The Leadership Conference on Civil and Human Rights

The Nation's Premier Civil and Human Rights Coalition

The Leadership Conference on Civil and Human Rights  & The Leadership Conference Education Fund
The Nation's Premier Civil and Human Rights Coalition

Tenn. Medicaid Changes Could Have Detrimental Effect Nationwide

Feature Story by civilrights.org staff - 6/15/2004

Changes to Tennessee's Medicaid system, TennCare, could set a dangerous precedent nationwide, according to groups at a June conference sponsored by the Center on Budget and Policy Priorities.

Gordon Bonnyman of the Tennessee Justice Center and national organizations in support of equal access to health care, including the National Women's Law Center and Children's Defense Fund, said that because TennCare's changes go beyond what federal law allows, the changes could be referred to as federal waivers.

According to Bonnyman, the bill in Tennessee that amends TennCare offers a limited definition of "medical necessity;" restricts drug benefits for enrollees in TennCare; and establishes the TennCare Foundation, which allows eligible private health care providers to render services for TennCare enrollees who cannot afford them or are newly ineligible for them due to the bill.

One change to TennCare redefines "medical necessity" to require TennCare to cover the "least costly" treatment which "need not be based upon the prevailing practice of any geographic area." The new definition diverges from the past definition, said Bonnyman, which allowed for coverage of the most "cost effective" treatment.

Bonnyman also objected to the sovereignty of TennCare, rather than the health care provider, to come to a final decision on necessary treatments. According to the bill: "The fact that a provider has prescribed, recommended or approved a medical item or service does not, in itself, make such an item or service medically necessary."

In sum, Bonnyman said, TennCare administrators are saying, "Medical necessity is what we say it is on a case by case basis. Get over it."

The proposal also prohibits coverage of off-label drugs—drugs used for purposes other than those for which the drugs received FDA approval—and any alternatives to the generic brands of medication, according to the bill's transcript.

The bill also could disallow coverage of preventative care and pain management such as gastric acid reducers and antihistamines.

Preventative care includes immunizations, newborn hearing screens, developmental screens, diabetes screening, pap smears, mammograms and more, according to CBPP. CBPP also maintains that, under the proposed definition of "medical necessity," pain medications for the terminally or chronically ill, epidurals, and nausea medication for the side effects of chemotherapy will no longer be covered by TennCare insurance.

Children with cystic fibrosis, cancer, and other serious diseases often suffer from stomach ulcers. Without gastric acid reducers, the CBPP writes, these children could incur gastrointestinal bleeds and, in extreme cases, die. Antihistamines, which the waiver also strikes from the list of insured treatments, are necessary to control severe allergic reactions and asthma.

The third major change to TennCare establishes the TennCare Foundation. According to Bonnyman, though the TennCare Foundation is supposed to act as a safety net, there is not adequate funding to operationalize it. Further, almost all Latinos and almost one-third of African Americans do not have a private medical provider, leaving these groups unable to benefit from the TennCare Foundation at all.

AARP Tennessee said that though they appreciate that changes need to be made to TennCare, there are still "enormous issues to be resolved."

The proponents and opponents of TennCare's changes agree that TennCare needs massive reworking in order to become financially viable. But Bonnyman and his colleagues believe that the proposed bill will undermine the program's goals. Further, they worry that changes to Tennessee's Medicaid system could affect nationwide Medicaid policies.

"We have to do something about this, because this is the biggest change I've seen to our health care system in a very, very, very long time," said CBPP's Bridget Taylor.

"Can we get an 'Amen'?" replied Bonnyman, as the room erupted in applause.

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