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Medicaid Expansion: Not a Done Deal

Advisory Board

A week ago, Gov. Rick Scott made a surprising announcement that he will support one of the key parts of the Affordable Care Act: the expansion of Medicaid coverage to about 1 million Floridians. He was the seventh Republican governor to do so; Chris Christie of New Jersey became No. 8 this week.

On a color-coded Medicaid expansion mappublished and updated by The Advisory Board, a consulting company, Florida shows up as one of 24 blue states -- a "yes." (Another four are leaning yes; so the positives outnumber the negatives 28 to 16.)

Advocates for the poor and uninsured are elated. Ron Pollack of Families USA called Scott's decision a "hallelujah moment." People who don't have coverage will finally get it at a price they can afford, he said, "so this is a big deal."

It may be a BIG deal, but it's not a DONE deal.

"This is a fight that is not yet over," said Leah Barber-Heinz, advocacy director for the consumer group Florida CHAIN.

The wobbly leg

Remember middle-school civics class? State lawmaking is a three-legged stool: the governor, the House and the Senate. In Florida right now, at least one of those legs is wobbly.

That would be the House, where the Speaker is Will Weatherford, a Republican from Pasco County. He doesn't think much of Medicaid.

"I'm extremely skeptical that somehow, magically using federal money to try to put a lot of people on a broken health care system is going to somehow give people access to care," Weatherford said in an interview last week posted on The Florida Channel.

The Speaker said he is concerned that the billions of dollars the federal government has promised to send Florida to cover most of the cost of expanding Medicaid will peter out, leaving the state in the lurch.

"We're talking about a federal government that is not able to pay its bills," Weatherford said.

Living on $15,000 a year

The Medicaid expansion as described in the health law would apply to low-income people who are not already covered -- mostly adults under 65 who have no children at home and who earn no more than 138 percent of the federal poverty level. That translates to about $15,000 a year for an individual, or just over $30,000 for a family of four.

For this new population to be covered under Medicaid -- estimated at about 1 million in Florida -- the federal government says it will pay 100 percent for three years.  Then the ratio would taper  until 2020, when it would hit 90 percent and remain there.

That was the reason the governor cited in suggesting that the Legislature include a "sunset" provision in the Medicaid expansion bill at the three-year mark. To continue covering the group after that, the Legislature would have to act.

But some -- including Attorney General Pam Bondi and Agriculture Commissioner Adam Putnam -- have argued against the Medicaid expansion. They say it would be too difficult for the state to dump the million new enrollees from Medicaid after three years, even if the program proved more costly than expected.

Gaetz: I haven't decided yet

Supporters of the Medicaid expansion have taken heart from Senate President Don Gaetz's recent comments about the Affordable Care Act being "the law of the land," following the Supreme Court decision upholding most of it in June and President Barack Obama's re-election in November.

But Gaetz sent a press release out Tuesday reiterating that that doesn't necessarily mean he's a "yes" vote on Medicaid expansion, since participation in that is voluntary. "I have not yet made a personal decision regarding how I will vote on Medicaid expansion and will not do so until the Senate (Affordable Care Act) Committee has completed its work," his statement said.

The ACA committee chairs are both Republicans, Sen. Joe Negron of Palm City in Martin County and Rep. Richard Corcoran of Lutz, in northern Hillsborough County. 

Corcoran, an attorney, rattles off a rapid list of "concerns" that he and others share about expanding Medicaid. But some of the concerns are related to the way the Affordable Care Act was written, and won't change no matter what the Legislature does about Medicaid.

Apart from finances, Corcoran's main worry is that the number of newly-insured poor people will flock to doctors' offices, crowding out senior citizens.  Primary-care physicians' Medicaid pay, historically far below that of Medicare, was raised to be equal as of Jan. 1 as an incentive for more doctors to see Medicaid patients.

"We’re a state that has 17 percent -- approaching 20 percent -- seniors over 65 that are on Medicare," not to mention the oncoming Baby Boom Generation, Corcoran said. "What do we do with their access (to care) issues?"

Recommendation coming soon

Corcoran's committee is scheduled to meet today to discuss changes in state workers' coverage that will be required to comply with the new law.

Both committees will hold a joint meeting Monday morning to hear the latest cost estimates. They will then meet separately to come up with their recommendation. And then the matter will go through all the regular committees that would have some say in the matter. It could be a long, hard slog.

One of the most important factors in the Legislature's decision could be the cost-benefit report that the state's chief economist, Amy Baker, is scheduled to present at the joint hearing  Monday.  Her team has been doing a new, more sophisticated cost-benefit analysis of Medicaid expansion using a million-dollar software program that was custom-built for Florida by a team at Monash University in Melbourne, Australia.

The economic-modeling software takes into account Florida's unusual taxation system, its industries and other pertinent information so that it can yield an estimate that should be closer to the mark than forecasts of the past, Baker said.

The most recent forecast from Baker and the legislative budget commission was that the 10-year cost to Florida to expand Medicaid would be about $3 billion -- with $5 billion as an upper limit. But Baker said that forecast, conducted on an older economic-m0deling system, did not fully consider "ripple" effects from the stimulus of billions of dollars coming to the state from Washington.

--Health News Florida is a service of WUSF Public Media. Contact Editor Carol Gentry at 813-974-8629 or by cell at 727-410-3266, or by e-mail at

Carol Gentry, founder and special correspondent of Health News Florida, has four decades of experience covering health finance and policy, with an emphasis on consumer education and protection.