Just as House lawmakers were putting together their annual “trains” — cramming multiple, tangentially related bills into hundreds of pages of amendments so they could pass them all at the 11th hour — a funny thing happened. They upped and quit.
On April 27, House Speaker Steve Crisafulli prematurely banged his gavel, ending the session, leaving the Senate holding the bag on this year’s biggest, most contentious issue: Medicaid expansion under the Affordable Care Act. Now a group of Senate Democrats has sued the GOP-dominated House, and as of this writing, the Florida Supreme Court says the lower chamber must explain its abrupt adjournment.
In a nutshell, the House doesn’t want Medicaid expansion but the Senate does. The upper chamber has a nifty non-Medicaid name for it, too. The Florida Health Insurance Exchange (or FHIX) is, in name, an attempt to help GOP senators get past the program’s unpalatable association with “Obamacare.”
FHIX focuses on people who wouldn’t qualify for the old, traditional Medicaid but who can’t afford private healthcare insurance. It’s being billed as a “free market” solution, and would finally give Florida its own Internet-based healthcare exchange. (In 2012, Florida opted out of creating an exchange for the ACA, following a Supreme Court decision that said it could, and Florida residents used Healthcare.gov instead.)
The current, Senate-endorsed FHIX plan was crafted with the help of business leaders across the state, all of whom are warning that hospitals that serve indigent patients will be closing their doors if the legislature doesn’t get its act together soon. Former Jacksonville mayor and current UNF president John Delaney is chief among those sounding the alarm.
The statewide consortium advocating for expansion of health benefits to the uninsured is “A Healthy Florida Works.” The details of the FHIX plan can be found in state Senate Majority Leader Bill Galvano’s letter to News-Press.com.
Basically, FHIX is a way for lawmakers to add a Florida twist to Medicaid expansion, much like the creation of “Florida Standards” distanced the state from association with the negative connotations of “Common Core.”
FHIX requires working Floridians to pay nominal monthly premiums to get their “skin in the game” and get coverage, so that the state can draw down remaining Low Income Pool (LIP) funds and other federal subsidies for the uninsured people. The controversial LIP fund is “low income pool” money that goes to hospitals, health departments, and community-based organizations that serve Florida’s uninsured, including our working poor.
A cursory look at the proposal reveals the “free-market plan” resembles former governor Jeb Bush’s Med-waiver plan (see below) more than traditional, “straight” Medicaid. The key difference? Under the new FHIX plan, LIP money would decrease as Florida moves closer to universal coverage.
LIP was the brainchild of former governor Jeb Bush. Bush got permission from the feds to outsource some Medicaid services to private companies through programs known as Med-waivers, and was permitted to relay any overage funds to the LIP cache. (The right-leaning Heritage Foundation has published a study that found favorable outcomes for Med-waiver participants, as compared to their traditional Medicaid cohorts nationally.)
Proponents of the waiver-and-LIP combination say the programs save money. While it’s true that about 250,000 uninsured people qualify for Med-waiver programs, that still leaves more than 600,000 uninsured, according to a graph-meme Republicans published on Twitter. The website for “A Healthy Florida Works” reports its goal is to insure one million uninsured Floridians, but the number that would benefit is generally reported at 800,000.
The high number of uninsured Floridians begs the question: How would the Medicaid waiver and LIP combo “save money,” as Republicans claim? The ostensible answer is that the waiver programs pay out 5 percent less to private companies than Medicaid would.
But there are two main problems with the projected savings, one of which, identified by Politifact, is that Florida might have saved even more money in the long run by setting up managed care outside the purview of profit-driven companies, which put investors and shareholders first, not patients. It’s unclear if the FHIX proposal addresses the profit-motive in the insurance business.
The second problem with projecting “savings” in the old waiver-plus-LIP scheme is that there are still 800,000 uninsured Floridians. GOP logic goes something like this: “We once had three people in our family, and we worked hard to save money on our grocery bill, so why should we spend more money now that we’ve added six more kids?”
In 2012, Washington made clear that LIP was going to be phased out, because Healthcare expansion would render it obsolete. Health advocates on the ground have been preparing for the switch by planning to flip LIP beneficiaries to “straight” Medicaid. Insure everyone, and we won’t need LIP, the logic goes.
But Crisafulli insists “Medicaid does not work,” and Washington shouldn’t be engaged in deficit spending, anyway.
The Speaker doesn’t seem to mind “deficit spending,” though, when it comes to using federal dollars for LIP without expanding healthcare. And his family’s South Florida agriculture business didn’t seem to mind getting six figures of “deficit spending” in the form of farm subsidies, according to columnist Michael Mayo of the South Florida Sun-Sentinel.
As for #MedicaidDoesNotWork — which is launching like a lead balloon on Twitter — the question is, #comparedtowhat?
Last year, former Speaker Will Weatherford — Crisafulli’s predecessor in the House — cited a well-reported Oregon study as justification for not expanding Medicaid. Oregon took Medicaid-expansion dollars, and used some of them to study outcomes for randomly selected Medicaid recipients. Random selection raised the reliability of its findings.
But conclusions based on the Oregon study are as diverse as the reporters who covered it. In other words, the study is ripe for cherry-picking. Observers keep the results they agree with and discard the results they don’t like, so as to support which position they’re arguing.
The main finding Weatherford skipped over in his interpretation of the Oregon study is one that most healthcare policy experts agree on: Medicaid is no more broken than our non-Medicaid, private health insurance system. Advocates point out that, in terms of health outcomes, the Oregon experiment found the two paths to be equitable.
As the Robert Wood Johnson Foundation reports, healthcare policy researchers have discovered the real culprit driving up healthcare costs is one percent of people with insurance who over-utilize emergency rooms. Programs in Camden, New Jersey and Cleveland have aimed a laser focus on these “over-utilizers,” and have lowered costs while measurably improving health outcomes.
Targeted attention to over-utilizers could be applied to the privately insured and those covered by regular Medicaid, as well as those covered by the Senate’s proposed hybridized FHIX program. But this kind of reform happens on the front lines of care and it belongs to doctors, nurses, and hospital administrators, not politicians.
The far-right’s rationale for declining to expand healthcare coverage in Florida simply doesn’t hold water, and the business community, religious leaders, and moderate Republicans all know it.
Meanwhile, uber-conservatives in the Florida House are making fools of themselves on Twitter as they hold fast on their far-right, anti-Obamacare agenda. (Medicaid expansion is a key component of the ACA but, as mentioned above, it requires states to opt in.)
House Republican and former heir-apparent to his father’s Senate seat Matt Gaetz decried the Senate’s lawsuit over the House’s adjournment in a Tweet. The problem is, while poking fun at the lawsuit, Gaetz happened to mention two African-American senators by name:
This lawsuit reads like it was researched and drafted by Sen Joyner ... and spell checked [sic] by Sen Bullard #sayfie
The Twitter-sphere responded vehemently with charges of racism directed at Gaetz. In an odd move, the House Speaker apologized on his colleague’s behalf:
I don’t condone the Tweet by @MattGaetz.
He is an agitator, yes, but not a racist. Please accept my apology to those offended. #Sayfie
Crisafulli should be apologizing for a lot more than his colleague’s Tweet.
He walked off the job, after all, before the state’s business was done, leaving at least 800,000 uninsured Floridians without access to Medicaid.
Now, taxpayers get to shell out even more, so the legislature can hold a yet-to-be scheduled special session in Tallahassee. Lawmakers still need to pass a budget. In fact, it’s the only thing they’re really required to do.