Poor in Peril as Tennessee Debates Health Care Cuts

Tennessee lawmakers and health officials debate the state's definition of "medical necessity." TennCare, the state's health program for the poor, is at the center of the debate. Jacqueline Fellows of NPR station WPLN notes that state officials say cuts are needed.

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RENEE MONTAGNE, host:

Tennessee's governor announced earlier this year that more than 300,000 people would be cut from the state's health-care program for the poor and uninsured. He blamed the cuts on several consent decrees that the state entered into years ago. By changing one of them, the governor says he'll be able to reduce the cuts by nearly a hundred thousand. Opponents don't believe him and say his changes will destroy the rights of poor patients. From member station WPLN, Jacqueline Fellows reports.

JACQUELINE FELLOWS reporting:

TennCare is the name of Tennessee's Medicaid program, at one time a model for showing other states how to take care of the uninsured. Now it's in federal court over how to reduce care and costs.

Tennessee entered into what's called the Grier Consent Decree five years ago. It gives the state's TennCare patients the right to appeal health-care decisions. TennCare officials are asking a federal judge to approve 20 changes to the Grier Consent Decree. They spent nearly two weeks in court trying to show that Grier's broad appeal provision essentially gives patients unlimited access to medical care. TennCare spokesman Michael Drescher.

Mr. MICHAEL DRESCHER (TennCare Spokesman): What we're trying to get away from is the flood of appeals we get that are not based on a factual inaccuracy. They're based on appealing the fact that I think I need a service even if it hasn't been prescribed by a physician. They can appeal that; it can go to hearing. We think that is not a wise use of finite resources.

FELLOWS: After a study showed that TennCare would consume 90 percent of new revenue by 2008, Governor Phil Bredesen cut 226,000 people from the program. Without the federal court's approval to change Grier, the governor says another 97,000 will also lose their coverage.

The Tennessee Justice Center is the small not-for-profit law firm that originally negotiated the Grier Consent Decree. They dispute the governor's claim that 97,000 will be saved and called on State Representative Joey Hensley to testify on their behalf. Hensley is the Legislature's only doctor. He sees about 70 TennCare patients a week. He told the court that Grier is not responsible for TennCare's runaway costs and that the governor's proposed changes are dangerous.

State Representative JOEY HENSLEY (Tennessee): I'm concerned people will die. There'll be thousands of patients without medical coverage. They will have to fend for themselves, especially rural areas. Lewis County, which I represent, and Lawrence County, part of Wayne County, they all have about 35 percent TennCare patients, and about 10 percent of those are going to lose coverage. So that's a considerable number in my district.

FELLOWS: A major point of contention is the state's proposed definition of medical necessity. Under Grier, the treating physician has the final say in determining a patient's course of therapy. Among the criteria the state says it will consider are cost and adequacy, two words that opponents say are absent from any other state's definition.

Andrea Morris(ph) is a 31-year-old single mother. Her seven-year-old daughter, Allie(ph), is autistic and a TennCare patient. Morris says it took years before finally finding a therapy that worked for Allie. Morris says she is scared her daughter will have to go back to something that doesn't work if the state's new definition is approved.

Ms. ANDREA MORRIS (Tennessee Resident): What works is not the least costly, and that's what scares me. If they're really interested in adequate, then we'll be OK. But if it has to be least costly, it's not going to be adequate.

FELLOWS: Closing arguments in the Grier hearing are scheduled for today and the judge says he will expedite his ruling.

For NPR News, I'm Jacqueline Fellows in Nashville.

MONTAGNE: This is NPR News.

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