Embargoed Until:
May 22, 2007
12:01 a.m. Eastern Time



Christopher Fleming

TennCare’s Flawed Structure Doomed The Program, Says Tennessee Governor

In Health Affairs Interview, Bredesen Also Discusses His State’s New Front-Loaded Coverage Initiative And Other Topics

Bethesda, MD -- Many of those who lost TennCare coverage when the state cut the program had access to other insurance, Tennessee Governor Phil Bredesen (D) says in an interview published today on the Health Affairs Web site.

Bredesen expresses frustration with TennCare enrollees “who were working on their own, or for some company that didn’t offer insurance” but “were perfectly capable of working someplace that does offer health insurance. This world is full of people who make choices about where they’re working based on things like availability of pension plans and health insurance. I don’t see why people in Tennessee should be immune from those same choices,” Bredesen tells Alan Weil, executive director of the National Academy for State Health Policy.

You can read Weil’s interview of Bredesen at http://content.healthaffairs.org/cgi/content/abstract/hlthaff.26.4.w456

“There was an active business in Tennessee -- there was even a price set, it might have been sixteen dollars -- of going to agents and getting a letter saying you’re uninsurable, which is all it took to get on TennCare,” Bredesen says. Begun in 1994, TennCare is a once-pioneering but now troubled Medicaid expansion program that aimed to cover many uninsured Tennesseans using redirected hospital payments and savings from introducing managed care and capitation into the state’s Medicaid program.

“The idea of TennCare, as it was implemented, failed. It was always more about federal reimbursement than about changing the way health care is delivered,” says Bredesen. The governor, a former managed care executive, tells Weil, “I really believe in managed care, even today. But with the way TennCare’s managed care was structured” -- with inexperienced and undercapitalized health maintenance organizations (HMOs) that had been started to deal with TennCare -- “you could see the end coming early on.”

TennCare is only one of several topics covered in Weil’s wide-ranging conversation with Bredesen, a second-term Tennessee governor who also served as mayor of Nashville. Other subjects include health information technology; reforms in the way physicians and nurses are licensed; and Tennessee’s new coverage expansion initiative, Cover Tennessee, which offers generous front-end coverage but no catastrophic coverage and annual caps of $10,000 and $15,000, depending on which policy is chosen.

Other Interview Highlights:

Cover Tennessee. Bredesen explains that Cover Tennessee is aimed at the bulk of Tennessee’s uninsured population, who “overwhelmingly” have full-time jobs and tend to work for small employers. Bredesen explains: “We said, Let’s not create an entitlement program, and let’s not say what benefits we think they ought to have, and then hop on that horse and see where it takes us. Instead, we’re going to say, Here’s how much money we have to spend.” The program’s $150 monthly cost is split in thirds between the state, the employer, and the employee, but there is also a “a big personal-responsibility component, where people pay more if they’re substantially overweight or if they smoke,”

Bredesen explains that Cover Tennessee’s benefits are front-loaded because “we did focus groups” and found that people “weren’t interested in paying money for some catastrophic thing when they’re probably going to get taken care of by the hospital anyway. They really did want some benefits that they could see in the next month. So we structured it that way. In that regard it is probably different from any of these other low-benefit kinds of programs around.”

Weil asks: “What happens to the person with the heart attack, the person with the motorcycle accident?” Bredesen responds: “The same thing that’s happening to them now. Which is, they’re going to go into a hospital, and they are going to be one of those uninsured people, and the hospital is going to provide the care. They may be bankrupted by it, but they’re no worse off on those things than they are today, and they’re much better off on all the front-end things.” Bredesen adds that he has been talking to health and human services secretary Mike Leavitt -- who instituted similar front-end-loaded coverage when he was governor of Utah -- about making “some sort of catastrophic wrap-around available to people.”

Health information technology. Weil asks whether overly quick federal standardization in the health IT area could stifle state-level experimentation. Bredesen responds: “There’s a difference between the freedom to experiment with things and some level of standardization. . . . If the federal government were to set some basic standards, drawing on the best practices and the best ideas around, it really would free up a lot of creativity at different levels, which is now just going into complexity and competing systems.”

Provider licensing reforms. Bredesen cochairs the National Governors Association’s State Alliance for E-Health. He says that “if we could do one concrete thing, it might be to create some model for licensure” of medical professionals that works well “in a world where information usually flows across state lines.” The governor explains: “We’re not going to try to change the entire licensure system and say that licenses are reciprocal. But we certainly might say, when you’re dealing with certain kinds of information across state lines, here’s how the liability issues work; here’s how the licensure issues work.”


Health Affairs, published by Project HOPE, is the leading journal of health policy. The peer-reviewed journal appears bimonthly in print with additional online-only papers published weekly as Health Affairs Web Exclusives at www.healthaffairs.org.


©2007 Project HOPE–The People-to-People Health Foundation, Inc.