TennCare once was model for public health care, but now is cautionary tale
Over 1,000 HIV patients left with no coverage
Tennessee's expanded health care system once was the envy of many, and a model to states that wanted to do something to assist the working poor.
Now, TennCare's chief features of expanding health care coverage to uninsured and uninsurable people have been eliminated, and many HIV patients will lose their health care coverage, says Stephen Raffanti, MD, MPH, chief medical officer of Comprehensive Care Center in Nashville, TN.
"From 600 to 900 HIV patients in our clinic will lose TennCare coverage," Raffanti says.
Statewide, probably more than 1,200 HIV patients are losing their TennCare coverage, says Joseph Interrante, PhD, chief executive officer of Nashville CARES (Community AIDS Resources Education and Service).
TennCare's new income and eligibility requirements are set so low that the only way a man with HIV will qualify is if he's homeless and disabled, Raffanti says.
HIV-infected women who qualify for Medicaid through pregnancy will still receive care, but too few others will, he says.
"We went from being the most progressive health care in the country to one of the most restricted," Raffanti adds.
With so many former TennCare clients switched over to ADAP, it's likely the ADAP program will run out of funds by the spring of 2006, Raffanti predicts.
"We've had in our clinic at least a four-to-six-fold increase in ADAP enrollment," Raffanti says. "We've hired a full-time employee who does nothing except enroll patients in patient assistance programs."
These changes jeopardize the lives of Tennessee HIV patients, who will have increasingly problems accessing the drugs and care they need, Raffanti says.
"We have patients who have interpreted all of this change as one more reason why people think they have no value, and it's hard to make an argument against that when everything you see are people who have less support and power and whose lives are being jeopardized by cuts in social services in this country," Raffanti says.
"What's really amazing is when there's a huge push to treat HIV in developing countries when we have states with AIDS drug waiting lists," he adds. "I think it's great to have a huge push to treat HIV in sub-Saharan Africa, but nobody notices the disconnect when hundreds are on waiting lists in this country."
The reasons why TennCare has fallen into such hard times are debatable, but Raffanti and Interrante say it probably was a combination of mismanagement, poor decisions on the part of state officials, and the economic downturn in recent years.
TennCare wasn't more costly than the typical Medicaid program, but the number of people it originally covered was significantly greater, Interrante says.
"It covered expanded populations and all of these groups of people who were unable to find insurance because of life threatening illnesses, like breast cancer, diabetes, and other illnesses," Interrante says.
"No one denies there were fiscal management problems," Interrante says. "They privatized it by turning it over to managed care/managed cost organizations (MCOs), and most MCOs didn't do a good job of managing care or costs."
So the state of Tennessee went above and beyond its original, capitated cost deal with these organizations and assumed more of the risk, and then state officials began to cut out pieces of the program in a futile attempt to contain costs, Interrante explains.
"First they cut the uninsured population, which were the working poor, who were healthier than the other groups, so they increased the risk pool and increased the cost of the program this way," Interrante says.
"When you looked at the number of people covered on a per cost basis, Tennessee still was one of the most efficient Medicaid programs in the country, but given the fiscal problems the state was having like other states, these changes didn't resolve the problem," Interrante adds.
So the state began taking out more pieces of TennCare, including cutting the program for the uninsurable population it once served. The state also put in reforms that were supposed to eliminate waste and increase the program's efficiency, such as a retrospective drug utilization and requiring more accountability from the managed care organizations, he says.
"Many of us are still waiting to see if any of these other reforms get implemented," Interrante says. "The cuts this past summer and fall will be repeated and deepened in 2006 because the other reforms that would keep the program at a certain level of costs have not been implemented yet."
Meantime, the situation is dire for many in the HIV community.
"We need an increase in both federal funding through the Ryan White Care Act, as well as getting the state to realize that their one-time increased appropriation last year was not a one-time commitment and needs to be ongoing," Interrante says.
"The entire safety net we've built up in the last 10 years will begin to unravel as we redirect greater proportion of funds in care services strictly into medical care," Interrante says. "And even with that, it's only a matter of time before we have waiting lists in Tennessee."
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