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Making Sense of Medicaid Expansion

One million of the lowest-income adults in Florida may get health coverage on Jan. 1 as part of the Affordable Care Act, paid for mostly with federal funds. Or maybe not. It all depends on what the Florida Legislature decides in the coming four weeks.

House and Senate members and staff have spent months reading studies and listening to wonks -- supporters of Medicaid expansion like MIT's Jonathan Gruber and opponents like Tarren Bragdon of the Foundation for Government Accountability.

Claims were confusing and contradictory. So were the calculations of Florida's own budget analysts.

Chief State Economist Amy Baker told the House and Senate committees studying the health law that at various times in the past year, state forecasters calculated that Medicaid expansion would  benefit the state by $2  billion a year, cost the state $3 billion a year, or yield a net surplus of over $5 billion a year.

It was all a bit much for non-actuaries. State Sen. Eleanor Sobel, D-Broward, thanked Baker for all her presentations and simulations, adding: "Maybe one of those will actually pan out so you'll definitely be right."

As Michael Cannon of the Cato Institute put it, "There's a lot of uncertainty; there's a lot of room for error here."

That became clear right after Gov. Rick Scott said it would cost Florida $26 billion to expand Medicaid to the uninsured. It turned out he was off by 2,500 percent.

So, how can the experts reach such different conclusions? Health News Florida talked about this phenomenon with Jay Wolfson, professor of public health and associate vice president for health law, policy and safety at University of South Florida's USF Health:

"Research design is very important -- here is what we want to study, and here is the method we’re going to use, and here are the data points we think are important," says Wolfson. "Sometimes, either out of intention or  ignorance or negligence, a researcher will leave certain data points out."

In the case of Gov. Scott, he left out the $51 billion in federal funds (over the next decade).

"It happens a lot," says Wolfson. "As a consequence  of that,  those important data points don’t get put into the equation and you get different results. That’s why you have to have multiple people checking, the research design, methodology, data points, as well as the conclusion."

University of Florida researchers say that the state could gain more than 120,000 jobs if it covers those million people. But the Florida Hospital Association, which favors the expansion, sponsored that study. Does that matter?

"It matters to a point," says Wolfson. "I know the researchers at the University of Florida and they have a long history of doing really good work."

Besides, as he mentioned, the results make sense. To give health care to more people, you have to hire more caregivers.

"Unless we can look at the actual study and say that it has design flaws, and that’s going to require a statistician, an epidemiologist and an economist to sit down and then you have that war of the experts again," he says.

That's no help!

"Financial economics are a very soft science; we can look into a crystal ball and it’s not too much more accurate than predicting what your health will be five years from now," he says, "or whether you’ll win the lottery."

So what do we do?

"We don’t have to be statisticians; we don’t have to be physicists," Wolfson says. "We have to say what makes sense. Does it make sense to prevent illness in our community? Or does it make sense to say, "You know something, I don’t care. Let them get sick and somebody will pay for it later on?" That somebody will be you."

---Health News Florida is a service of WUSF Public Media. Contact Editor Carol Gentry at (desk) 813-974-8629 or (cell) 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.