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Behind the Scenes at FMA

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Dr. Larry Floriani
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The Florida Medical Association surprised many this week when word came that its House of Delegates embraced a resolution calling for the legislature to expand Medicaid, the state-run program that's supposed to cover low-income people.

The money to do so, an estimated $51 billion over 10 years, had already been set aside by the federal government to begin in January this year, but the state House of Representatives refused to take  it. The FMA delegates want the Legislature to change its position.

In addition, their resolution called for state Medicaid officials to raise doctors' pay to the amount paid by the federal Medicare program, a concept called "parity."

Since FMA's meetings are not open to the public, Health News Florida looked for someone who was there who could describe what happened. Dr. Lawrence Floriani, an orthopedic surgeon in Tarpon Springs, volunteered.  Floriani, a delegate to the meeting from the Pinellas County Medical Society, is also deputy state director of Doctors for America, which has pressed for coverage of the uninsured.

Floriani was co-sponsor of one of the resolutions calling for Medicaid expansion, along with Dr. Owen Linder of Safety Harbor. In the end, the House of Delegates adopted a similar but more comprehensive resolution authored by Dr. Aaron Elkin of Hollywood.

Health News Florida Editor Carol Gentry spoke on Monday with Dr. Floriani, who began with a bit of history:

Floriani: Well, up to now, the FMA has been silent on the issue, and their reasoning was basically that there are a lot of issues that the FMA addresses with the Legislature. And given the political climate, particularly the stand of the Speaker of the House Will Weatherford (who was opposed to the Affordable Care Act in general and Medicaid Expansion in particular), they basically were told if they wanted anything done by the Legislature on behalf of organized medicine, they should not push the Medicaid expansion and that was at least part of the reason that I believe they remained silent.

Gentry: So what changed?

Floriani: I don’t  know that anything has changed with the leadership. I believe that what changed is the physicians themselves, the delegates, almost 300 of them who make up the House of Delegates, I believe they changed. I believe the physicians have come to realize that expanding  health care to 800,000 Floridians who are suffering without it was a good thing, a necessary thing, and something that they should get behind.  That’s really what changed.

Gentry: So it bubbled up from the grassroots?

Floriani: Yes, I think that’s exactly where it finally came from.  There were physicians who testified in the reference committee, where the various resolutions are heard before they are brought to the floor of the House of Delegates. These physicians really, they were passionate about the fact that they take care of a lot of indigent patients, they care about these patients, but their hands are really tied in seeing  them and trying to give them good quality care when they have absolutely no access to any kind of health insurance, no funding to help them, they’re really just poor. These physicians were just plain tired of not being able to do the best that they could do for these people. They fully intended to keep seeing them, but it came to the point where they said we need this. There were probably close to a dozen of them that gave that kind of testimony when these resolutions were being considered. So I think that’s where it came from. And none of the practicing physicians there testified against it.

Gentry: Did anybody express worry that it might anger the Legislature?

Floriani: Yeah, well the president of the FMA did. The immediate past president, Dr. (W. Alan) Harmon (of Jacksonville).

Gentry: Oh I see. How did he put it?

Floriani: Well, it was basically that this was an issue that might set the Legislature against the FMA and that they had to trade off what they thought was most important. And if they wanted to get other issues such as scope of practice, telemedicine, things of that nature dealt with, then they could not push Medicaid expansion. So they felt that in order to keep the Legislature on their side they would not push Medicaid expansion. Actually as it turned out, the House of Representatives went ahead and pushed bills on both of those issues that were not to the liking of the FMA, in spite of the fact that the FMA gave in on the Medicaid issue.

Gentry: But it’s still the people at the top who have to push it, right?

Floriani: Yes, that is up to the leadership. But they do have an obligation to honor the resolution that the House of Delegates has passed, so we will see what they do in response to this. Yes, that is at this point unknown.

Gentry: I heard it was an overwhelmingly positive vote.

Floriani: Yes the way it worked, actually it was an extraordinary circumstance.  People who’d been there for years said they can’t remember when a reference committee’s recommendations were universally accepted without debate. It was a shock to those of us who were prepared to have to debate and defend the resolutions; it just was a marvel, it was marvelous. It was extraordinary.

Gentry: Well ok, and tell me about the part of the resolution that had to do with parity of pay. I thought that already got passed.

Floriani: But it’s never really been enforced as far as we can tell. Physicians are still complaining that they don’t get paid anywhere near Medicare levels. There’s an economic limit as to how many indigent patients a doctor can treat without any reimbursement, and how well he can provide treatment if their care is totally unfunded. It was important that some recommendation to pay physicians reasonably became part of this, because it really goes to the heart of access to care. Care will be limited as physicians  fill up with a certain number of patients who are non-paying and finally get to the point where they say, I can’t see any more of them. Poor pay – and I’m talking about poor pay, pay that may be somewhere around half of Medicare levels – it really hampers patient access, and we’re not talking about giving doctors a lot of pay, because Medicare payment rates are  not considered by anyone to be extravagant.  So the Medicare parity of pay for Medicaid patients, it really is important so the physicians who really care for these patients can actually take care of them.