TALLAHASSEE — For years, Florida has turned down federal money to expand the Medicaid program under the Affordable Care Act, known as Obamacare.
But the novel coronavirus has renewed a call by Democrats and public health experts to expand Medicaid, the public health insurance program for low-income people, during a time when more people need medical care, safety net hospitals need reinforcement and thousands of Floridians have fallen into low income brackets due to unemployment.
On a press call about coronavirus Monday, Harvard T.H. Chan School of Public Health professor and health economist Ben Sommers called the lack of expansion in states like Florida ”pretty galling.”
Florida is one of 14 states that has not yet expanded its Medicaid program under the Affordable Care Act, mostly because of concerns about political optics and the potential impacts on state budgets.
In a new paper published in the New England Journal of Medicine, Sommers and his colleague, Massachusetts Institute of Technology economist Jonathan Gruber, analyzed budget data from all 50 states. The research shows Medicaid spending has been subsidized entirely by increased federal funding to states that have expanded access, with no significant changes in spending from state revenues associated with Medicaid expansion. The paper also finds no evidence that Medicaid expansion forced states to cut back on spending on other priorities, such as education, transportation, or public assistance.
They found that the federal dollars from Medicaid in expansion states also offset costs incurred by public hospitals, mental health centers and healthcare providers for people involved in the criminal justice system. The paper notes that both federal and state policymakers are increasingly looking to Medicaid as a central tool in their response to the national emergency that is coronavirus in the United States.
Covering more people under Medicaid, the paper argues, would infuse federal dollars into state economies that are on the verge of a major downturn due to coronavirus. And unlike other types of stimulus spending, it requires no new infrastructure.
“As states consider what they’re going to do in light of a likely recession where millions of people need insurance and care … this is a key time for the 14 states that have yet to expand Medicaid to seriously consider it,” Sommers told reporters Monday.
According to a March report from the Center on Budget and Policy Priorities, Florida ranks in the bottom 10 in three out of four measures of recession preparedness because of a “weak unemployment insurance system,” “failure to expand Medicaid” and “inadequate reserves,” according to the report.
Sommers said while epidemics can be a catalyst for change in states like Florida, “there has to be a groundswell for that change.”
“It depends on what policymakers see as their incentives,” Sommer said.
Agency for Health Care Administration Mary Mayhew has said that the agency, which administers the state’s Medicaid program, has not considered expansion. Before she came to Florida, Mayhew restricted Medicaid eligibility standards in her previous role as chief health and human services officer in Maine.
She delegates that task to the Legislature, she said.
A political issue
House Speaker José Oliva said in a statement that talk of Medicaid expansion “continues to be an unfortunate distraction” from other moves the state has made on healthcare like repealing Certificate of Need requirements, introducing telehealth services and increasing the supply of healthcare providers thru scope of practice reforms for nurse practitioners.
“The coronavirus pandemic only further reinforces the need to continue these reforms,” he said .
The speaker, a Miami Lakes Republican, harshly criticized Medicaid expansion as “the worst of all mandates” when he took his leadership position in 2019.
“We’re going to take a form of healthcare that most doctors don’t accept, that reduces the quality the more people you pile on it, and we’re going to find that as a solution to access to healthcare,” he said.
Florida spends a little less than $9 billion in state funds each year on Medicaid. It spends $14 billion in federal dollars, according to Urban Institute estimates based on data from the Centers for Medicare and Medicaid Services as of August 2019.
By comparison New York, an early expansion state with a comparable population, spends $34.2 billion in state and $40.6 billion in federal dollars on Medicaid.
Rep. Nicholas Duran, a Miami Democrat and ranking member of the House Health and Human Services Committee, said on a press call with other Democrats and healthcare experts last week that Florida is “walking two steps behind.”
Duran said that because Florida has not expanded Medicaid, “we are left with a state that doesn’t have the nimble set up” to react quickly in helping recently uninsured Floridians.
As more Floridians need access to healthcare, Democrats and advocacy groups have rallied behind the idea of expanding the eligibility for people to enroll.
In a letter last month, the Florida Policy Institute and 44 other organizations called on Gov. Ron DeSantis and state agencies to expand Medicaid to all adults with income up to 138% of the poverty level. That would be about $17,608 for an individual and $36,156 for a family of four, according to 2019 numbers from the federal Centers for Medicare and Medicaid Services. More than 800,000 uninsured Floridians with low income are excluded from Medicaid coverage in Florida, they noted.
Florida Democratic Party Chair Terrie Rizzo has slammed Republicans for not considering Democrat-led bills that would expand Medicaid, and Democratic Senators like Gary Farmer, of Lighthouse Point, have asked that the state waive Medicaid eligibility requirements for all residents not currently insured.
Medicaid expansion efforts in Florida
Most recently, a proposed ballot initiative backed by political committee Florida Decides Healthcare attempted to land a spot on the 2020 ballot. The proposal would offer Medicaid coverage to low-income adults who currently are not eligible. Backers, who collected about 90,000 signatures, say they now have their eyes set on the 2022 ballot.
In January, Democratic legislators introduced bills in both chambers to put a constitutional amendment expanding Medicaid to a statewide vote. Both bills failed to make progress in the Republican-controlled Legislature.
For years, Florida lawmakers have rejected expanding Medicaid eligibility.
In 2015, the Florida Senate proposed a plan, the Florida Health Insurance Affordability Exchange Program, that would have accepted federal money under the Affordable Care Act to establish a state-run private insurance exchange for about 850,000 presently uninsured low-income residents. The program had work requirements and included paying monthly premiums. But House leaders and then-Gov. Rick Scott opposed any expansion because they said they don’t trust the federal government to keep its promise to pay for covering more Floridians.
Congress recently passed the Families First Coronavirus Response Act, which includes a provision that allows states to draw down a significant chunk of cash for Medicaid. The act bumps up the amount the federal government pays into the program, making it responsible for about 67 cents of every Medicaid dollar. Florida is expected to receive $1.6 billion in additional funding.
In return, Florida cannot restrict Medicaid eligibility, raise premiums or terminate coverage for those already enrolled in the program.
Earlier in March, the Trump administration also approved a waiver that allows Florida to sign up and pay doctors and hospitals through Medicaid.
The state’s Medicaid program can waive application fees, certain criminal background checks and other requirements for doctors who provide care to people on Medicaid, according to the approval letter. Florida’s Medicaid program can now waive certain rules, such as prior authorization requirements for care, certain hospital admission requirements and rules for residents who are transferred between nursing homes.
The waiver also allows hospitals, nursing homes and clinics that are forced to evacuate to an unlicensed facility to receive payment for the care they give at the unlicensed facility.
Florida was the first state to get the waiver approved.
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