1. Winokur, Julie

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Judy Ritchie had diabetes and thrombocytopenia. Heather Bridges had amyotrophic lateral sclerosis. These are just two of the Tennesseans who have died, some health care advocates say, as a direct result of being cut from TennCare, the state's expanded Medicaid program. And while the number crunchers celebrate the ostensible savings, patients, families, and communities face incalculable losses.

FIGURE. Shirley Elli... - Click to enlarge in new windowFIGURE. Shirley Ellis, age 59, and her husband, Loren, age 71, at the Vanderbilt-Ingram Cancer Center in Nashville, Tennessee. Recently dropped from TennCare, the state's Medicaid program, Ms. Ellis has been battling ovarian cancer for two years. She now faces losing access to chemotherapy, which costs $8,000 a month.

TennCare, an innovative program that had been mismanaged for the past decade, covered not only the traditional Medicaid population but also the "uninsurables"-people with preexisting conditions who didn't qualify for other insurance but weren't poor enough to qualify for Medicaid. By 2005 the program covered 23% of the state's residents-a higher percentage than in any other state. In November 2004 Governor Phil Bredesen announced that he would overhaul TennCare. Like governors nationwide, Bredesen was struggling with a health care budget that threatened to squeeze out other programs (TennCare accounted for one-third of the overall state budget). His remedy: slash 190,000 people from the TennCare roster of 1.3 million beneficiaries and limit those staying in the program to five prescription medications. The cuts were the single largest reduction in Medicaid since the program was launched.


J. D. Hickey, deputy commissioner of TennCare, announced last fall that the dramatic reduction in pharmacy benefits alone would save the state $1 billion a year. But as a result of the cuts, patients with cancer can't get their chemotherapy drugs, patients with epilepsy are without antiseizure medications, and people with multiple conditions are forced to choose which they will treat.


For Barbara Reinhardt, the result was devastating. "I just can't function without my psychiatric medications," she says. "I stopped taking my heart medications so I could get my other drugs." She had a heart attack within two months of discontinuing her blood pressure- and cholesterol-lowering medications. Her angioplasty cost the state tens of thousands of dollars; her medications would have cost hundreds.


A matter of politics.

Governor Bredesen, who earned millions as an HMO entrepreneur, was elected in 2002 on a platform of TennCare reform. Instead, he has used slash-and-burn tactics that have resulted in allegations of suppressed information, leaked memos about political maneuvering, and a no-bid contract to a drug-benefits giant. It seems that state officials didn't calculate the increased cost of having nearly 200,000 newly uninsured residents, many of whom are now showing up in clinics, EDs, morgues, and even the Davidson County Jail, where several young men found themselves after not taking required psychiatric medications.


Gordon Bonnyman, Jr., founder of the Tennessee Justice Center, a public interest law firm, says, "We're grossly overpaying the managed care organizations, and we're not holding the system accountable for the way it uses pharmacy services, the highest cost area of the program. It's coming out of the hides of the sickest and the weakest."


As part of a "safety net" for uninsured residents that the governor said would begin in January, $13.5 million was allocated to county clinics, enabling uninsured Tennesseans to visit the clinics for as little as $5. But the oversight committee for the safety net had yet to meet by late December, and the senator who initiated the committee had resigned in frustration.


TennCare has gone from one of the most expansive programs in the country to one that provides barely the minimum required under federal law. And other states are following suit: Florida received a waiver last fall that will enable the state to cap spending on a per-patient basis, and Missouri has announced plans to phase out coverage for 90,000 people.


Tennesseans like Loren Ellis, whose wife Shirley suffers from ovarian cancer and bipolar disorder and who has been cut from TennCare, are asking just how many lives must be sacrificed for the numbers to balance. The state granted Shirley extended benefits that expired in December, and then the Vanderbilt-Ingram Cancer Center in Nashville gave her three free treatments. After that, she's on her own.