Dr. Marcy Howard, a pediatrician with a small practice in rural Citrus County, felt a sense of relief in December when a federal judge ruled Florida's Medicaid program was shortchanging needy children.
Howard had long struggled to be profitable in the face of Florida's low Medicaid reimbursement rates. Almost all of her young patients receive coverage through the publicly funded program, which pays doctors a fraction of what private insurers pay for the same services.
With the ruling, Howard assumed change was imminent.
But eight months later, the high-profile case is once again tied up in court. U.S. Circuit Court Judge Adalberto Jordan has yet to issue a final judgment mandating changes to the Florida health insurance program that covers thousands of poor and disabled children.
Meanwhile, Howard and other pediatricians say the problems have gotten worse.
"It's spiraling out of control," said Howard, who has stopped offering urinalyses and hemoglobin tests at her Crystal River office because she loses money on the services. "There's a shortage (of pediatricians and pediatric specialists) because there's no financial return."
The three state agencies named in the lawsuit — the Agency for Health Care Administration, the Department of Health and the Department of Children and Families — declined to comment for this story. But in court filings from April, the agencies said Florida's Medicaid program had gone through "numerous fundamental changes" that made Jordan's original findings moot.
(The) plaintiffs can prove no ongoing violation of federal law," the attorneys for the state wrote.
The legal battle dates back to 2005, when a group of physicians and advocates sued the state for underfunding Medicaid. They said the low reimbursement rates had driven many pediatricians and pediatric specialists out of the program, and as a result, families in the Medicaid program had limited access to providers.
The plaintiffs also said state health officials had failed to make sufficient outreach efforts, and had put up unnecessary barriers by erroneously dropping children from the program and switching their providers without notice.
In his 153-page ruling, Jordan agreed that "many pediatricians and family practitioners refuse to take any new Medicaid patients and other pediatricians sharply limit the number of new Medicaid patients they will accept."
The state's policies, he concluded, had left one-third of enrolled children without their expected preventative medical care, and 79 percent without dental services — a violation of federal law.
The judge stopped short of requiring any changes — in part because state officials said the problems had been fixed when Florida overhauled its Medicaid program in 2014. The state asked for additional time to prove the privately managed system has remedied the issues.
"The changes to (the Managed Medical Assistance program) have been thoughtful and considered with the intention of ensuring that enrollees receive access to medically necessary care in a timely fashion," the state's attorneys wrote in April.
But Stuart Singer, the attorney representing the pediatricians, says managed care "has not really improved things."
"In many ways, it has made things worse," Singer said in an interview. "The number of children getting preventative services is down. It is still difficult to find specialists who will treat children with Medicaid."
He is seeking another judgment from the court.
"Ultimately, it is going to require an injunction in which the judge directs the state to take steps to bring its program in compliance with federal law," Singer said. "That will require the Legislature to appropriate some more money to deal with these issues."
That may be a challenge. In March, the U.S. Supreme Court ruled Medicaid providers cannot challenge the state's reimbursement rates, leading Jordan to dismiss one of the pediatricians' arguments in May.
The judge did not, however, dismiss claims that the state had failed to provide medical care with "reasonable promptness," or that the outreach efforts had been lacking. Both of those issues could be tied to funding.
As the case crawls along, some Tampa Bay area pediatricians say the problems have become more pronounced.
Dr. Toni Richards-Rowley, who has a solo practice in Lithia, said she frequently sees her Medicaid patients switched from one plan to another, or dropped from Medicaid without any warning.
What's more, she said, she usually needs to get prior authorization from the Medicaid plan before she can prescribe medications. "There's a delay of care because they can't get their medicine," she said.
And then there's the issue of the rates.
"You can't keep your lights on as a practitioner when you are getting paid $32 for a 15-minute visit," Richards-Rowley said, noting that a private insurance company would pay more than $70 for the same visit.
Howard, the Citrus County pediatrician, said she often directs her patients to specialists in Orlando because there aren't any closer options.
"I have no idea where to send the kids for their dental care," she said. "They have to go far, far away."
Her practice, too, has had financial problems. Rather than hire another part-time assistant, Howard helps tidy up the office and answer the phones.
"I'll do whatever it takes to keep this place going," she said. "But it's ridiculous. The system needs to change."
Contact Kathleen McGrory at firstname.lastname@example.org or (727) 893-8330. Follow @kmcgrory.