Gov. Phil Bredesen may well be Tennessee's best governor in decades, but he still will have stains on his record. He came into office making huge and controversial cuts in TennCare, the state's Medicaid program, and it looks like he will go out making similarly harsh cuts again.
One the table now is another round of proposed cuts in the already downsized TennCare program that would sharply restrict or eliminate a range of needed services. Medical providers characterize these cuts as "devastating," and a spokesperson for TennCare admits the cuts are "painful."
"In normal circumstances," TennCare's Kelly Gunderson said, "these are benefits we would not be touching."
Cutting coverage, not disease
That's no consolation. More to the point, it won't stop the need for the services from occurring. If approved, the cuts would mainly leave the most needy TennCare patients in impossibly difficult positions; compound their medical problems due to lack of attention to chronic conditions; and excessively burden medical care providers by shifting the cost of denied coverage for care to them.
The TennCare cuts, moreover, would come on top of cuts implemented in a Nov. 30 freeze on CoverKids, the state's label for the insurance program it provides under the federally subsidized State Children's Health Insurance Program, known as S-CHIP.
In effect, the governor has focused on cuts that perforce will fall on the most vulnerable individuals among us.
The proposed TennCare cuts must yet be approved by the U.S. Centers for Medicare and Medicare Services. If implemented, they seem certain to land most onerously on chronically ill citizens who have the least resources to sustain their health through out-of-pocket payments.
What $10,000 buys
The new restrictions, for example, would impose an annual limit of $10,000 per person on inpatient hospital or inpatient psychiatric hospital services -- a limit often exhausted by a single emergency room visit.
This cost ceiling clearly would not pay for a hospital stay of days or weeks for a seriously ill person. That suggests that the governor is willing to leave the state's safety-net hospitals, and other providers, in a harsh bind. Hospitals are required to provide a minimal level of services to stabilize a patient's condition. Thus a load of TennCare/Medicaid patients whose hospital coverage would essentially vanish under the governor's cuts -- leaving them effectively at the level of indigent patients -- could put hospitals like Erlanger in a deep fiscal hole very quickly.
There's some irony in this. Gov. Bredesen has been complaining about Washington's proposed expansion of Medicaid eligibility as an unfunded mandate. Yet his cuts similarly could be cast as an unfunded mandate on safety-net hospitals.
Among other proposed cuts, he would fix a limit of eight nonemergency visits to outpatient hospitals per person; an annual limit of eight physician office visits per person; and an annual limit of eight occasions for lab and x-ray services.
Coverage for hospice care, a widely praised, cost-efficient service for terminal patients who often choose to die at home, would be eliminated. So would coverage for occupational, speech and physical therapy. Such therapies are often critical to help people return to work or to become more functional, healthy and self-sustaining in terms of their care.
All of these cuts would most harshly affect chronically ill, often elderly patients who must seek medical care often. Conversely, healthy people may not need to see a doctor or seek hospital treatments for a year or two.
Why target the sick?
The governor's strategy, of course, follows the maxim that a relatively small percentage of chronically ill and elderly patients generally account for the bulk of health care spending. Thus the target, and the consequence, of the governor's proposed cuts go where the spending is.
The governor's restrictions on the Coverkids program that took effect Nov. 30 are equally harmful. CoverKids' current $115 million budget will remain intact for the 44,000 children already enrolled. But CoverKids is now shut to the 147,000 children who have not yet been brought onto the CoverKids' rolls, as had been intended.
CoverKids excludes 75 percent
Shutting out three of every four kids is not a laudable way to run CoverKids. It will jeopardize their health.
Gov. Bredesen for years has correctly preached the gospel of expanding early reading programs to bolster reading skills and academic achievement in a state that typically ranks in the bottom five nationally on school funding. Hampering child wellness for so many working families' children is contradictory. Children do not do well in class if they're sick. And SCHIP/CoverKids is designed to cover children in families that need health care.
SCHIP programs like CoverKids are largely funded by matching federal subsidies that generally provide dollars at a 3-to-1 federal-to-state ratio. They target children in families that earn too much to qualify for the TennCare/Medicaid program for the very poor, but make too little to afford insurance.
A most unconscionable path
Tennessee has disproportionately low rates of employer-subsidized insurance available to median-income working families. Thus we have a relatively high need for a robust SCHIP/CoverKids program. Gov. Bredesen's recent freeze directly harms the very working families and their children that most need public help to get insurance.
It is true, to be sure, that Gov. Bredesen must make deep cuts in all state programs to balance the budget. At least three dozen states remain in this quandary because the recovery from the worst recession since the Great Depression is and will continue to be slow, and joblessness is and will remain high, depressing consumer spending and tax revenue.
Still, taking those cuts out on sicker and mainly older poor people, and the children of working families without health insurance, is unconscionable. A modest tax increase of almost any sort would be infinitely preferable.