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FL's Health Care Dispute: A Conversation

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WJCT
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Jacksonville's public-radio call-in show First Coast Connect on WJCT 89.9 hosted a discussion Monday of Florida's stalemate over health-care funding.

Health News Florida Special Correspondent Carol Gentry took questions from host Melissa Ross and a number of callers, all of them irked at Gov. Rick Scott's standoff with federal officials over whether Florida should accept billions of dollars to cover 800,000 of the state's low-income uninsured.

Here is a transcript:

Ross:
Now, a couple of years ago, Scott really startled supporters when he went on TV to say he dropped his long-standing objections to the Affordable Care Act.  Now though, Scott says that admission was not true. It’s the latest twist in the governor’s long-running dispute with the feds over Medicaid expansion in the state. That dispute resulted in the state legislative session shutting down three days early. Lawmakers have to go back in June to try to hammer out a budget and figure out what to do about health-care funding. Lots to discuss here.

On the line we welcome Carol Gentry, special correspondent for Health News Florida. She’s been covering the story.

So Carol, Gov. Scott was known - he even ran for governor - his signature issue being opposition to Obamacare, the Affordable Care Act. Two years ago the governor - after his mother passed away - the governor went on TV to say he dropped his objections to the Affordable Care Act. Now he’s saying that’s not the case. Let’s talk about the reasons why.

Gentry:
I found it interesting. I have listened to the tape of him explaining why he changed his mind several times, and I don’t quite understand it. The Associated Press sent out a story saying that Scott in effect said he had made up the whole thing as a ruse to just get the federal government to give Florida a waiver that it wanted at the time. The waiver  of course being  to turn all Medicaid patients in to managed-care plans. So the governor’s office angrily came back and said, “He did not say any such thing.” So I went back and I looked at the tape on The Florida Channel several times, and if you’re familiar with Gov. Scott, you may know this feeling of not understanding what he’s talking about. It was just too convoluted.

Ross:
Right, yeah, the governor is denying that there was any ruse. But shortly after he made that announcement two years ago, Florida got the federal waiver so that private companies can manage Medicaid benefits in the state for more than 3 million residents.

Two weeks ago, Scott sued the federal government saying that President Obama is illegally coercing the state to expand Medicaid to more of the working poor. What about that allegation from the governor’s office?

Gentry:
Right, I’m familiar with it. He is responding to some memos that came out of the Centers for Medicare and Medicaid Services about a month ago that could be read that way. It’s sort of like the situation with Gov. Scott himself. CMS was saying it would really help your case if you were expanding coverage because expanded coverage means you have more insured people, you have fewer uninsured people, you don’t have as much charity care that you have to make up. So the two are related in a funny way, and it’s ridiculous to say they’re not related. But he is using that as the basis for the federal lawsuit.

Ross:
Gov. Scott  is saying he shouldn’t be forced to expand Medicaid. Financial terms for Medicaid are better than they were. Right now Florida’s paying about 40% of the bill, the federal government  paying 60%. If Florida were to accept the Medicaid expansion, the feds would cover the entire bill at first and then 90% after a period of time.

Of course, the Florida Legislature shut down three days early over this because the Senate was in favor of taking the federal dollars, the House wasn’t. Can you explain why  the members of the Florida House were so opposed to taking these dollars to cover low-income Floridians?

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Credit WUSF Public Media
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Carol Gentry, special correspondent, Health News Florida

Gentry:
Well, it has been a real challenge to try to figure that out. I have heard so many different excuses or rationalizations or reasons, depending on your point of view. And some of them are contradictory. For example, the other night one of the House Republican members was on a political program on TV and at one point he said, “We can’t accept the federal dollars because the federal government is going bankrupt and we cannot in all conscience  add to that problem and we can’t count on them to continue to pay for it.” But then later in the program he said, “We would take the federal dollars if they just didn’t have any strings attached, if they’d give us a block grant.”

So I’m tending to think it’s a situation where they don’t want the feds to have any say-so over what Florida does with the money, even though the feds would be paying almost all the bill.

Ross:
Right and the statehouse saying they don’t trust the federal government to come through with the money the way that it’s being proposed.

Gentry:
Right, and it may be helpful for people to understand that this goes back to the creation of Medicaid, back in 1965. The reason that the feds were given some power over what the states do with this money is that really, if there weren’t that power, states could take the money and build a stadium with it, or whatever. So under the law the feds do have the right and responsibility to make sure the money is spent in accordance with regulations.

Ross:
The stakes are high over this too, Carol. Florida’s budget has this huge hole in it. The lawmakers must pass a budget by July 1, they’re going back into session June 1. Do you anticipate they can come to terms on this at all?

Gentry:
I don’t know. I wish I did. They don’t have a choice. They have to come together because they have to have a budget by, well realistically, at least a week before July 1 so the governor has a chance to read it and sign it. But it may not look like an animal we know. It may have the front of a camel and the back of a rhinoceros. It may be a combination of ideas that is really bizarre.

(Caller: Dennis from Atlantic Beach: It’s quite obvious that Gov. Scott decided to change his position because it was politically expedient.  He was running for re-election… worst governor we’ve ever had.)

Gentry:
He is not the only one who thinks that… it was curious timing, I will say that. And right now, the political reporters are saying he is guarding his right flank, he does not want someone even farther to the right than he is to go up against him if he runs for the U.S. Senate seat.

I am not a political reporter and thank God for that. My role is to tell people how the health care system works. …

(Caller: Craig from Arlington: I hate to be a ditto head, but I agree with the last caller. I watched on Florida Channel, I was kind of laid up with my hip recently and I watched that play out.  The House has stomped on Florida's constitution… the amendment we passed for the environment, the fact that they adjourned (early). The governor just stood by and laughed, and filed suit. That’s the leadership we’re getting from the Republicans these days.)

(Caller: Bud in St. Augustine: I’m the third ditto, head I see no redeeming characteristics with Gov. Scott. This guy knows a lot about the hospital business, he certainly understands how to make money in the private sector off it… I think he’s completely and absolutely disingenuous. I think if the money were given with no strings attached, these they could care less about health care, especially the health care of the poor.)

Ross:
Gov. Scott did go to Washington to meet with the Secretary of Health and Human Services trying to persuade that office to extend this money even without a Medicaid deal. He came back empty-handed.  How do you see the governor’s stance playing out? What’s the end game here?

 Gentry:
 I know there are those who assert this was all about a photo op. I don’t know that. I know that Sec. Burwell of HHS, that he met with, that she met with a bunch of hospital executives before she met with him. They were clamoring just as loud for the Low Income Pool money. There are I think nine states that have these pools for charity care... they all want their funding.  Florida is the first to come up for renewal since the feds said they were going to stop putting money into that.

Now that the states have 100% federal funding to cover the uninsured  with Medicaid, they say we shouldn’t keep giving you money to dole out to hospitals, that just doesn’t make any sense.  She’s listening to people. But given the statements HHS has made, I don’t see that it makes any sense for them to continue to fund the charity care pool unless they get some significant movement by Florida and the other states toward providing up-front coverage for primary and preventive care, especially diabetes…

Ross:
The governor said he wanted more information about hospital profit margins.

Gentry:
Right after he was elected the first time he set up a commission to look at publicly financed hospitals that received tax money from local hospital districts. There were a lot of people who were afraid he was attacking them. He didn’t get the answer he wanted from the first panel.

This time he’s appointing all the members – last time the Senate President and House Speaker were each given an equal number of appointees.  So it seems that he wants to make sure he has control over the members of that panel. That leads me to believe he wants a certain outcome.

What he said last week I had to check to make sure it wasn’t in The Onion. He was quoted as saying that hospitals that had profits should share their profits with the hospitals that don’t. I just couldn’t believe that he said that.  Because that is about as opposite of his point of view up to date as anything I can imagine.

Ross:
Right, in the past he’d been focused on private-sector view of health care and really opposed to any additional public funding, he wanted to keep it mainly in the private sector. The CEO of UF Health, the former Shands-Jacksonville, has been quite vocal about this issue,  in saying that if the state legislature doesn’t resolve this quickly, the hospital will close. How many safety-net hospitals around the state are facing this possibility?

Gentry:
Well a lot of them say they are. And it’s a good question.  I think it would be fascinating to deconstruct the money that goes into and out of hospitals, how do they spend their money? I would love to know. I would love to see a commission that is not political look at that. How do they spend their money. Because if you’re paying $1 for an aspirin, that means you’re paying 30 cents for nursing and what, 40 cents for...

But this is not that kind of arrangement, this is political, it appears political, entirely.

(Caller vents about Scott)

Gentry:
Based on Gov Scott’s experience in the private sector, it is very surprising that he would want to ask hospitals to share their profits among one another. That is completely antithetical to his past.

Ross:
The House is more ideologically driven than the Florida Senate, which is seen as a more moderate body. How do you see public pressure from constituents affecting lawmakers as they go back into session to resolve this?

Gentry:
I don’t think, not one in 100 people understand how the health care system works, which is why I’m still covering it 40 years after I started, trying to explain how it works.   It’s very easy to fool people. If a constituent were to complain to a House member, “Why won’t you cover the poor?” That House member might say, “Well, we cover the deserving poor, the parents of young children who have no income, the elderly, the frail.”

I think—I don’t just think it I know it, I have heard it said over time – there is this idea among members of the House that people who don’t work are lazy and do not need to be rewarded by getting any benefits. That is what’s behind this…

(Caller—The Senate is much more moderate. They are not as stressed for financial dollars for upcoming elections, so they can represent the moderate people of Florida. They want the Medicaid dollars. The House, however, is looking for money for their next election.  They are looking for money from the 1%. Right now those people are making money off acute care and emergency care.  There is less money in preventive care. That’s why nurse practitioners in this state and Alabama do not have full prescription power.)

Ross:
It is true that the Affordable Care Act does change the entire delivery and payment system for health care. There’s a big change in terms of the preventive care model. What about what that caller said?

Gentry:
She was obviously well-informed. I think it’s good to point out that 80% of people didn’t have their insurance change at all. People tend to forget that. For the ones who lost their insurance because it didn’t cover everything the law required, they were able to get other plans, I don’t hear from anybody who can’t get insurance.  

I think it’s 19 million more people are insured now than there were five years ago. That’s considerable, that’s huge, if you take a step back and look at it from way up high. But the harder-to-reach people, the people who work but don’t get benefits through their jobs, those people are harder to reach. It’s going to take an extra effort to reach them; we can do it, but the state has to want to do it.

The Senate plan is not a straight Medicaid plan, it has all kinds of interesting private-sector rules attached to it.

Ross:
A tweet from a listener: Is Gov. Scott’s concern legitimate that down the road, Florida would be stuck if the federal health care funding ends?

Gentry:
All of us are always up against uncertainty. We don’t know whether our job will end, we don’t know if our 401K will still be worth what it is today. I think what he’s doing is saying, because they’re Republicans they’re visualizing a Republican President in 2017, winning in 2016, and a Republican Congress. If they were to defund all of that, yes, Florida would lose (that money) because of the election. But that’s hypothetical.

Ross:
So what are your final thoughts?

Gentry:
I would like for everybody out there to listen for the talking points. I went through the packet that the House Republican caucus passed out to their members. It included a list of talking points.

If you listen closely, they say exactly the same thing. They sound like little parrots. It would be funny if it weren’t  so sad.

Ross:
She’s Carol Gentry, special correspondent for Health News Florida. Thanks for joining the show.

Gentry:
 You’re welcome.