President Barack Obama's signature health care program, which could extend coverage to most of the 4 million uninsured Floridians, is hardly a done deal in the Sunshine State.
Republican state leaders, counting on a Mitt Romney victory and the end of Obamacare, stalled key action to set the program in motion here. Yet they have considerable power over how many Floridians will be covered and what their insurance might be like.
Now it's decision time.
The state is all but certain to blow a deadline next week to tell Washington how it will create private insurance exchanges for those who struggle to get group insurance.
Under the Affordable Care Act, derisively called Obamacare, the federal government will set up exchanges if Florida doesn't.
But under the Supreme Court ruling upholding the law, states have power over the costlier provision: expanding Medicaid to cover more low-income families.
Washington has offered billions of dollars to the states and would pay the entire cost of the expansion in the initial years, but Republican leaders have balked at creating what they say will become another costly government entitlement.
Gov. Rick Scott, who has opposed Obama's health reforms from the start, stood strong this week against both the exchanges and the Medicaid expansion. But Republican leaders may be softening. "It's on our porch, and so we're going to have to deal with it," said incoming House Speaker Will Weatherford, a Wesley Chapel Republican.
"A simple 'no' is not an adequate answer," said incoming Senate President Don Gaetz, R-Niceville. "If the state of Florida is going to refuse Medicaid expansion, it has to be, 'No, and here's our solution.' " Lacking alternative proposals, state leaders face pressure from constituents, hospitals, physicians and even insurers, all of whom stand to benefit from the new rules.
In Florida, about a million people would qualify for the Medicaid expansion, which would cover those who make up to about $32,000 a year for a family of four.
"We have seen a long list of excuses in states like Florida as to why they aren't moving ahead with implementing health reform that is going to provide real benefits to families. I think the time for excuses is done now," said Joan Alker, a research associate professor at Georgetown Health Policy Institute who has long studied Medicaid in Florida. "State leaders need to roll up their sleeves and get to work."
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As governor, Scott has rejected millions of dollars in federal grants that could have been used to set up the exchanges. Even after the election results were clear, he refused to talk about creating exchanges.
"No one has been able to show me that that health care exchange is going to do anything rather than raise taxes, raise the cost of our companies to do business, and reduce access to health care, all things I am concerned about," the former hospital executive said this week.
But Weatherford is among those who say that because exchanges are here to stay, Florida should have as much control as possible over a system that will affect consumers and the insurance companies that will sell coverage through the exchanges. "We're not going to have a federal exchange, I can say that," he said.
Gaetz, the rising Senate president, said he hasn't made up his mind on who should run the exchange. He said he has Senate staffers calculating the costs of various options.
Florida is not alone in stalling. As of late September, only 19 states had begun setting up exchanges or agreed to do so in partnership with the federal government, according to the Kaiser Family Foundation.
Florida Hospital Association chief Bruce Rueben said Florida is so complex and large, it should design its own system.
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Florida has one of the nation's stingiest Medicaid programs. Poverty alone won't qualify you; most nondisabled adults under 65 who don't have minor children can't get any coverage.
Under the new law, the federal government will send billions to states that expand coverage to families who make up to 138 percent of the federal poverty level — about $32,000 for a family of four. Beginning in 2014, the federal government will pay the entire cost of expansion for three years, dropping to 90 percent by 2020. States that refuse to expand risk forgoing the money.
"It would be grossly irresponsible to deny that opportunity to Floridians," said Laura Goodhue, executive director of Florida CHAIN, which advocates for health coverage access. "The most the state would ever have to pay is 10 cents on the dollar."
State Republican leaders are skeptical that the federal government will keep its promises. Still, Weatherford acknowledged that failing to expand Medicaid could hurt hospitals that serve large numbers of uninsured patients.
"It's a double-edged sword," he said. "If you don't take advantage of it, there's a hit to your hospitals."
For years, hospitals that care for the uninsured have received supplements from the federal government. But since Obamacare extends health insurance to nearly all the poor, that hospital funding will be cut, Alker said.
And failing to expand Medicaid could create a class of people at a disadvantage: those who can't qualify for Medicaid, yet don't make enough to afford insurance through the exchanges.
Republican Mike Fasano, a longtime state senator from New Port Richey who was elected this year to the state House, believes the Legislature will come around on the expansion. "I believe our governor came out much too early in saying we wouldn't expand Medicaid coverage," Fasano said. "We have a lot of Floridians who don't have access to primary health care, or can't afford health insurance, and end up in an emergency room. That ends up costing taxpayers more money."
Times staff writer Tia Mitchell contributed to this report.