Florida has more people covered under Obamacare than any other state, and is second only to California when it comes to seniors on Medicare. Yet the state's uninsured rate is still higher than the national average.
So it's no wonder that health care is among the top concerns for voters in the midterm elections — or that Florida has become fertile ground for a new debate over an old idea: "Medicare for all."
The concept has been a major talking point for Andrew Gillum, the Democratic candidate for governor, at least during the primary campaign. He has said he supports Sen. Bernie Sanders' proposal, which calls for a government-run health care system funded by income-based premiums on employers and households, and tax code changes that would make higher earners pay more.
"Politicians are using the Medicare for all program as a spring board for universal coverage. That's the ultimate goal, and that conversation is not going away," said Anne Swerlick with the Florida Policy Institute in Tallahassee.
So what would such a program look like? And what changes would it bring for Floridians, many of whom already rely on government-funded health care?
Without a clear plan, it's hard to know, experts say. Even if Democrats are able to take back the governor's mansion, any upheaval of a federal health insurance system couldn't be done overnight, or by one state, or even one governor.
"Medicare is a federal program. The governor of Florida or even the president can't do anything. It's a congressional issue," said Jay Wolfson, a professor at the University of South Florida's Morsani College of Medicine. "Currently there is no vehicle in Florida through which this could be created."
But change is on the horizon and voters are paying attention. More than half of Americans say they support universal health coverage, according to a poll by the Washington Post and the Kaiser Family Foundation. About 43 percent oppose it.
"Medicare for all at this point means a lot of different things to different people," Swerlick said. "Right now, it's a political trigger. But voters will be impacted on this issue even if they have coverage right now."
Ideas like Medicare for all will continue to circulate beyond this voting cycle as they have for years, experts agree. Not all the proposed bills that lean toward universal coverage focus solely on Medicare either. Some rely on tweaking Obamacare, known formally as the Affordable Care Act, or state Medicaid programs, which can add to the confusion.
"Some of these ideas have been around for a very long time. There have been Medicare for all proposals for decades," said Tricia Neuman, director of Medicare policy at the Kaiser foundation. "There has been more traction since the 2016 presidential election, where it got a lot of attention from Sen. Bernie Sanders. People have now been thinking of the next steps beyond the Affordable Care Act and what can be done. There are many proposals out there that vary quite a bit."
Support for universal coverage seems to waiver based on what you call it, another Kaiser poll shows. More than 60 percent of the public supports a Medicare for all or universal coverage platform. But interest wanes to around 40 percent when the same ideas are described as "socialized medicine" or a national health plan.
"These proposals cover a range of ideas and have multiple elements that affect insurance providers, employers and consumers in different ways. It's the details that really matter," Neuman said. "This is not the first year in any stretch of the imagination that tactics have been used prior to elections to motivate seniors to vote. … But it's not clear how any of these proposals would affect the coverage people get."
Obamacare has been driving many changes in recent years, with its focus on controlling costs. Hospitals are penalized more often by insurance companies and the government when patients have more frequent stays. So the pressure is on to keep patients out of the emergency room, which is changing the role of insurance providers, hospitals and even retailers across the health care industry.
But Medicare, which covers millions of those patients, isn't designed to support everybody.
"Medicare coverage is for the aging. People think it's free, but it's not. It's paid for through general tax revenues, Social Security monies and individuals purchasing supplemental plans from private insurers," Wolfson said. "The bottom line for Medicare for all is, who is going to pay for it?"
President Trump addressed the cost issue in a recent USA Today op-ed, saying a single-payer system "would end Medicare as we know it and take away benefits that seniors have paid for their entire lives."
Experts say his claim is simply not true. Neuman called it a stretch.
"These plans don't have a big impact on the current Medicare plan at all," she said. "In fact, many of them would enhance the current program with more generous benefits and zero premiums."
Most analysts turn to Massachusetts and its health care reform law passed in 2006 to get a glimpse into how something like Medicare for all could work in other states. Under then-Gov. Mitt Romney, Massachusetts mandated that every resident obtain a minimum level of insurance coverage. The state also provided free insurance for poorer residents who qualified, and required employers with more than 10 full-time employees to provide it. The system was tweaked over the years to comply with the Affordable Care Act.
"The Florida Legislature would have to create a similar state-mandated benefits program for everybody. But Florida can't even expand Medicaid," Wolfson said. "What's more likely is tweaking the ACA to make it more affordable for people."
In the Democratic primary for Florida governor, Gillum strongly supported Medicare for all, citing proposed legislation by Sanders. Others in Congress have put forward similar proposals, including U.S. Rep. Keith Ellison of Minnesota and Sen. Debbie Stabenow of Michigan.
More recently, however, Gillum has backed away from Medicare for all, declining to discuss it in his first debate with Republican opponent Ron DeSantis and saying that Florida couldn't do it alone.
Medicare for all is a "north star that we should look to which would define health care as a right for all citizens," said Carlie Waibel, a spokeswoman for Gillum's campaign. "He will always support policies that cover more Floridians and reduce costs and barriers to accessing care."
If elected, Gillum would use his platform to urge legislators in Washington and Tallahassee to pass legislation that would give Floridians the health security they need, Waibel said.
But analysts urge voters to read between the lines when politicians talk about health care, and lower any expectations.
"People should stand by and wait for more specifics," Neuman said. "At this stage, only general discussion is taking place. It may move forward in more concrete ways. But until it does, it's hard to know the potential impact."
Contact Justine Griffin at email@example.com or (727) 893-8467. Follow @SunBizGriffin.