State's Chronically Ill Are Missing Out

In the absence of some form of comprehensive health care coverage in this country, perhaps the most pernicious gap has been the inability of individuals with chronic diseases to get any form of health insurance at any price.

Until TennCare terminated coverage for some 60,000 uninsurables in 2004, Tennessee had gone further than any other state toward closing this gap. But especially given the budgetary bind in which the state now finds itself, it's hard to quarrel with Gov. Phil Bredesen's conclusion that escalating TennCare costs had become prohibitive.

With a lot less attention than they should have gotten, Bredesen's subsequent initiatives have brought Tennessee back to the forefront in offering coverage in a state-subsidized high-risk pool to individuals who've been denied commercial health insurance. No, it's not the unrestricted coverage at little or no charge that TennCare provided. But among 33 states that now have such high-risk pools, Tennessee's is the most beneficent both in terms of eligibility criteria and cost to low-income applicants.

Where most state pools impose a 12-month waiting period on coverage of pre-existing conditions, on Jan. 1 Tennessee reduced its exclusion period to three months—with no wait at all on coverage of chemotherapy and other outpatient cancer treatments. Where most state pools set their premiums for all comers at 150 percent or more of commercial health insurance rates, Tennessee offers discounts that, since Jan. 1, range up to 90 percent for those with incomes below the Federal Poverty Line (FPL) of about $10,000 for individuals.

What seems pernicious now is the lack of uptake for the program, which is known as AccessTN. Only 3,080 Tennesseans had signed up as of the end of March. That's fewer than were enrolled in a high-risk pool known as TCHIP that predated TennCare (and didn't offer any low-income premium assistance), let alone the 60,000 TennCare disenrollees for whom AccessTN waived any pre-existing exclusions for a time.

Conjecture is all that anyone seemingly has to go on as to why the sign-up has been so low.

Tony Garr of the Tennessee Health Care Coalition ventures that even with the steep discounts, premiums are unaffordable for the poor. Standard premiums range from roughly $400 to $1,000 per month, depending on a person's age, weight, and tobacco use. For a 50-something, non-obese, non-smoker with income below the FPL, a premium of $60 a month doesn't seem beyond reach. But there's also a $1,000 deductible and a 20 percent co-pay up to a maximum out-of-pocket expense of $5,000 a year.

Dennis Freeman, CEO of Cherokee Health Systems, which serves the poor at clinics in 11 East Tennessee counties, believes enrollment could be facilitated if an organization like his were enlisted to lend a helping hand to applicants.

Then there's the theory that organizations offering charity care have started filling needs that TennCare dropped. The Knoxville Academy of Medicine, for example, has provided care to 9,000 patients over the past two years through its Project Access, which has a network of over 800 doctors who donate their services to Knox County residents with incomes below 200 percent of FPL.

It's not as if AccessTN is trying to keep a low profile or make it difficult for people to enroll. Far from it. AccessTN's director, David Hilley, is actually promoting participation through meetings with physician groups, social workers at hospitals, and the media. He now has an outreach staff of four, up from one when AccessTN was launched in early 2007.

Moreover, a "Call-In for Coverage" has been scheduled during which "individuals can simply dial 1-866-576-0028 to speak one-on-one with program representatives who can determine if uninsured adults or children qualify and then help them enroll in one of the programs." In addition to AccessTN, these programs also include CoverTN, CoverKids, and CoverRX, all of which have been collectively labeled Cover Tennessee.

One deterrent to AccessTN enrollment may be confusion with CoverTN, which is a program that offers limited benefits to lower-income employees of businesses with no more than 50 workers for premiums averaging $150 per month—with the state, the employer, and the employee each paying one-third. By contrast, AccessTN benefits are comprehensively comparable to those provided to state employees.

Nor is there any danger that AccessTN coverage could be jeopardized by the state's current budget crunch. When the program was established in 2006, $23 million was appropriated for each of the three ensuing fiscal years. Because of low enrollment, nearly half of the first-year money was carried forward, and Hilley foresees an additional carry forward from the current fiscal year. Should this funding get fully utilized at some point, the state is also authorized to impose assessments on insurance companies as is the case with most high-risk pools in other states.