Who’s Minding the Store for Tennessee Children Relying on Medicaid and CHIP?

When I began my career as a children’s advocate in the 90s, Tennessee led the nation in the percentage of its children with health insurance. It was a proud moment for our poor Southern state that was brought about by the vision and political effectiveness of Democrat Governor Ned Ray McWhether and by the courage and compassion of Republican Governor Don Sundquist. Congress’s creation of the Children’s Health Insurance Program (CHIP) subsequently enabled other states to catch up with Tennessee. But Tennessee had a head start in insuring its children, thanks to bipartisan clarity at the highest level of government that giving children a healthy start was both morally and economically beneficial. Research shows that kids who have health coverage do better in school and are more likely to complete college. They earn more as adults and are less likely to die of preventable causes or go bankrupt because of medical expenses.

This context makes the unfolding crisis in Tennessee children’s health all the more tragic. The Tennessean reported that 128,000 children have lost coverage in a little over two years. There was a net loss of 100,000 children from Medicaid and of another 30,000 from CHIP.

The state reversed a 10-year trend of covering more children in November 2016 when it started eligibility redeterminations without a functioning computer system. The state provided no in-person assistance to families overwhelmed by a 98-page packet. Families were told to complete a separate packet for each child.

This slow-moving red tape hurricane triggered a steady erosion of enrollment and a deluge of panicked calls to our office. Many families were terminated for failing to return packets they had never received in the first place. They learned of the disenrollment only when they sought care for their child at a pharmacy or ER and were told their TennCare card was no longer valid. Others repeatedly submitted completed packets and had proof of delivery, but TennCare denied receiving the packets and terminated coverage for failure to respond. There were entire categories of eligibility for which the state failed to screen children, resulting in children being wrongly terminated despite their continued eligibility. In some families, one sibling would be found eligible while another would lose coverage, even though their circumstances were identical. TennCare’s contractor sent packets to addresses where families had never lived.

This came to a head when the state posted February 2019 numbers showing that over 52,000 children had lost TennCare in that one month. When questioned by The Tennessean, the state took the numbers down, saying they were in error. At this writing, they have yet to post the numbers.

Until the media started investigating, state officials were dismissive of our concerns, assuming that disenrolled children had moved to other coverage as the economy improved. They made that claim even for counties where enrollment was plummeting, while the local economy continued to stagnate. Officials continued to rely upon their assumption that disenrolled children were moving to other coverage, an assumption we now know to have been false. Georgetown’s analysis shows that the number of Tennessee children with no coverage at all rose by 20% during the first year of eligibility redeterminations.

Tennessee officials do not know how many disenrolled children were left without any coverage. The state cannot even say how many of the children whom they cut off were no longer eligible, and how many were eligible but were terminated due to the programs’ well-documented administrative deficiencies. Local governments are trying to mitigate the impact, with several mayors organizing outreach efforts to try to find affected kids and reconnect them to coverage.

Although of course children’s health is the first concern, the disarray in Tennessee’s Medicaid and CHIP programs raises questions about fiscal management. The state pays HMOs a monthly fee, in advance, per enrolled child. If the state is struggling to come up with an accurate number for current enrollment, taxpayers cannot be confident that contractors are being paid correctly.

And so, a state that once proudly led the nation in coverage of its children is now a leader among the small minority of states that are losing ground. The historical context helps reminds us that such reverses are not inevitable but result from choices made by public officials in Tennessee and at CMS. It appears that no one in the federal agency questioned the state about its stewardship of over $8 billion in federal funds, all the while that one in eight of the programs’ kids were losing coverage. One wonders who’s minding the store for Tennessee’s children and, ultimately, for all of the nation’s children who rely on Medicaid and CHIP.