When Florida’s Rick Scott became the seventh Republican governor to support Medicaid expansion, he gave President Obama unexpected momentum for the nationwide effort, a key piece of the federal health care overhaul.
But just as quickly, federal regulators stalled the effort with an out-of-the-box policy decision that critics say now clouds prospects for bringing health coverage to 1 million low-income Floridians.
“They gave us an opening,” Sen. John Thrasher, R-St. Augustine, said of the Obama administration. “And we started to do more thinking about this.”
A week after Scott’s dramatic declaration in February, federal officials gave Arkansas Gov. Mike Beebe, a Democrat, the go-ahead to work on an alternative to Medicaid expansion. Republican-led Indiana soon followed with its own proposal.
Now, Florida Senate Republicans, who have rejected Scott’s call for expanding the traditional Medicaid program, are beginning work on crafting their own health care plan for low-income Floridians.
A couple of concepts are being roughed out. But the legislative session is approaching the half-way mark, and any proposal that clears the Legislature and Scott will still demand weeks, if not months, of review by federal officials.
Florida stands to draw $51 billion in federal money over 10 years – at a cost of $3.5 billion to state taxpayers – under the Medicaid expansion.
Democrats and health care advocates are anxious that the Republicans’ legislative delays will jeopardize these dollars. They’re also angry.
“It’s a missed opportunity,” said House Democratic Leader Perry Thurston of Fort Lauderdale. “We already have something that can bring health coverage to people who need it. It’s called Medicaid.”
Supporters of the Affordable Care Act, buoyed by Scott’s surprise support for Medicaid expansion, have gone from praising the governor to expressing frustration with Republican legislative leaders.
“We’re just going to have to see the details of what exactly they’re talking about,” said Laura Goodhue, executive director of Florida CHAIN, a statewide health care advocacy organization. “It’s sort of, here we go, yet another plan.”
But some say U.S. Health and Human Services Secretary Kathleen Sebelius effectively put the brakes on Medicaid expansion in Florida by signaling the Obama administration was willing to let states use federal dollars under the Affordable Care Act for non-traditional Medicaid programs.
“Arkansas has opened the door,” said Tony Carvalho, president of the Safety Net Hospital Alliance of Florida, which represents public hospitals and teaching hospitals, supporters of Medicaid expansion.
“It was a pretty significant change in the way the Centers for Medicare and Medicaid has been interpreting how states can expand coverage. Because of that, I think a lot of leaders in the Legislature now see an option besides Medicaid expansion…We have to see what it is.”
Hospitals see expansion as a means to easing the $2.8 billion in uncompensated, charity care they paid last year for treating a large portion of Florida’s almost 4 million uninsured.
Business lobbies, including the Associated Industries of Florida and the Florida Chamber of Commerce, also generally support expansion.
These groups, which normally provide lockstep support for Florida’s leading Republicans, see expansion as shielding businesses from mandatory insurance coverage for some employees, required under the Affordable Care Act.
More people qualify
Under the Medicaid expansion, eligibility for coverage would increase to 138 percent of poverty, meaning a family of three could qualify with an income of about $26,300. The current cutoff is about $9,600. For the first time, adults without a disability or children can qualify with an income about about $15,000.
Scott’s support, announced last month, was a remarkable reversal.
He had fought the Affordable Care Act. Florida also spearheaded a constitutional challenge by 27 states that went to the U.S. Supreme Court, which upheld the sweeping health care measure but ruled Medicaid expansion could not be mandatory for states.
By last week, 24 states had agreed to expand Medicaid; 20 indicated they would not. Florida is among six states still considering it.
Joan Alker, a Georgetown University health policy professor who has extensively studied Florida’s Medicaid system, said the debate over expansion has “gotten more complicated than ever” with the federal approach to Arkansas and Indiana.
Arkansas is considering a plan that allows those qualifying for Medicaid to obtain private insurance coverage through health exchanges, the online marketplaces that are a key part of the federal health care changes that mostly begin taking effect next year.
Indiana Gov. Mike Pence, a Republican, is spearheading a drive to enroll as many as 400,000 low-income residents in state health savings accounts, with the federal government picking up the costs.
Managed care OK’d
In Florida, Scott’s call for expansion came only hours after Sebelius informed him that federal officials were poised to finalize the state’s request from 2011 to move most of its 3.5 million Medicaid patients into managed care.
Scott and the Republican-led Legislature approved that shift. They argued that HMOs and other private providers would save money and improve health care for those in Medicaid. The state and federal government had negotiated for two years on the plan.
But Republican lawmakers now resisting expansion said that even when managed care is fully in place in 2015, Medicaid will remain a flawed program.
Alker, of Georgetown University, said that while Florida lawmakers criticize what they see as a top-down approach from Washington, expansion already gives states many options.
“You have to remember, the Affordable Care Act offered states a lot of flexibility in how they would enact expansion,” Alker said. “States can charge co-payments for services, they can take steps to promote healthy behavior. There are many paths states already could explore.”
Alker acknowledged, though, that the Obama administration may have blunted the drive toward Medicaid expansion by indicating it was ready to negotiate further.
She pointed out that Sebelius, a former Kansas governor, knows the kind of deal-making state executives and legislators must deploy to bring policy objectives in for a landing.
“But should they have stuck with a traditional Medicaid expansion? That’s a good question,” Alker said.
While Scott seems to be evolving away from his rigid opposition to what was once derided – but now embraced – as Obamacare, many Florida Republican legislators haven’t.
Sen. Joe Negron, Stuart, last week likened Medicaid to a Soviet system from the 1950s that stigmatizes patients enrolled in it and subjects them to lesser care.
Echoing much of the Republican rhetoric against the Affordable Care Act, Negron said the Florida Healthy Kids program could serve as a framework for expanding coverage and “rejecting the Washington plan but creating a Florida plan.”
What about Healthy Kids?
Senate staff has begun working on the outline of a plan, he said. But Negron said that whatever emerges is still a week away from being heard in Senate committees.
Healthy Kids, created under late-Democratic Gov. Lawton Chiles, serves 250,000 children, aged 5-18, whose parents pay $15-$20 monthly for health coverage. Families can choose from at least a couple of private health plans available in each of Florida’s 67 counties.
Negron wants Healthy Kids repositioned to accept the potential 1 million adults and children who could be eligible under the Medicaid expansion. It would need Obama administration approval to be financed by the billions of federal dollars promised states.
Senate Republicans insist that patients in the fortified program pay some kind of fee, to discourage abuse in the Medicaid system.
But Florida’s legislative session, scheduled to end May 3, is a political petri dish where policy experiments often yield strange outcomes.
Even as Negron is advancing a proposal, Sen. Aaron Bean, R-Fernandina Beach, told The Palm Beach Post last week that he is “working on Plan C.”
Plan ‘C’ developing
He wants lawmakers to use another state program, Florida Health Choices, an insurance exchange created five years ago but never widely used, as the building block for Medicaid expansion.
House leaders, who also rejected Scott’s call for expansion, continue to challenge the idea of relying on assurances that the federal government will fully finance the expansion’s first three years, and then most of the remaining cost.
“We’ve established that Medicaid is a horrible health care delivery system,” said Rep. Richard Corcoran, R-Land O’ Lakes, chairman of a House committee examining the Affordable Care Act.
“Now we’re moving toward a better one. That’s great,” he said.
Asked about the possibility of the Legislature reaching agreement, Corcoran said he was optimistic.
“The clock is a factor right now,” he said. “But our time frame is to get it right.”