to come up with enough loaves and fishes to feed the multitudes. Lee suggests that some leavening can be derived from more extensive use of what are known as pharmacy-assistance programs under which many manufacturers furnish their drugs at little or no cost to those without the means to buy them on the market.

What’s really needed, though, is some way to leverage state dollars with the sort of federal matching funds that were lost when TennCare was dismembered. A safety net that attempts to meet the needs of all the uninsured with purely state dollars won’t go very far.