1. Florida Politics

PolitiFact Florida: Could Charlie Crist have expanded Medicaid in Florida?

Published Oct. 23, 2014

To hear Florida Gov. Rick Scott and Charlie Crist tell it, the 2014 gubernatorial campaign isn't about policy positions, but more about which candidate did less as governor.

Take the Affordable Care Act's Medicaid expansion. No, really, someone should take it, because neither governor did. Now each is berating the other for it.

"He will not lift a finger to get Medicaid expansion done," Crist said during Tuesday's CNN debate in Jacksonville.

Scott answered by first accusing Crist of running up the state's debt. "And then you want to talk about Medicaid," he said. "You were governor when it passed. Why didn't you get it passed right then? Why didn't you expand it right then?"

Say, why didn't he expand it right then? Could Crist have even done anything about the Medicaid expansion while he was in office?

One of the original provisions in President Barack Obama's signature health care law was to expand Medicaid, the joint federal and state program to cover the poorest of the uninsured. The new Medicaid guidelines covered everyone up to 138 percent of the federal poverty level.

In Florida, this would have amounted to between 800,000 and 1 million residents getting coverage. The federal government would have paid 100 percent of the costs for the first three years, starting in 2014, gradually decreasing to 90 percent by 2020.

To get the funds for this expansion, the Affordable Care Act presented states an all-or-nothing proposition: Change state law to cover every eligible resident and get the expansion money, or refuse to comply and lose all federal money for Medicaid. That isn't just the expansion money, that's every dollar for a state's Medicaid program — billions of dollars every year.

Crist was in the final year of his term when Obama signed the bill into law on March 23, 2010. Florida joined Virginia and a dozen other states in suing the federal government the same day, insisting Washington couldn't force citizens to buy insurance and protesting terms of the Medicaid expansion. Elements of the law were slated to take effect in stages (the Medicaid expansion wouldn't take effect for more than 3 ½ years), so many states waited to see what happened with the lawsuit.

What's a governor to do? The Republican-controlled Legislature had already started its 60-day lawmaking session, so it's possible Crist could have pushed for compliance with the law. But considering legislators begin their work on bills in the September prior to a session, and given how unpopular the new law was to begin with, this was a pretty unlikely scenario. Also, Florida creates budgets one year at a time, and too much of the law's specifics were up in the air to be fully addressed in 2010.

"I think it would have been difficult, but perhaps not impossible, for Charlie to have moved on the Medicaid expansion, because components of the law were very uncertain with the ACA at that point in his term," Kevin Walsh, assistant political science professor at Broward College, told PolitiFact Florida.

The Scott campaign told us Crist could have addressed expansion in a special session. But that's impractical. There was no rush to implement an expansion of Medicaid — remember, it wouldn't start until 2014 — and there was little to no chance Republican lawmakers would agree to the expansion even if Crist called them back (at a cost of around $45,000 a day).

The idea of creating compliant legislation so quickly wasn't practical either, experts told us.

"Technically, Scott is correct," said Gail Wilensky, senior fellow for the Center for Health Affairs at Project HOPE. "However, since the benefit wasn't going into effect for a couple of years, there wasn't an obvious need to pass legislation immediately."

The U.S. Supreme Court eventually ruled, on June 28, 2012, that although the federal government could compel people to buy health insurance, it couldn't threaten to withhold Medicaid money for refusing to comply. That made expansion a choice for each state. By then, Scott was in office.

Most states — even those that overwhelmingly supported expanding Medicaid — waited until the Supreme Court decision was final to formally expand their Medicaid programs through legislation.

Before this year's campaign, Crist said little on the subject.

In March 2010, Crist said he was against the Affordable Care Act and favored repeal. In July 2010, he waffled on repeal but still wanted it modified. And within two hours on Aug. 27 that year, he said he would have voted for the bill — and against it.

For the record, Crist now says he is for it.

Scott, an opponent of the Affordable Care Act, initially was against the Medicaid provisions, largely because of concerns about added costs for state taxpayers (that 10 percent we mentioned). In 2013, he had a change of heart, but still did not push the Legislature to enact a law for more Medicaid coverage. To this day, Florida has refused the expansion.

Crist has floated the idea that he could issue an executive order if elected, in the same vein as Ohio Republican Gov. John Kasich. Kasich signed an executive order last year expanding the program, using an obscure government entity called the controlling board.

Florida doesn't have one of those, so it's unclear if Crist could take similar action. Scott certainly doesn't think so.

"An expansion of Medicaid could not be accomplished on a whim from the executive office," Scott has said. "It requires legislative action."

Edited for print. Read the full version at