TennCare, One State's Experiment with Medicaid Expansion

Christina Bennett

Description

A history of the struggle among competing stakeholders in one of the oldest and most controversial experiments in US health care policy, a precursor to ObamacareIn 1993, Tennessee launched a reform initiative designed to simultaneously expand the proportion of residents with health insurance and curtail cost increases. It was guided by principles that nearly match those that guided the creation of the Affordable Care Act, also known as Obamacare. Like the ACA, TennCare used corporations, rather than a single government payer, to implement the plan, and it relied on a mix of managed care, market competition, and government regulation.

While many states cut back on their Medicaid enrollments from 1993 to 2001, TennCare grew from 750,000 to 1.47 million enrollees. The state was less successful in controlling costs, however. Each major stakeholder group (the state, the managed care organizations, the providers, and the enrollees and their advocates) pushed back against parts of the state's strategy that adversely affected their interests, and they eventually dismantled the mechanisms of cost constraint.

The author lays out the four stakeholder perspectives for each period in the history of TennCare and provides a link to difficult-to-access primary documents.

Sujets

• Public Policy
• Health Care Issues
• Region
• Health
• Regional
• History
• Fitness

Informations

• Publié par: Vanderbilt University Press
• Date de parution: 29 septembre 2014
• Nombre de lectures: 1
• EAN13: 9780826520043
• Langue: English

Extrait

TENNCARE, ONE STATE’S EXPERIMENT WITH MEDICAID EXPANSION
TennCare, one state’s experiment with Medicaid expansion
Christina Juris Bennett
Vanderbilt University Press
NASHVILLE
© 2014 by Vanderbilt University Press
Nashville, Tennessee 37235
All rights reserved
First printing 2014
This book is printed on acid-free paper.
Manufactured in the United States of America
Library of Congress Cataloging-in-Publication Data on file
LC control number 2013041120
LC classification number KFT187.H4A3 2014
Dewey class number 368.4'2009768—dc23
ISBN 978-0-8265-2002-9 (hardcover)
ISBN 978-0-8265-2003-6 (paperback)
ISBN 978-0-8265-2004-3 (ebook)
This book is dedicated to my family, who taught me about the struggles within the health care system and supported me through this process. A special dedication goes to Ella, my perpetually patient sidekick .
Contents
Preface
Introduction
1. From Medicaid to TennCare: 1965–1993
2. Implementing the Plan: Getting TennCare Running: 1994–1998
3. The Disintegration of Control: 1998–2002
4. Keeping the Program Alive: 2002–2005
5. Rebuilding the System: 2005–2010
Epilogue: 2010–Present
Conclusion
Appendix: Methods for Teaching This Case Study
Notes
Index
Acknowledgments
I COULD NOT HAVE BEGUN OR COMPLETED this publication without the tireless effort of Roger L. Conner, who has taught me about scholarly research, health care, and conflict resolution. His ever-encouraging spirit made this book possible. I also want to thank two students: Alexandra Vuxton, the Vanderbilt University Law student who helped me fill in blanks and figure out enigmatic citation forms for various sources, and Cody Wilson, the University of Oklahoma College of Public Health graduate who helped me with graphs, tables, financial analysis, and editing in the final hours. Finally, I extend a special thanks to the Cal Turner Family Foundation for timely support for the Common Ground Cases project and to Search for Common Ground for its administrative role. Thank you.
Preface
IN 1993, TENNESSEE AND OTHER STATES FACED a fiscal and policy crisis when Congress changed the law to disallow strategies by which the state had expanded its Medicaid programs at federal expense. Most states shrank eligibility rules during this period, but Tennessee embraced an innovative idea being advanced by newly elected president Bill Clinton: that it would be possible to expand the number of people covered by health insurance without increasing total expenditures for health care. Increasing coverage would eliminate the need for many expensive treatments, and managed care would squeeze out inefficiency and reduce per capita costs. From 1994 until the present, TennCare, Tennessee’s Medicaid program, operated under a federal waiver, has been a laboratory for health care reform.
Throughout the years, enrollment in TennCare grew to nearly 1.5 million citizens. However, what had begun as a collaboration of sorts in 1993 soon devolved into a polarized conflict where each stakeholder group felt that the state was asking it to sacrifice unfairly and fought hard to protect its own interests. Doctors periodically threatened to withhold services unless fees were raised; safety net hospitals laid off hundreds of workers and closed entire specialties; insurance companies went bankrupt and failed to pay their bills, blaming inadequate capitation rates; and patient advocates filed lawsuits protesting the state’s alleged failure to provide services guaranteed by the Medicaid Act.
The governor’s attempts to restrain per capita costs through regulatory reform and to increase revenues through a new state income tax were rebuffed. After 2002, the state met projected deficits by disenrolling 250,000 people and restricting available benefits.
TennCare is a paradox for students of public policy. Every major stakeholder group in the state lamented the loss of care for needy patients; each insisted that most of the cutbacks could and should have been avoided; and each still insists, with equal fervor, that the other stakeholder groups or the state officials bear all of the blame.
Author Christina J. Bennett does not choose between these competing claims. Her purpose is to allow readers to decide for themselves the “lessons to be learned” from this important experiment.
TennCare, One State’s Experiment with Medicaid Expansion is an intellectual feast for scholars and students who are interested in policy-oriented learning and change over very long periods of time. Teachers in particular will be delighted with a level of detail in the footnotes that is normally found only in law journals.
The most important audiences for the book are leaders, activists, intellectuals, and journalists concerned with health care policy. For them, TennCare, One State’s Experiment with Medicaid Expansion is a cautionary tale because the consequences of policy failure in this arena are not abstract. As a result of the decisions chronicled in this book, important businesses went bankrupt, whole sections of safety net hospitals were shut down, medical school education suffered irreversible losses, people with treatable illnesses became sicker and died, and thousands of doctors were forced to choose between paying their bills and practicing the healing arts.
The most important finding of Bennett’s case study is that the key players wanted TennCare to succeed. To this day, virtually all of them insist not only that the outcomes were suboptimal but also that they were avoidable . Although mendacity and ordinary greed played their parts, this is not primarily a story of “right versus wrong” or “good versus evil.” It is more like a tragedy. Despite their best efforts, a group of reasonably skillful people with mostly decent intentions could not collaborate to secure the outcomes that they wanted for themselves and for others.
As America prepares for the implementation of health care reform in 2013, the questions raised by this case are more urgent than ever. Are the participants correct that some of the failures could have been avoided? Could the players have uncovered win-win outcomes by more effective collaboration? How important was the polarization and beggar-thy-neighbor, finger-pointing advocacy? Can anything be done to encourage policy-oriented learning and foster collaboration in the future? If polarization is not inevitable in the current political context in the U.S., what would it take for the leaders to escape the trap in the next round of decision making?
Christina Juris Bennett’s book is an important resource for everyone interested in finding answers to those questions.
Roger L. Conner
Adjunct Professor of Law, Vanderbilt Law School
Introduction
IN MARCH 2010, PRESIDENT BARACK OBAMA SIGNED the Patient Protection and Affordable Care Act and the Health Care 1 and Education Reconciliation Act. 2 The Affordable Care Act (ACA), as the Obama Administration refers to the combination of both bills (known as “ObamaCare” to the act’s opponents), 3 was intended to increase the number of Americans with health care insurance while reducing the growth rate of national expenditures for the delivery of health care services. 4 Mechanically, the act imposed an individual mandate for every citizen to have some type of health care insurance or pay a fine, and it strongly induced the states to expand their Medicaid coverage limits to 133 percent of the federal poverty limit. 5 The act also provided for preventive care, eliminated insurance denials for preexisting conditions, and contained other such consumer-friendly provisions. 6 The policy underpinnings of this act were to:
(1) Achieve near-universal coverage and to do so through shared responsibility among government, individuals, and employers . . .
(2) Improve the fairness, quality, and affordability of health insurance coverage . . .
(3) Improve health care value, quality, and affordability while reducing wasteful spending and making the health care system more accountable to a diverse patient population . . .
(4) Strengthen primary health care access while bringing about longer-term changes in the availability of primary and preventive health care [and]
(5) Make strategic investments in the public’s health, through both an expansion of clinical preventive care and community investments. 7
This act proved to be quite controversial, and opponents immediately sounded the alarm of individual rights being trampled by the government. Individual citizens filed lawsuits against having to pay a fine if they continued without health insurance, and state attorneys general sued on the theory that the Medicaid inducement was actually a requirement that violated federalism. 8 These claims coalesced into one large lawsuit titled National Federation of Independent Business v. Sebelius, Secretary of Health and Human Services . 9 Separating out the preliminary issue of taxation versus fine, the United States Supreme Court decided on June 28, 2012 (a presidential election year), that the individual mandate was constitutional under the taxation powers but the Medicaid expansion was unconstitutional for violating federalism principles. 10 (The unconstitutional mandate was permitted to be severed from the act so that the residual constitutional components remained.) Despite the Court’s ruling, many Republican leaders (including presidential nominee Mitt Romney) vowed in their campaigns to overturn the Affordable Care Act. As the election approached, the states refrained from most action related to the ACA. In November 2012, President Barack Obama was reelected, and the Affordable Care Act remained the law of the land. At this point, the