If Tennessee can't, or won't, pay for medical care, it's fair to ask a stark question: How can the thousands of people thrown off the rolls--including heart-transplant patients and people with lupus, diabetes and severe mental illness--survive?

Kathy Chamberlain would like to know. The 46-year-old, who used to play acoustic guitar at Nashville blues cafes, fights back tears as she describes an incessant ringing in her ears, the result of slipping on a puddle of water in a local supermarket and hitting her head on the floor. She has never been the same since, and she relied on TennCare to pay for her treatment and for antidepressants--drugs she didn't need before the accident. Those drugs now cost $639 a month; a discount card from the state, sent to TennCare enrollees who lost their coverage, pares her bill to $463. Chamberlain still can't afford it; she has to use her mother's credit card to buy her prescriptions.

"I have never encountered anything that I could not change until this," Chamberlain says. Even if she could afford to buy insurance, her illness would prevent her from getting a policy. She can't change that, either.

The thousands of Chamberlain's fellow Tennesseans who have been kicked off TennCare haven't seen the worst of it yet. The Center on Budget and Policy Priorities estimates that the massive loss of TennCare coverage will lead to an increase in uncompensated care that will cost "safety net" hospitals and clinics in Tennessee as much as $450 million annually. Waiting lists will grow longer, and the lost revenue could force some hospitals and clinics to close. Mary Bufwack, director of Nashville's United Neighborhood Health Services, says her budget is not big enough to serve all the newly uninsured who are showing up at her five clinics for the indigent. Forty percent of UNHS's budget had been coming from TennCare payments.

Some former TennCare patients are turning to drug-company assistance programs for help, but the wait for free drugs is six to eight weeks--if their incomes are low enough to make them eligible. Others are begging doctors for medication samples left by sales representatives. Hickman County healthcare activist Cindy Clark says doctors are running out of free samples. "They are overwhelmed," says Clark. "We see a disaster taking place in this state."

A disaster indeed. The Center for Health Services Research at the University of Tennessee-Memphis estimates that TennCare cuts will result in the deaths of as many as 3,311 people over the next fifteen years. Fifty-two-year-old Diane Wood can only hope she's not one of the casualties. Wood, who lives in the rolling hills east of Nashville, calls herself "fortunate" to have breast cancer; so far, women with breast or cervical cancer have been allowed to stay on TennCare. But this past summer's remake of TennCare instituted severe caps on prescription drugs, limiting recipients to two brand-name prescriptions and three generics per month. That has forced Wood to choose which of her other illnesses--diabetes, osteoporosis, failing kidneys--she will treat. Wood, who earns $50 a week baby-sitting her grandchildren, has decided to treat her cancer and kidney disease and say "to heck with" the diabetes and osteoporosis.

"Caps are the crudest cost-containment policy I can ever imagine," says Dr. Stephen Soumerai, a professor and drug-policy researcher at Harvard University Medical School. "What caps do is completely counter to everything we know based on research in the field." They certainly don't save money in the long run. When people like Wood can't get the medicines they need, they get sicker and end up in nursing homes and other institutions where the cost of care is greater than the savings generated by the caps.

A growing number of Tennessee doctors, particularly specialists and those in rural areas, refuse to take TennCare patients. Doctors grumbled from the start that the state paid them too little to treat these patients. Like doctors everywhere, they prefer to serve those insured by commercial carriers like Aetna or Blue Cross, which pay more than Medicaid. In a recent survey of its members, the Tennessee Medical Association found that although 88 percent said they still work with TennCare, 20 percent are not taking new TennCare patients and 27 percent are considering ending their contract with the program. The main reason, says association senior vice president Russell Miller, is that cuts in benefits are compromising the care doctors want to give--and increasing the legal liability they are exposed to.

Doctors who still accept TennCare patients know what's going to happen. "We kept a lot of people from dying for over a decade," Nashville gastroenterologist Robert Herring said recently, after a long day of performing colonoscopies on people about to lose their coverage. "It's a shame we couldn't provide a bridge until we have national health insurance," the doctor said. "Now I am going to cry."

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