Tennessee Race for Medicaid: Dial Fast and Hope

On two nights each year, Tennessee holds a health care lottery, giving the medically desperate a chance to receive help.

State residents with high medical bills that would not typically qualify for Medicaid can call a state phone line and request an application. But it’s not easy — the line shuts down after 2,500 calls, typically within an hour — and with such a strong demand it is difficult to get through.

(Related: Medicaid expansion in trouble in Mich. Legislature)

Increasing the difficulty, applicants must be elderly, blind, disabled or the “caretaker relative” of a child who qualifies for Medicaid, known in Tennessee as TennCare. Their medical debt must be high enough that if paid, their income would fall below a certain threshold.

“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 dialed from her cordless phone. Ms. Gordon, 63, had qualified for TennCare until her grandson, previously in her custody, graduated from high school last spring. Now she’s uninsured, with crippling arthritis and a few recent trips to the emergency room hanging over her head.

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

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Gov. Bill Haslam, a Republican, has indicated that a decisions will soon be made whether to support an expansion of Medicaid to cover more low-income adults, as called for in the federal health care law. In the event of Medicaid expansion, more than 180,000 people would be added to the TennCare rolls by 2019, according to the state, most of them adults like Ms. Gordon whose incomes are within 138 percent of the federal poverty level.

Ms. 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.

Currently, TennCare provides health coverage to 1.2 million people, more than half of whom are children, at a combined state and federal cost of $9 billion a year. Even though the federal government has promised to pay the full cost for the first three years and 90 percent after that the expansion is opposed by many in the Republican-controlled legislature, which includes a strong Tea Party element.

The opposition argue that Washington cannot afford to keep their health care law 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, until costs spiraled, and 170,000 people were cut from the rolls in 2005 under Gov. Phil Bredesen, a Democrat.

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Ms. 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 totals earnings. The program covers only a tiny portion of TennCare recipients — close to 1,000 people, at a cost of $32 million a year. It is also a bit 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 argue the frenzy for the spend-down programs is a reminder of the apparent 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 sufficient budget to cover 3,500 people, but that only about 1,000 were enrolled at any given time due to the complicated screening process. The screeners, she said, must examine medical bills and records, among other duties.

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Roughly 500 people are deemed eligible for the program each time the state opens the phone line. The line has opened six times since the program started in 2010.

Callers’ chances are often thwarted by technical glitches. According to the Tennessee Department of Human Services, callers did not start getting through until 6:38 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 claimed he owed $6,000 in medical bills, said he repeatedly got a recorded message but kept dialing. Mr. Casteel, 55, has a heart condition along with a steel plate in his back, the result of a car accident years ago that rendered him in constant pain and unable to work. For nine years he has been on Medicare 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.”

Ms. Gordon also heard the recording that enrollment was closed, but persisted, never looking up from the phone in her hand. She had called about 50 times when, at 6:40, she got through. The woman on the other end of the line asked for Ms. Gordon’s name, birth date, Social Security number, telephone number and address. Ms. 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 rejected for the spend-down program, Ms. Gordon said she would wait until next year, when President Obama’s health care law is supposed to make insurance more accessible to millions of low- and middle-income Americans. But even then, she wouldn’t know the 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. She offered that 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,” Ms. Gordon said. “But I’ll figure out how to pay something if I got to. I’ll squeeze.”

Read more: http://www.nytimes.com/2013/03/25/us/tennessee-holds-health-care-lottery-for-the-poor.html?nl=todaysheadlines&emc=edit_th_20130325&_r=2&

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