Outside of Tennessee, the most radical response to the nationwide Medicaid crisis has unfolded in Missouri. Earlier this year legislators axed 104,213 people from Missouri Medicaid--and ordered the state to get out of the Medicaid business altogether by 2008. Where Missouri was once one of the dozen states with the lowest number of uninsured residents, it will become one of the dozen with the highest number after all its cuts take effect. Already, the state has stopped paying for feeding tubes and nutritional formula for thousands of residents with brain damage and other disabilities. It won't pay for other lifesaving items, like breathing machines, either.

In October, the federal government gave Florida permission to radically transform its Medicaid program into a "defined contribution" arrangement instead of an entitlement. Recipients will get a set amount of money for medical care, and private insurers will make many of the decisions about coverage--with no public scrutiny. If Florida's plan becomes the model for other states, as some healthcare activists fear, it will mean that poor people will get less and less medical care over time.

While the states chop benefits, the federal government is also aiming to cut its share of Medicaid funding. Congress has ordered a commission--chaired by former Tennessee Governor Sundquist--to recommend ways to slash $10 billion from the federal government's Medicaid budget. While the cuts will devastate thousands of Americans, they will do little to address the real financial problem facing the US healthcare system: how to create a new revenue source that will provide coverage for everyone and spread the risk of illness, much the way Social Security spreads the risk of citizens having no income in old age.

While Tennessee once aspired to be a leader in expanding health coverage, its current governor wants to make it the national model for retrenching and privatizing Medicaid. A confidential document called "Back to Medicaid Kick-off," prepared by TennCare's deputy commissioner and the state commissioner of finance and administration, not only outlines steps for gutting TennCare but also vows to "set the stage to allow the Governor a broader healthcare reform platform." In the view of Michele Johnson, a lawyer with the Tennessee Justice Center, Bredesen's "political future depends on transforming Medicaid into a market-based system, and he believes he can ride the market-based approach to the national stage."

Bob Corney, the governor's communications director, says the governor has no plans to run for any office except his current one; Bredesen will seek re-election next year. But the governor's stand on Medicaid has already brought him national attention. At a University of North Carolina "emerging issues" forum in February, and again in June at the National Press Club in Washington, Bredesen gave his vision for what he called Medicaid 2.0. The governor called for all Medicaid recipients to pay "something"--i.e., higher deductibles and co-payments. Medicaid, Bredesen declared, should pay only for treatments that work and for "things that are important."

While few experts would quarrel with paying only for "what works," it's far easier said than done. No drug company or medical-technology firm peddling ineffective treatments will give up its business without a political fight. And shifting costs to those who can't pay for treatment only increases long-term costs to the state.

Bredesen has steadfastly refused to seek new money to insure those who are being booted off TennCare. Indeed, his staff's "Back to Medicaid Kick-off" document sets a goal of stifling any alternative proposals for new revenue. Bredesen has also declined to dip into the state's $200 million surplus funds. "You can't revenue your way out of this problem," insists TennCare spokesperson Drescher.

However noble the TennCare experiment was, it ultimately demonstrated the futility of states' efforts to solve a national problem by themselves. In late July, protesters at the state capitol hauled a bell from the Edgehill United Methodist Church onto Nashville's legislative plaza. They rang it to represent every Tennessean affected by the TennCare cuts. It took four days to complete the roll call.

The tolling of that bell is the real lesson of TennCare for people all across America: The bell tolls for thee.

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