Up@dawn 2.0

Tuesday, February 24, 2015

Healthcare programs within USA

                My part of the project in my group is to talk about one of the largest healthcare benefits organizations in the American healthcare system and how it has changed over time, TennCare. My family used to participate in this program at some point in time and I thought it was perfect to look up the history of what I once was a part of. Tenncare has an overall goal of giving people healthcare benefits and insurance to the people who need it most. The one thing that has changed over time is the ideal situation and people that they could do something about. Over time, it has created 18 programs to help those in need. Just to give an idea of the history of Tenncare and changes in eligibility and benefits over time, here’s a summary I made of the changes that have occurred. One thing that I did not know before was that Tenncare, a major health care organization, is made up of multiple health organizations. So while looking into the history, you will find out some organizations left, some disappeared forever and new ones and came in over time to help out. Also, the history further reveals the importance of a role of being a health care provider. Your words in the future may honestly bring stability to state or national funding programs for health care. Your opinion WILL play a major role in shaping society in some form in the future.

Tenncare was implemented in 1994 and at first covered three programs: Group 1(Medical Eligibles), Group 2(Uninsured people who lacked access to insurance of a prior date-March 1993- and still continued to lack access) and Group 3(Uninsurable people who were turned down for health insurance due to certain medical conditions).In December 1994 Tenncare almost reached its capacity for the uninsured category and couldn’t accept anyone else, but if you were on Medicaid at the time and were about to lose and fit the uninsured category, you were allowed to continue the program. This was when TennCare possibly realized that they need to be more specific about benefits to make sure the ideal capacity is reached. Tenncare expanded to have services for substance abuse and mental health in 1996. An agreed order known as Grier had helped people in appealing denials they had gotten from the program and in April 1997 uninsured children under the age of 18 could get Tenncare. There wasn’t any income limit for anyone in this category, but if you were over poverty level, cost sharing was required. In May 1997, enrollment was opened to dislocated workers, who were defined as people who lost work through a bonafide plant closing. By January 1998, uninsured children’s category was extended to 19 years of age with same rules applying as before. Also if parents had insurance, had a family income 200% below poverty level, and the children did NOT have insurance, they could get insurance. If income was above that level, cost sharing was need in family. Xantus, one of third largest medical care organizations, was placed in receivership under Tenncare by March 31, 1999. Prudential, a small medical care organization, gave notice in June 1999 that it would be leaving Tenncare. It only served people in the Shelby County area. By November 1999, Xantus was struggling to pay health care providers for participants in its programs so the state of Tennessee gave it $26 million as a loan to pay providers. By December 1999, Blue Cross Blue Shield, one of TennCare’s largest Medical care organization gave notice it was leaving but it withdrew its termination. By January 2000, the governor, Sundquist arranged a 17 member commission on the future of Tenncare to figure out what to do when Tenncare waiver expired in 2001. By March 2000, Sundquist hosted a  summit on the future of Tenncare to gather ideas from hospital executives, doctors, managed care executives and tennessee lawmakers to get ideas for the program in the near future. A man named John Tighe proposed the idea of Tenncare II. It outlined a business model that called for more accountability in the program in May 2000. Also during this time, Tenncare had been approved for children heald under state custody(foster care; children removed from homes). By July 2000, pharmacy benefits for dual eligibles were taken out of the MCO program. This meant that if you were trying to  use benefits in two different Tenncare related programs, you couldn’t use two at the same time to get certain medicines. By September 2000, multiple MCO’s denied the implementation of Grier to be appealed. By November 2000, Commission on the Future of Tenncare presented its ideas to the governor. By July 2001, Tenncare acquired two operational MCOs: Better Health Plans and Universal Care. By July 2002, Tenncare was altered in the following matter:
 “TennCare was revamped with the intention of dividing it into three programs: one for Medicaid eligibles (TennCare Medicaid), one for demonstration eligibles (TennCare Standard), and one for low income persons who needed help in purchasing available insurance (TennCare Assist). Each of the programs was to have a separate benefit structure.
TennCare Assist has not yet been funded, and the TennCare Standard benefit package has not been implemented due to a settlement agreement reached in Federal Court. All persons enrolled in TennCare currently have the same package of benefits.
Eligibility changes in the new program included the following:
A new Medicaid eligibility category was added. This category covered uninsured women under the age of 65 who had been determined by a Centers for Disease Control (CDC) site to be in need of treatment for breast or cervical cancer. There was no income limit on this category for Medicaid, although CDC required that women receiving screenings at a CDC site have incomes below 250% poverty. Medicaid eligibles have no cost-sharing requirements.
The category of "Uninsurables" was replaced by a category called "Medically Eligibles." New persons can enroll in this category if they do not have insurance, they meet "ME" criteria, and their incomes are below the poverty level. Medical eligibility must be proven through a medical underwriting process, rather than being proven simply by a "turn-down" letter from an insurance company.
The definition of "Uninsureds" was tightened by providing a more restrictive definition of the term "insurance." Certain groups of uninsured people who were already on TennCare were "grandfathered" into the new program.
Persons losing Medicaid eligibility or already enrolled in TennCare in some other category on July 1, 2002, were allowed to remain on the program if they were uninsured AND their incomes did not exceed 100% poverty for adults and 200% poverty for children OR if they were determined to be "medically eligible" at any income level.
New enrollment in the Uninsured category was closed. Provisions were made for an annual open enrollment period for low-income people in this category, depending upon the availability of legislative appropriations.
A process called "reverification" was begun whereby all persons in the demonstration population were asked to make appointments at the Department of Human Services so that DHS could determine whether these individuals were eligible for Medicaid, eligible for TennCare under the new criteria, or no longer eligible for TennCare under the new criteria.”(Citation: tn.gov)
                                              Figure 1: Example of some of TennCare's programs

By October 2002, Tenncare had acquired dental care benefits. All Pharmacy services had been moved to one Pharmacy benefits manager by July 2003. By 2004, more regulations were placed over pharmaceuticals and adults in the uninsured category. Children who were uninsured got to keep same benefits while restrictions were made more tightly around adults, especially eligibility into the uninsured category. Another reform called TennCare Transformation was proposed in 2004, but unless certain modifications were made, it was not going to get enacted. The governor did not want to pursue these modifications, so he was planning to drop Tenncare as a whole and just focus on Medicaid, but he did not want to leave children without benefits. In 2005, they closed the non-pregnant adult medically needy category of its programs because of expenses. In 2006, they broughtthis program back by creating an initiative to lower spending. In 2008, home health and nursing services were limited. By May 2009, re-verification forms were set in place so that TennCare can determine on a yearly basis if enrollees are still eligible for program. For those who lost eligibility, they still had benefits through MediCare. In February 2010, Affordable Health care Act was passed, which greatly impacted Tenncare. In the same month, TennCare submits Amendment nine for requests in benefit reductions and elimination of most adults participating in Tenncare. TennCAre choices in Long-Term Care program was available for people in Middle Tennessee by 2010. It provided community and home based services for people in need. The General Assembly had also passed in 2010 a hospital assessment for hospital that will generate revenue for TennCare because of the recession. By May 2010, TennCare had more than enough revenue to survive, so Amendment 9 was no longer necessary. By December 2010, Tenncare implements Public Hospital Supplemental Payment program, which was passed by submitting Amendment 11. By February 2011, Tenncare submits Amendment 12 to limit adults in program to state budget. By July 2011, Tenncare began covering medically approved smoking cessation products. Previously the benefits were only for pregnant women and people under age 21. By November 2011, surveys were done on TennCare. It was discovered that it had 95% participant satisfaction. Over the years TennCare keeps accepting applicants in their Spend Down program for people in need of health insurance.

Some statistics from the Healthcare and Finance Administration FY 2015 Budget presentation(http://www.tn.gov/tenncare/forms/HCFAbudgetFY15.pdf)

Figure 2: TennCare overall use in 2014

Figure 3: Estimate Increase in costs for 2015

Figure 4: Participant Satisfaction 

Links: http://www.tn.gov/tenncare/news-timeline.shtml


  1. Group Presentation: Healthcare (My Portion)

    My group is discussing healthcare and healthcare systems in the United States and comparing them to other countries. The countries we are comparing them to either are developing a healthcare system, or they don’t have a system at all. Our project will mostly be based on the healthcare system of the United States which the other group members will compare and contrast the change in the system over time. From there we will be discussing countries with developing healthcare, and that’s where I come in. My portion of the project is dedicated to finding information on these countries. I will speak about which countries are in the process of developing a healthcare system, the reasoning for not having a system in place, and why that particular country has chosen to implement a system at that certain time. I will also be discussing on how the countries, before trying to implement a healthcare system, were functioning without it. Most of my research will be devoted to countries in Asia because that is the place where most of the developing healthcare system countries are. Furthermore, these countries are not trying to get a mandatory healthcare system put in place but rather a universal healthcare. The developing countries suffer the most because they do not have the funds or means to implement such a beneficial system for everyone to securely have. Another factor is that the developing country’s populations are mostly in poverty which makes it even more difficult to help those who can’t afford it.


    Universal health care is a broad term denoting a system that offers some level of basic health care to all its citizens. As the name implies, universal health care is available to everyone in a given population, regardless of socioeconomic status, existing health conditions, or ability to pay. The World Health Organization, a specialized agency of the United Nations that is concerned with public health, defines the goal of universal health care coverage is “to ensure that all people obtain the health services they need without suffering financial hardship when paying for them.” The W.H.O. lists a number of factors that must be in place in order for a community or country to achieve universal health care, including a strong, efficient, well run health care system, affordability, access to essential medicines, technology, and procedures, and a sufficient capacity of well-trained, motivated health care workers. The organization goes on to state that universal coverage has:
    A direct impact on a population’s health. Access to health services enables people to be more productive and active contributors to their families and communities. It also ensures that children can go to school and learn. At the same time, financial risk protection prevents people from being pushed into poverty when they have to pay for health services out of their own pockets. Universal health coverage is thus a critical component of sustainable development and poverty reduction, and a key element of any effort to reduce social inequities. Universal coverage is the hallmark of a government’s commitment to improve the wellbeing of all its citizens.
    To illustrate the various ways that different countries seek to implement universal health care, we will take a closer look at three countries to see how they ranked in the W.H.O. World Health Report, which is basically a long, boring chart. Despite its mundanity, this chart is very useful for ranking each member nation using two separate metrics related to health care. The first metric ranks each nation by how efficiently the health system translates expenditure into health as measured by the Disability-Adjusted Life Expectancy (DALE) Index. Performance on the level of health is defined as the ratio between achieved levels of health and the levels of health that could be achieved by the most efficient health system.

    It is worth noting that some of these countries are actually what are termed micro-countries. Since these are unique situations, I have not included them in the scope of this report.

    TOP 10 OF 191:

    1. Japan – universal.
    2. Australia – universal.
    3. France – universal.
    4. Sweden – primarily government funded.
    5. Spain – universal.
    6. Italy – universal.
    7. Greece – universal.
    8. Switzerland – compulsory; nearly universal
    9. Monaco – second smallest country in the world: 0.78 sq. miles.
    10. Andorra – 181 sq. miles; essentially part of France.

    The report further ranks countries by their overall health system performance, and this is the metric most commonly cited.

    TOP 10 OF 191:

    1. France – universal.
    2. Italy – universal.
    3. San Marino – 24 sq. miles.
    4. Andorra – 181 sq. miles.
    5. Malta – 122 sq. miles.
    6. Singapore – universal.
    7. Spain – universal.
    8. Oman – universal.
    9. Austria – universal.
    10. Japan – universal.

  3. My group is presenting different healthcare systems in the world. My portion is about the developing healthcare in developing countries in the continent of Africa. Africa lags behind the rest of the world on all indicators of health. Much of the cause of this is due to diseases such as HIV/AIDS epidemic that has hit the continent more than any other in the world. Other factors are the widespread corruption that is prevalent in many African countries. Conflicts such as war has also directly affected African’s health with a great number of deaths and injuries. African countries has one of the worst ratio of doctors to patient. There are not a lot of doctors.
    African countries have still not been able to control infectious disease.
    A flourishing society is better able to control infectious and viral diseases, the risks of unhygienic living conditions and the perils of unsupervised childbirth. People in developed and rich countries usually die either from the expected consequences of ageing or from conditions brought on by unhealthy lifestyles.

    “Primary healthcare, as per the WHO statement adopted in Alma-Ata in Kazakhstan in 1978, includes health education, promotion of proper nutrition, safe water and basic sanitation, maternal and child health care (including family planning), immunization against major infectious diseases, appropriate treatment of common diseases and injuries, and provision of essential drugs.” (2012 KPMG Africa Limited)
    The best recent example of this is Ethiopia.

    Africa still lags behind on immunization.
    Secondary healthcare:
    The major private healthcare companies in Africa are three major South African operators, all listed on the Johannesburg Stock Exchange: Mediclinic, Netcare and the relatively smaller Life Healthcare.
    African Medical Investments operates private hospitals in Maputo, Dar es Salaam and Harare, and intends to expand into other East African countries and Nigeria.
    _Lagos State, Nigeria
    -Nairobi, Kenya
    Spending on healthcare in Africa can be separated into three groups: government spending (which goes into directly supplied healthcare services as well as towards national health insurance schemes), private spending (which is split between out-of-pocket payments for healthcare services at point of delivery and private health insurance), and external sources (2012 KPMG Africa Limited).
    – Notable territories: Botswana, Ethiopia, Ghana, Libya, Mauritius, Rwanda, and South Africa

    In conclusion: As The Economist describes it, healthcare funding in Africa is a “patchwork of meager public spending, heavy reliance on foreign donors and a large dependence on out-of-pocket contributions and user fees that place the greatest burden on the poorest members of society (2012 KPMG Africa Limited).
    African countries healthcare system is still developing and needs more funding than it has in place.
    References: WHO, 2012 KPMG Africa Limited, our-africa.org, the economist, Yale, World Bank,etc.