LeMieux: The case against Medicaid expansion

Published May 12, 2015

The Florida Legislature will return to Tallahassee on June 1 to approve a state budget, the only task it is constitutionally required to perform, and that work must be finished before July 1 to avoid an interruption in government services.

What is the problem?

The House and Senate cannot agree on whether to expand Medicaid as provided by the Affordable Care Act.

Florida pays 40 percent of Medicaid's cost (more than $8 billion) and the federal government pays 60 percent (about $12 billion). Medicaid as a federal-state partnership has traditionally provided health care to pregnant women, children, needy families, the blind, the elderly and the disabled.

Under the Affordable Care Act, Congress required states to expand Medicaid and provide health care coverage to all individuals under the age of 65 with income levels below 133 percent of the federal poverty line — a fundamental change and huge expansion of the program.

At the beginning, expanding Medicaid is a good deal for the states as the federal government pays 100 percent of the cost. But after 2016, the federal government decreases its contribution until it reaches 90 percent and the state pays 10 percent. I was serving in the U.S. Senate when Obamacare was debated. I spoke out against this expansion as a requirement the states should not be forced to adopt. The provision was challenged as unconstitutional by many states, including Florida.

Three years ago, the U.S. Supreme Court held that the federal government could not force states to expand Medicaid. Finding the expansion requirement tantamount to "a gun to the head" of the states, the court held "the Constitution simply does not give Congress the authority to require the states to regulate" and struck down the Medicaid expansion requirement as unconstitutional.

Now, the Obama administration is at it again. In an effort to force expansion, the administration recently told state officials it would cease funding an existing indigent health care program, the Low Income Pool, unless the state agreed to expand Medicaid. The anticipated LIP funding from the federal government for the upcoming fiscal year is $1.3 billion.

Several states, including Florida, have opted not to expand Medicaid beyond its current form, and for good reason. While free money in the early years, the budgetary burden of expanding Medicaid in the out years will force Florida to cut other programs, raise taxes, or both.


Unlike Congress, the Legislature is required to balance the state budget each year. While Congress deficit spends year after year, Florida can authorize the expenditure of only as much money as it projects it will receive in any given year. What that means is that the Florida Legislature must prioritize. Every dollar spent on health care, for example, may be a dollar not spent on education, building roads, expanding ports and the like. A lesson that every newly elected legislator learns is that the vast majority of the nearly $80 billion state budget is spoken for when commitments are met to health care, K-12 education, prisons, roads and other mandatory funding requirements. So while expanding health care for the poor is laudable, it must be balanced with other important priorities.

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Gov. Rick Scott and Attorney General Pam Bondi have sued the federal government for again tying current health care funding for the indigent to Medicaid expansion, and they are right to do so. The offer of free money for the first few years is "poison candy" — alluring at first, but detrimental in the end. Instead of expanding Medicaid, Florida should do a better job managing the current system. A large percentage of Florida health care providers won't even accept Medicaid as its reimbursement rate is too low. A 2011 study by the journal Health Affairs found that 40 percent of Florida office-based physicians would not accept new Medicaid patients. Expanding a broken system at the expense of other priorities makes little sense.

Our Founding Fathers realized that too much power concentrated in one branch of government, or one level of government, could foster tyranny. Our system of federalism guarantees to the states all rights not specifically delineated and enumerated as powers of the federal government. Florida should not expand Medicaid, and the Obama administration is wrong to terminate health care funding for low-income Floridians to force us to do so.

George LeMieux is the chairman of the board of the Gunster Law Firm and served as a Republican U.S. senator, governor's chief of staff and deputy attorney general. He wrote this exclusively for the Tampa Bay Times.