Health Cuts Create Dilemma for Tennessee's Poor New limits on Tennessee's health coverage for the poor has created a painful dilemma for many. If you have restricted insurance, but several chronic illnesses, as Linda Warner does, how do you choose which one to treat?
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Health Cuts Create Dilemma for Tennessee's Poor

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Health Cuts Create Dilemma for Tennessee's Poor

Health Cuts Create Dilemma for Tennessee's Poor

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From NPR News, this is ALL THINGS CONSIDERED. I'm Robert Siegel.

We're going to begin this hour with a look at health care and one state's effort to provide it to the poor. Twelve years ago Tennessee made news with a bold experiment. The state guaranteed health insurance to every poor resident. Now Tennessee is again drawing attention, this time for revoking that guarantee. Last August, some 200,000 people were cut from its TennCare program and more than half a million are living with new limits on their health care.

NPR's Julie Rovner recently traveled to Cocke County to meet a woman who's living with the cutbacks.

JULIE ROVNER reporting:

Linda Warner's doublewide trailer is comfortable, if a bit cramped. The walls are covered with pictures of her children and grandchildren.

Ms. LINDA WARNER (Tennessee resident): That's something I enjoy.

ROVNER: All over the shag carpet are dozens of toys. They belong to her three-year-old great-grandson, Bryson.

Ms. WARNER: Turn around. Come on and help grandma with lunch.

Mr. BRYSON WARNER (Grandson of Linda Warner): I'm coming.

Ms. WARNER: Okay, come on buddy.

BRYSON: I'm coming.

ROVNER: Linda looks every bit the grandmother, with thick white hair piled on top of her head. She looks after Bryson most weekdays.

Ms. WARNER: Dry your hands, honey bunny. Here we go.

ROVNER: His father, Linda's grandson, drops him off each morning at 4:30 a.m. before driving an hour and a half to his own job. His mother works fulltime and studies to be a nurse.

Ms. WARNER: I don't see a fork. I don't see a fork.


Ms. WARNER: We're trying to be independent. We're trying to help and be as independent as possible.

ROVNER: Independence is important to Linda Warner. Even though she's in a wheelchair living on $600 a month in disability payments, she still makes time to help those in her community who have even less.

Ms. WARNER: I'm not totally useless yet. A lot of people see me sitting in a chair and they think I'm, you know, dead weight. Well, I'm not really dead weight. I'm involved in our church. I worked many, many hours and still volunteer, like do a lot of the paperwork, a lot of referrals, counsel a lot of people.

ROVNER: She does all this and looks after Bryson despite a series of disabling health problems. First came three failed joint replacement surgeries, then a case of pneumonia that's made it hard for her to breathe. And last year's TennCare cuts are threatening what little independence Linda Warner has left.

TennCare now limits adults to five prescriptions per month and only two of them can be brand name medications. That's one of the tightest limits anywhere in the country and it's forced Linda, who was taking eight different medications, to make some painful choices.

Ms. WARNER: I stopped taking the antidepressant. I stopped taking the medicine that I take for my stomach because I had a serious gall bladder surgery. The hormones to stop all the hot flashes and everything I don't get anymore. It's over my limit. So I had to change out and say, okay, what do I absolutely have to have? It comes down to me choosing what I absolutely have to have.

ROVNER: For most of the fall and winter after the cuts, things were bearable. Then in February, Linda Warner got sick.

Ms. WARNER: I thought maybe it was a sinus. I thought maybe it was just the change of weather. Well, I was taking some sinus pills and running the vaporizer, Vicks, anything that I thought would make the fever go away.

ROVNER: But the fever didn't go away and she'd already reached her five-prescription limit for the month so she resisted her family's urging to go see her doctor.

Ms. WARNER: My daughter said, please, mom, please. You're not getting better, she said. And I said I understand that, honey. I said, I can't get an appointment. That wasn't true. I can get an appointment anytime I call, but there's no sense in going to the doctor if you can't get the medicine.

ROVNER: By early March, she wasn't much better and when her fever reached 103, it was time to get help.

Ms. WARNER: So I went to see Dr. Williams and it was on a Thursday. And he fussed at me and asked me why I waited so long before I come and see him.

ROVNER: She turned out to have strep throat as well as a kidney and bladder infection. The doctor gave her a couple of injections, which don't count against her monthly drug limit. But he also gave her two prescriptions for antibiotics, which do count.

Ms. WARNER: So that means I have to decide for the month of March what I'm going to do without.

ROVNER: James Williams is Linda's doctor. He says she's hardly the only one of his patients with these problems.

Dr. JAMES WILLIAMS (Physician, Cocke County): I see it all the time. Patients who don't come in at all and you never know what happened to them. And then they show up critically ill in the emergency room with congestive heart failure or have had a heart attack or terrible pneumonia or their diabetes is out of control, their thyroid's out of control because they haven't taken their medicines.

ROVNER: So Linda gathered up all her prescriptions and her portable wheelchair, climbed in her car and went to the drugstore.

Ms. WARNER: I said them, I need you to fill these prescriptions for me but don't fill the bladder medicine. Even though I take it four times a day, it stops me from wearing a diaper, a disposable diaper and so and so forth. I really hate to do without the bladder medicine because I can't go anywhere without it. It makes it more bearable for me.

ROVNER: And along with the bladder medicine, she decided to skip her pain medication for the month. That way TennCare would cover the $28 worth of antibiotics she needed.

Ms. WARNER: You have to choose, you know? And I have to have the inhaler and I have to have the medicine because I have to breathe. It's okay that I'm wet, but I've got to breathe.

Dr. EDWARD CAPPARELLI (Physician, Cocke County): My next patient is a 61-year-old female who -

ROVNER: Dr. Edward Capparelli has a whole stack of files from patients in the same situation as Linda Warner.

Dr. CAPPARELLI: This is a younger patient. This patient actually is only 38 years old.

ROVNER: Capparelli practices family medicine at a community health center in nearby Parrotsville.

Dr. CAPPARELLI: It's very frustrating. It's especially frustrating when I know that some of the medications that we're choosing to leave out have long-term health implications. And so are we providing what would be the best care? No.

ROVNER: Since the drug limits took effect, he says he's spent almost as much time figuring out how to take people off medications as figuring out which medications to put them on.

Dr. CAPPARELLI: This is a real problem because actually the clock resets on the first of the month and so if you happen to get your medicines on the first of the month and then on the 15th, you get sick, you really are not allowed to get any more prescriptions on that limit until the first of the following month.

ROVNER: Capparelli says that for relatively healthy people, the five-prescription limit hasn't been much of a hardship.

Dr. CAPPARELLI: But for people that have more than one chronic illness, it's impossible to try to pick which is more important. And unfortunately, physicians have had to often choose for what's life threatening today and give up on what might be life threatening tomorrow.

ROVNER: Keeping them on the blood thinner Plavix, for example, to prevent a heart attack instead of a drug to prevent bone fractures from osteoporosis.

Dr. CAPPARELLI: Osteoporosis won't kill them tomorrow. A heart attack might.

ROVNER: You didn't learn this in medical school, I assume?

Dr. CAPPARELLI: No, there's no way to teach that and I don't think any two people sitting down would necessarily make exactly the same choices. Still and all, we're making the best of a series of bad decisions and certainly there's no way we can predict that the drugs that we take them off might not have some dire consequences to the patient down the road. You just have to make decisions and hope for the best.

BRYSON: I don't like that song. I like this song.

ROVNER: Despite her difficulties Linda Warner can get out of her wheelchair when she needs to, particularly when she's dealing with her rambunctious great grandson, Bryson.

Ms. LINDA WARNER: We're learning potty. We're learning to potty. Just give me a minute. Walking is kind of hard for me. I'm hoping that pretty soon he learns to use the wipes.

ROVNER: Linda manages a smile as she eases herself back into her wheelchair. She says she dreads the possibility she'll get sick again.

Ms. WARNER: I remember laying there with a high fever praying a lot. Like, you know God, I know it's your will, your will be done, but isn't it enough that I don't walk? Do I have to be so sick, you know, for a $28 prescription? I was sick for that long.

ROVNER: Did you really not have $28?

Ms. WARNER: I didn't have 28 dollars. I only get $600 a month, $352 goes to pay the mortgage and the mandatory insurance.

ROVNER: Then there's the phone, water and electric bills. Insurance for her aging sedan.

Ms. WARNER: By the time it's done, I have, I have $9.75 left out of my budget. And if the truth be known, that $9.75 has to go for Pauly's pads. And that's what it comes down to. So people who say only $28, well yeah when you only have $9, it's no way to stretch.

ROVNER: And Linda won't take money from her children who work long hours and barely get by themselves.

Ms. WARNER: How do I ask a boy who's paying $150 for his son's medicine, or Cindy, who's paying you know $92 for her daughter's medicine? That makes them do without for me. See because they're children, they can't cope. I set, if I have to set on a waterproof pad all day, it's okay, but I won't ask children to do that.

ROVNER: In fact what pains her the most about her ill health is how it stops her from helping others.

Ms. WARNER: It affects my family. It affects my volunteers. It affects my friends. It affects my church. You know, just not Linda. It, it ripples right out to everybody.

ROVNER: That ripple may be hurting people like Linda Warner, her family and her community, but it's helping Tennessee's bottom line. Last year's TennCare cuts helped produce a $266 million budget surplus. The cut saved so much that Democratic Governor Phil Bredeson is looking to put some money back into healthcare.

But the governor says his first priority is not to help people like Linda Warner, who are struggling under the TennCare limits. Instead, he's aiming at the 600,000 to 700,000 Tennesseans who currently have no health insurance at all.

Governor PHIL BREDESON (Tennessee): It's always struck me as odd that we argue about whether somebody gets five, six or seven prescriptions in one group of people and totally ignore several hundred thousand other Tennesseans who are also uninsured and who, you know, get cancer, have high blood pressure and get heart disease, too.

What I'm trying to do is get you know the basic, most important benefits into the hands of every Tennessean who needs them before we worry about you know the fringes and the add-ons to any one given insurance program.

ROVNER: In other words, people like Linda Warner. And the governor says while he's sympathetic to her plight, TennCare had simply become too expensive for the state to support.

Governor BREDESON: We're trying in this very difficult situation of, you know, a TennCare which had just gotten totally in the ditch, we're trying to address these issues in a reasonable, sensitive way. And I think we're frankly doing a better job than a lot of the big states in terms of what we are able to provide.

ROVNER: The state has announced it will ask the federal government for permission to relax some of the prescription limits for those on TennCare. But even if those changes are approved, it's not clear whether Linda Warner's case will be "unique and complicated enough" to allow her to get all the medications her doctor prescribes.

Julie Rovner, NPR News.

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