Timeline: How Florida's Medicaid expansion fight paralyzed lawmakers

TALLAHASSEE — Medicaid expansion in Florida has been a contentious issue since 2013 when the Obama administration, through the Affordable Care Act, encouraged states to allow more people with low incomes to qualify for the health insurance program.

The Florida Legislature, led by House Republicans, rejected it in 2013 and again in 2014.

But the issue came back to life in the months leading up to this year's 60-day regular session, dividing the Republican-dominated Legislature and creating a historic crisis that has kept lawmakers from passing a budget. A special session now awaits.

Here's a time line detailing how lawmakers got to this point over the controversial issue of health care in Florida.

Dec. 3: A coalition of business interests and private citizens unveils a plan to use federal Medicaid expansion money to extend subsidized health care coverage to nearly a million Floridians. The plan, called A Healthy Florida Works, offers an alternative to the Affordable Care Act model by creating a state-run exchange for private health insurance. It has the support of Senate Rules Chairman David Simmons, a close ally of Senate President Andy Gardiner. House Republicans are skeptical.

Jan. 14: A state report finds that Florida is at risk of losing about $1.3 billion in federal funds if the so-called Low Income Pool program ends. The federal-state LIP program reimburses hospitals that treat large numbers of poor and uninsured patients. It is scheduled to expire June 30 under an existing agreement between the state and the federal government.

Feb. 10: Eliot Fishman of the U.S. Centers for Medicare & Medicaid Services (CMS) tells attendees at an Orlando health care conference that the federal government won't extend the LIP "in its current form."

Feb. 11: State Medicaid director Justin Senior says his agency and CMS are negotiating a possible successor to the LIP program.

March 3: The 60-day legislative session begins.

March 4: The Senate Health Policy Committee says Medicaid expansion could help hospitals and county health departments affected by the loss of LIP funds. Separately, Republican Gov. Rick Scott says he will not support using state money to backfill LIP if the program is not renewed.

March 10: The Senate Health Policy Committee introduces — and gives its unanimous support to — the so-called Florida Health Affordability Exchange program, or FHIX, an alternative to Medicaid expansion that closely resembles the Healthy Florida Works plan (SB 7044). The proposal requires beneficiaries to meet a work requirement and pay a small monthly premium. House Republicans say they are not interested.

March 17: The FHIX plan wins support from a second Senate panel.

March 19: The House and the Senate roll out vastly different health care spending proposals. The Senate plan includes $2.2 billion in LIP money and $2.8 billion in federal Medicaid expansion money. The House proposal includes neither. The Senate also announces that it has developed a new model for a LIP successor program.

March 25: The FHIX plan wins support from a third Senate panel.

March 31: Gardiner sends Sen. Garrett Richter, R-Naples, and Rene Garcia, R-Hialeah, to Washington to meet with federal health officials about the fate of LIP and Medicaid expansion. The senators say they are there to provide information and ask questions, not negotiate. Separately, the Senate Health Policy Committee votes in favor of Agency for Health Care Administration Secretary Elizabeth Dudek's reappointment. After the hearing, Dudek says she was unaware that Garcia and Richter had traveled to Washington.

April 1: Dudek sends out a press release saying that federal health officials have suspended the LIP negotiations for two weeks. A spokesperson for CMS denies the allegation, explaining that one member of the negotiating team will be on a holiday vacation, but the talks will continue.

April 6: Scott, once a tepid supporter of Medicaid expansion, backs off his position, saying Florida can no longer trust the federal government to continue funding Medicaid.

April 7: The Senate Health Policy Committee declines to confirm state Surgeon General John Armstrong after he repeatedly refuses to give an opinion on the Senate Medicaid expansion plan. The lack of action is largely symbolic. Armstrong is a Scott appointee who has two years to be confirmed.

April 14: In a letter to Florida's Medicaid director, federal health officials say LIP and Medicaid expansion are tied together, adding that Florida's "expansion status is an important consideration in our approach regarding extending the LIP program." Several Republican members send a letter to the federal government that same day saying the LIP program should not be "held hostage to Medicaid expansion." State health care officials later admit to helping draft the letter.

April 14: House Speaker Steve Crisafulli, R-Merritt Island, says the Senate is responsible for "muddled negotiations."

April 15: The state Medicaid director writes federal health officials requesting that Medicaid expansion and LIP be kept separate. Later, the Senate Ethics and Elections Committee grills Dudek for more than an hour about two issues, but votes in support of her reappointment.

April 16: Scott says he intends to sue the federal government for allegedly coercing Florida into Medicaid expansion.

April 20: AHCA submits the Senate LIP proposal to CMS.

April 21: House Republicans hold closed-door meeting to discuss Medicaid expansion and LIP. Crisafulli tells the caucus he felt blindsided by the Senate's decision to pursue Medicaid expansion.

April 21: The Senate holds a public meeting to discuss Medicaid expansion and LIP. Gardiner receives a standing ovation.

April 21: Scott says he is prepared to call lawmakers back for a special session to complete the budget — and calls for a new commission to evaluate hospital spending.

April 23: The House offers to use $200 million in state money to help hospitals and county health departments that would be hurt by the end the LIP program, and asks the Senate to begin building the budget before Florida hears back about the LIP program. The Senate refuses.

April 24: The House increases the figure to $600 million if the Senate gives up Medicaid expansion. Again, the Senate refuses.

April 27: Gardiner sends a letter to the federal government asking for guidance on the LIP situation.

April 28: Crisafulli adjourns the session three days early, saying lawmakers need to go home and "reset." Scott files his lawsuit against the federal government.

April 29: CMS releases a statement responding to Scott's lawsuit saying it will review Florida's LIP proposal regardless of its Medicaid expansion status. The statement prompts a war of words: Crisafulli says CMS has reversed its position; Gardiner said it has remained consistent.

April 30: Scott again calls for the creation of an interim budget and a commission on hospital funding.

May 1: The Senate adjourns.

Contact Kathleen McGrory at kmcgrory@MiamiHerald.com. Follow @kmcgrory.