TALLAHASSEE — In the months before he became Florida House speaker, Marco Rubio crisscrossed the state searching for ways to make Florida better.
The best proposals, dealing with topics ranging from property taxes to education, became a book: 100 Innovative Ideas for Florida's Future.
Chapter 8 is titled "Quality Healthcare at an Affordable Price," and it includes Idea No. 87: "Florida should launch a marketplace of affordable health insurance."
Why is any of this important now, more than five years later?
While Gov. Rick Scott has said Florida will refuse to participate in optional provisions of the federal health care law, including the creation of a state health insurance exchange, Rubio's vision for an insurance marketplace is about to come to fruition.
It's called Florida Health Choices.
And though Republicans such as Rubio and Scott won't admit it, Florida's marketplace is a lot like President Barack Obama's exchange.
"It's about competition, it's about choice, and it's about the marketplace," Rubio told the Palm Beach Post in 2008. (Rubio didn't respond to questions for this story.) "It's a priority of the House, and it needs to be respected and considered."
• • •
Florida Health Choices is scheduled to launch this year and is in the process of signing insurance companies and agents up for the program. Small businesses with four to 50 employees will be able to participate and coverage will begin in 2013.
Although Republican lawmakers like to play up the "marketplace" description of Florida Health Choices, it is set up like a health exchange. Like an exchange, it is a Web-based portal where people can shop for health insurance. And like an exchange, it is intended to create more options in hopes that more people will purchase coverage.
The exchanges, however, must be open to a wider range of individuals and have minimum coverage standards. The health care law, which passed in 2010 and was upheld by the U.S. Supreme Court last month, also creates subsidies to help people afford insurance and penalties for people who don't obtain policies through exchanges or other options.
In Florida, lawmakers have the option of creating an exchange, altering its marketplace to comply with the law or partnering with the federal government to create an exchange. The state can also do nothing and allow the federal government to create an exchange for the state.
Top Republicans in the Legislature said they wanted to take the time to study their options in light of the Supreme Court ruling.
But Scott made up his mind relatively quickly. Just 36 hours after the ruling, he went on Fox News and announced Florida would not set up an exchange and therefore continue to reject millions of dollars in federal grants. Scott's communications director, Brian Burgess, said the governor's complaint is about how health exchanges are forced to operate.
"It's one thing to set up an exchange, but when you set it up under the rules that Obamacare requires, there is no way it reduces cost of insurance," Burgess said. "The point is, in the governor's experiences, these exchanges don't keep the costs low for the people who may need to buy it."
Rubio also remains a vocal opponent of the law, giving critical remarks on the Senate floor the day of the ruling. A spokesman for Rubio said the differences between health exchanges and Florida Health Choices are problematic.
"He thinks the right approach is what Florida did in 2008 where he set up a marketplace where businesses can buy health insurance as part of the free market," Rubio spokesman Alex Conant said. "Obama's approach is very different. It forces businesses and individuals to buy government-approved health care or face a new tax."
So far, the nation's major insurance companies have not chosen sides. For example, a Humana executive serves on Florida Health Choices' Vendor Steering Committee and the company has also worked to implement the Affordable Care Act.
Liz Calzadilla-Fialo, UnitedHealthcare's regional director of public relations, said the company is open-minded.
"At this time, we are simply monitoring all discussions around the establishment of exchanges in Florida," she said. "It's simply too premature to tell what will actually materialize and how we will engage. Therefore, for the time being, we are monitoring and assessing all possible options."
• • •
The state must present a plan to the federal government by Nov. 16 if it wants to run its own Affordable Care Act-compliant health exchange. If it does not, the federal government says it is prepared to step in and create the exchange itself.
"Consumers will have the option to compare prices and coverage and get to the insurance that so many of them need," said Paul Dioguardi, director of intergovernmental and external affairs at the U.S. Department of Health and Human Services. "At the federal level, we're moving full steam ahead with implementing the changes and we'll be ready to go to make sure that consumers will be able to benefit through them."
Consumer organizations that supported the Affordable Care Act have resigned themselves to the idea of the federal government operating a health exchange in Florida. Now they are urging the state to cooperate, even if it doesn't want to participate.
The state should end its "stonewalling," said Laura Goodhue, executive director of health care advocacy organization Florida CHAIN.
"There are discussions that need to happen between coordinating with our agencies and the federal government," she said.
Initially, Rubio's Florida Health Choices also had its share of detractors.
The public-private corporation got off to a slow start because of resistance from former Gov. Charlie Crist, who along with state Democrats argued the program was using state funds to create another level of bureaucracy between health care and the people who need it.
Crist was slow to appoint members to the board, and Florida Health Choices didn't get a chief executive officer until Rose Naff was hired in 2010.
As Naff leads the efforts to launch the marketplace, the Affordable Care Act is simply not a part of the equation, she said. That is because everything the program is allowed to do is specifically outlined in statute and can only be altered by the Legislature.
"We have a statutory assignment to do a marketplace," Naff said. "We have to fulfill that mission. If someone wants to change our mission, it requires a change in law."
Tia Mitchell can be reached at firstname.lastname@example.org or (850) 224-7263.