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Wednesday, October 22, 2014         

NEW YORK TIMES


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Tennessee race for Medicaid: Dial fast and try, try again

By ABBY GOODNOUGH

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NASHVILLE, Tenn. » Two nights a year, Tennessee holds a health care lottery of sorts, giving the medically desperate a chance to get help.

State residents who have high medical bills but would not normally qualify for Medicaid, the government health care program for the poor, can call a state phone line and request an application. But the window is tight — the line shuts down after 2,500 calls, typically within an hour — and the demand is so high that it is difficult to get through.

There are other hurdles, too. Applicants have to be elderly, blind, disabled or the "caretaker relative" of a child who qualifies for Medicaid, known here as TennCare. Their medical debt has to be high enough that if they paid it, their income would fall below a certain threshold. Not many people end up qualifying, but that does not stop thousands from trying.

"It's like the Oklahoma land rush for an hour," said Russell Overby, a lawyer with the Legal Aid Society in Nashville. "We encourage people to use multiple phones and to dial and dial and dial."

The phone line opened at 6 p.m. on Thursday for the first time in six months. At 5:58, Ida Gordon of Nashville picked up her cordless phone and started dialing. Gordon, 63, had qualified for TennCare until her grandson, who had been in her custody, graduated from high school last spring. Now she is uninsured, with crippling arthritis and a few recent trips to the emergency room haunting her.

"I don't ask for that much," Gordon said as she got her first busy signal, hanging up and fruitlessly trying again, and then again. "I just want some insurance."

Gov. Bill Haslam, a Republican, has indicated that he will decide this week whether to support an expansion of Medicaid to cover more low-income adults, as called for in the federal health care law. Doing so would add more than 180,000 people to the TennCare rolls by 2019, according to the state, most of them adults like Gordon whose incomes are within 138 percent of the federal poverty level.

Gordon said she and her husband, who was injured on the job decades ago and is on Medicare, live mostly on his disability check of about $780 a month.

TennCare already provides health coverage to 1.2 million people, more than half of whom are children, at a combined state and federal cost of about $9 billion a year. Many in the Republican-controlled Legislature, which includes a strong Tea Party element, oppose its expansion even though the federal government has promised to pay the full cost for the first three years and 90 percent after that.

Opponents of the health care law here, as in other states, say Washington cannot afford to keep that promise. In Tennessee, the debate over expansion is particularly contentious because of TennCare's tumultuous history. It was once among the most generous Medicaid programs in the country. But costs spiraled, and 170,000 people were cut from the rolls in 2005 under Gov. Phil Bredesen, a Democrat. It was a painful episode that Haslam said was "weighing on a lot of people's minds." Gordon hopes to qualify for a program known as a "spend down" — in which a patient's qualifying income is determined after they subtract their medical costs from their total earnings. The program covers only a tiny portion of TennCare recipients — about 1,000 people, at a cost of $32 million a year. It is also something of an anomaly: While other states have similar programs, most do not limit the enrollment period to brief and infrequent call-ins. Advocates for the poor say the frenzy for the spend-down program is a reminder of the acute need for health coverage everywhere.

"At the end of the day, huge numbers of desperately ill people are being left out in the cold," said Gordon Bonnyman, the executive director of the Tennessee Justice Center, an advocacy group for families in need that focuses on access to health care. "And that is a story in every state."

Kelly Gunderson, a TennCare spokeswoman, said that the spend-down program had enough money to cover 3,500 people, but that only about 1,000 were enrolled at any given time because the screening process was so complicated. The screeners, she said, must examine medical bills and records, among other duties.

About 500 people are found to be eligible for the program each time the state opens the phone line. The line has opened six times since the program started in 2010. Technical glitches can thwart callers' chances. According to the Tennessee Department of Human Services, which operates the phone line, callers did not start getting through until6:38 p.m., and 2,500 calls, the maximum, had been received by 7:23. The department is investigating what caused the glitch, a spokeswoman said.

"People started calling here panicked and crying," said Michele Johnson, a lawyer with the Tennessee Justice Center. "We told them, ‘Just hang on, keep trying."'

Adrian Casteel of Nashville, who said he owed $6,000 in medical bills, said he heard the recording repeatedly but kept dialing. Casteel, 55, has a heart condition and a steel plate in his back, the result of a car accident years ago that left him in constant pain and unable to work. He has been on Medicare for nine years because of his disability, he said, but about 20 percent of his expenses are not covered.

"When you see as many doctors as I do," he said, "that's quite a bit."

In her small brick home on the city's north side, Gordon also heard the recording that enrollment was closed. But she, too, persisted, never looking up from the phone in her hand. Dusk fell and the room grew dark; she was too focused to bother turning on a light.

She had called about 50 times when, at 6:40, she got through. The woman on the other end of the line asked for Gordon's name, birth date, Social Security number, telephone number and address. Gordon wrote down a confirmation number, thanked her and hung up. The application, she was told, should arrive in a few weeks.

"I still don't know if I'm getting in," she warned her husband, Arthur. "If it's meant to be, it's meant to be."

If she is rejected for the spend-down program, Gordon said she would wait until next year, when President Barack Obama's health care law is supposed to make insurance more accessible to millions of low- and middle-income Americans. She does not know specifics, like the possibility that she could be covered by an expansion of Medicaid or qualify for federal subsidies to help cover the cost of private coverage. But she said she would eagerly pay what she could for insurance if it was within her limited budget.

"I can't pay no $200, $300, $400 a month," Gordon said. "But I'll figure out how to pay something if I got to. I'll squeeze."






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