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Medicaid expansion in Florida? South Dakota vote may show the way.

The red state dodged Republican opposition to expand the federal program by asking voters. Could Florida see the same success?
A sign in Rapid City, South Dakota, encourages people to vote in favor of Amendment D, a measure to expand Medicaid eligibility for state residents. The measure passed with 56% support, buoying supporters of expansion in Florida who believe the Sunshine state could follow the same path.
A sign in Rapid City, South Dakota, encourages people to vote in favor of Amendment D, a measure to expand Medicaid eligibility for state residents. The measure passed with 56% support, buoying supporters of expansion in Florida who believe the Sunshine state could follow the same path. [ ARIELLE ZIONTS | KHN ]
Published Nov. 15

The refusal of Republican state lawmakers to expand Medicaid in Florida has been a decadelong frustration for health care advocates and others in a state where 2.4 million people have no health insurance.

Expanding the federal program, which provides health insurance to low-income and disabled people, would make an estimated 900,000 Floridians eligible, or more than 4% of the state’s population. That includes more than 400,000 who earn below the federal poverty level, according to the Florida Policy Institute, a Tallahassee nonprofit.

The institute is one of the members of Florida Decides Healthcare, a political committee fronted by a coalition of health care advocates, nonprofits and the Florida Public Services Union. Their plan is to bypass the state Legislature and make the case for Medicaid expansion directly to voters as a constitutional amendment on the 2024 General Election ballot.

But would such a measure pass in increasingly Republican-leaning Florida? The group is drawing confidence from an unexpected show of support for Medicaid in one of the nation’s reddest states.

South Dakota voters last week approved expanding Medicaid in a ballot measure that easily passed with 56%. That result, in a state that voted 62-35% for Donald Trump over Joe Biden in 2020, is seen as evidence that the issue draws bipartisan support and could pass in Florida.

“What we’re seeing in South Dakota is very encouraging for Florida,” said Jake Flaherty, who was hired by the group as a full-time campaign manager in September. “This is an issue that is very much in play in red states.”

Related: Florida’s refusal to expand Medicaid cost 2,800 deaths, report says

South Dakota is the seventh state in the past five years to expand Medicaid through a ballot initiative. Expansion there is estimated to make 40,000 residents newly eligible for the program, or just under 5% of the state’s population.

But the bar for success is higher in Florida. Constitutional amendments must be approved by 60% of voters, not the simple majority required in South Dakota. And to get the measure on the ballot, the group must gather signatures equal to 8% of votes cast in the last general election, with a percentage of those spread across at least 14 of Florida’s 28 congressional districts.

That would mean collecting roughly 890,000 signatures, a target that would inevitably require paying firms to gather petitions. The campaign for the measure would likely need to raise around $10 million, Flaherty said. The coalition will be looking to collaborate with other organizations.

“It’s a tough prospect,” he said.

GOP lawmakers opposed to Medicaid expansion have typically cited concerns that the state would be on the hook for rising medical costs and also that the incentives to expand the program are part of the Affordable Care Act, which congressional Republicans have tried in the past to repeal.

Only four states in the nation have stricter Medicaid eligibility requirements than Florida, according to the institute. Adults with no children are not eligible no matter how little they earn. Neither are the adults of a family of three whose household income is above $6,984.

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Related: Florida’s Medicaid debate recharged amid coronavirus pandemic

The incentives to expand have never been greater following passage of the American Rescue Act, said Holly Bullard, chief strategy and development officer at the Florida Policy Institute.

Currently, the federal government covers 60% of the medical bills for the 5 million Floridians enrolled in the program. Under the new act, which was passed during the pandemic, the federal government will cover 90% of the cost of those added to the program by expansion.

That would mean savings for the state to provide medical coverage for inmates and prisoners, and uninsured people who need mental health treatment, Bullard said. Her group estimates expansion would reduce the number of uninsured by a third and save Florida $1.95 billion in the first year.

“You cannot point to any state, red or purple, that has unexpanded or had a fiscal nightmare,” she said. “It is good for your fiscal line; it’s good for budgets.”

Expansion is also supported by child welfare advocates who see access to health insurance as critical for parents to maintain healthy home environments for their children.

“When parents have insurance coverage, their children are healthier and better off,” said Robin Rosenberg, deputy director of Florida’s Children First, an advocacy organization.

Opposition would likely come from Americans for Prosperity, a libertarian conservative political advocacy group.

But it’s unclear if Republican lawmakers would also take steps to try to prevent expansion. When it was clear the issue was headed to the ballot in South Dakota, Republican lawmakers there placed a referendum on the ballot in the primary election to raise the threshold for any ballot initiative to 60%. It failed to pass.

Sen. Kathleen Passidomo, R-Naples, said it’s been a number of years since lawmakers addressed Medicaid expansion.
Sen. Kathleen Passidomo, R-Naples, said it’s been a number of years since lawmakers addressed Medicaid expansion.

Florida’s incoming Senate President Kathleen Passidomo of Naples said it’s been a number of years since lawmakers addressed expansion and said she would need to hear the pros and cons.

A higher priority for her is to increase the number of health care practitioners and nurses, which she said have not kept pace with Florida’s growing population. The state may need to increase the number of doctor residencies and to address the nursing shortage, she said.

“It’s a question of access, not insurance,” she said. “Once we tackle that, then we can talk about how we pay for it.”

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