That rate of uninsured, at almost 25 percent, is the second highest in the United States, where each of the 50 states is grappling with the pressing need to change the way health care is delivered to all citizens — but especially to those who remain uninsured.
Political battles have been so clamorous that the point of it all may sometimes seem obscured. But there is a simple pragmatism, at bottom: Citizens with insurance tend to care for themselves before problems become dire. That costs less. Citizens without insurance, usually working people with low incomes, wait until they face emergencies. That costs more and they can’t pay. Ultimately, businesses and individuals who pay for insurance pick up the extra tab. That has to be fixed.
Here, Florida Weekly explores how those fixes should be made — or not made — through the eyes of hospital administrators and caretakers, people who work with indigent and uninsured citizens every day, and political advocates.
Most of them agree on at least one notion: Politics may be obscuring common sense when it comes to accepting more than $50 billion in federal money earmarked to insure the poor between now and 2020.
The money is part of a program called Medicaid expansion. Republican leaders in the state House of Representatives have blocked it so far although their Senate colleagues both Republican and Democrat have said Florida should embrace Medicaid expansion, and take the money already available. Not to do that is a costly strategy for every citizen in the state, they insist.
“If you do not act, over $1.2 billion will be lost during the 2013-2014 fiscal year and billions will be left on the table in future years,” wrote U.S. Rep. Kathy Castor, a District 14 Democrat (Tampa and St. Petersburg) in a Feb. 28 letter to Florida House Speaker Will Weatherford and Senate President Don Gaetz, both Republicans.
Rep. Weatherford, who hails from Wesley Chapel in District 38 just north of Tampa, continues to lead the opposition to Medicaid expansion. He did not respond to a call and an email message from Florida Weekly asking him to comment, and Rep. Castor said she had no reply from either Rep. Weatherford or Sen. Gaetz.
Nor did Rep. Weatherford mention Medicaid expansion in his address to legislators kicking off the 2014 session, which ends May 3. But he did characterize the session as “a furnace for ideas — a melting pot of opinions and viewpoints,” and a place where “we are going to cut taxes — a lot of taxes.”
That’s politics, apparently.
“Politics, politics, politics. That’s all this is,” says the Rev. Israel Suarez, founder of the Nations Association in Fort Myers where indigent people are fed and helped each day, almost all of them without medical insurance. “How you think these people are going to get help? A lot of them work. But they don’t make enough to buy insurance, you know?”
He spoke from the open-door food pantry behind his headquarters where people black, white and brown queue up daily to receive meals.
Rev. Suarez chats with them about jobs, asks about family members or friends and commiserates when they say they’d prefer not to have their names mentioned or their pictures taken.
But for many, that mostly anonymous and sometimes soup-line reality is not about politics — not even in an election year or for Republicans such as State Sen. Rene Garcia of Hialeah. She joined members of the state League of Women Voters in a public statement last week that questions the judgment of her fellow party members in the House.
Instead, it’s about money, however you define it.
“This is not about politics — it’s about policy and being consistent and taking care of our own,” Sen. Garcia said, urging House leaders to embrace Medicaid expansion and bring in the money.
Others agree regardless of political persuasion, including businesses and regional chambers of commerce in Florida. The Greater Tampa Chamber, for example, argues that “using these dollars doesn’t lock us into one kind of program or another. Florida can design its own program that is not traditional Medicaid expansion.”
And it describes the headwaters of the big money that would pay for Medicaid expansion — money provided originally by Florida taxpayers — this way:
“The funding has already been made available through cuts to other programs. The federal dollars set aside to extend health care coverage were funded through reductions in Medicare and Medicaid payments to hospitals, taxes on health insurers, and taxes on durable medical equipment. Floridians will absorb these funding cuts and taxes whether the legislature chooses to use the federal funds or not.”
That’s the rub, and it’s nothing more than an accounting problem for officials who manage Medicare (a health insurance program for those 65 and older, or disabled, or living with kidney failure) and Medicaid (a health care program primarily for low-income people), some say.
“If you took the politics out of it — if you quit saying, ‘I don’t want to support this because it’s Obamacare and I’m a Republican’ — if you said, ‘It’s our money, we’re shifting it to the hospitals or primary care doctors and clinics to help these uninsured people,’ you could save a lot of money,” explains Jim Roach, a Republican candidate for the state House of Representatives in Lee County’s District 77.
“It’s another example of a political discussion that is not really political. It’s an accounting discussion,” he adds.
But not for those who either oppose or remain deeply skeptical of Medicaid expansion, both in principle and on practical terms.
Gary Aubuchon, a Lee County builder who served for six years in the State House before losing in a 2012 race for the U.S. Congressional seat won and recently relinquished by Trey Radel, sees the problem this way, based on his Michigan childhood in a lower-income working family.
“The real issue here is personal responsibility. When my parents were young they went to the doctor and paid the doctor for service. They paid for what they needed. They didn’t go to a doctor unless they were sick. Fast forward to a couple generations later, and Americans are generally unhealthy. We have diabetes, childhood obesity, people not taking care of themselves. But the bottom line shouldn’t be that government takes care of you.”
Such debate engenders caution in some and fear in others.
“We are very supportive of anything that enables more people to have access to health care,” says Tom Rice, the CEO of Fawcett Memorial Hospital in Port Charlotte. “However, since the Florida legislature has not yet passed new Medicaid expansion legislation, we do not yet know any specifics on how our patients’ coverage would be impacted.”
Dr. Allen Weiss, president and CEO of NCH Healthcare System in Naples, notes that, “In Collier County now, people tend to be fearful — they just don’t know what to make of the health-care debate.”
Bottom line, he adds: “It’s not so much that expansion is essential, but that it sure would be helpful. And particularly for people who get insurance, because there is cost shifting in health care. When we have people who can’t pay, we have to charge people who can pay a little more. It’s an offset. And it’s a little like Robin Hood.”
The devil’s details
To understand Medicaid expansion, a few more facts and details may be helpful.
The money, paid into the federal system previously by Florida taxpayers, would provide medical insurance for the poorest citizens, those with incomes of no more than 138 percent of the Federal Poverty Level. In 2014, that would amount to about $16,100 for a single person, or $32,900 for a family of four.
Whether they get insured or not, says Jim Nathan, president and CEO of Lee Memorial Health System, they’re going to get care.
At Lee, the fourth-largest public health system in the United States and the region’s largest employer with 10,500 staffers who see patients more than a million times a year, 11 percent of inpatients are uninsured, and even more out-patients, officials say.
The hospital receives no direct taxpayer support, and it stands to lose more than $40 million this year alone in Medicare cuts that were designed to be made up for by Medicaid expansion.
“Even if Florida doesn’t bring federal money back to care for the uninsured,” says Mr. Nathan, “they will still get their health care by camping out in emergency rooms and waiting too long, until it becomes a major problem.”
Nobody on any side of the debate denies that.
“A million people in Florida don’t have insurance,” Mr. Nathan adds. “So the real impact of all this is not on them so much as on 18 million others, and on visitors.”
And there could be another significant loss to Florida besides the $51 billion in earmarked Medicaid expansion money, or the double hit on hospitals such as Lee Memorial which are now also receiving significantly fewer Medicare funds — a loss few are talking about yet, says Rep. Castor.
That’s $4.5 billion in Medicaid money from something called the Low Income Pool, which state leaders have applied for to help pay for underinsured and uninsured patients.
“That is ironic to say the least,” wrote Rep. Castor.
“On the one hand, the state is blocking Medicaid funds, but on the other, the state has its hand out for billions of dollars of Medicaid funds. I anticipate that HHS (the U.S. Department of Health and Human Services that manages all Medicare and Medicaid programs) will be very skeptical of this approach.”
The upside, with questions
A University of Florida study of Medicaid expansion conducted for the Florida Hospital Association and published one year ago to analyze its effects suggests that expansion could prove a potent boon — not just to the uninsured, but to hospitals, businesses and the job-market bottom line, as well.
In Lee County, for example, Medicaid expansion would result in the addition of 4,160 full-time, permanent jobs, the data show. In Collier, that figure would be 2,402 jobs, and in Charlotte 814.
Between now and 2023, according to the report, “the cumulative employment impact (in Florida) represents an average of 121,945 ongoing permanent jobs, and the value-added impact represents an average of $8.97 billion annually.”
Impressive as those numbers may be, some remain deeply wary of the plan to accept federal money, but recognize the practical advantages.
Chauncey Goss, who, like Mr. Aubuchon, lost in his 2012 bid for a U.S. Congressional seat that now remains open before a June 24 special election, offers this view of Medicaid expansion:
“The pragmatic answer to Medicaid expansion — which is the one taken by conservative governors like John Kasich in Ohio — is to take the money and expand the program. Medicaid expansion will provide extra coverage for the indigent and nearly-indigent who need it. If Florida does not take the money, it will be spent by another state, which helps deflate the ‘we don’t want to add to the deficit’ argument against taking the money.”
But the pragmatic answer rankles Mr. Goss just on principle.
“As a conservative, I don’t necessarily like the fact that Washington takes money from the state’s taxpayers and returns it in dribs and drabs for Washington designed programs. Whether it’s funding for transportation, navigation, education or Medicaid, I would much prefer to never have to send our revenues to a middle man for redistribution.”
And Mr. Aubuchon adds this, in a nod to the logic of House speaker Will Weatherford:
“Speaker Weatherford’s concern and mine is, the federal government has a long history of developing new programs and putting a carrot out there for the states, and saying, ‘We will pay for a majority of the cost, and this will benefit citizens of your state’ — and then they put the financial burden back to the state level. If I was still in the Florida House, I would be concerned with that.”
Florida’s U.S. Sen. Marco Rubio put that concern this way, in a January interview with CBS’s “Face the Nation”:
“Under Obamacare, when you turn Medicaid over to the states, what you’re saying to them is the money will be available up front for the expansion for a few years, then the money will go away but you get stuck with the unfunded liability.”
The comment expresses concern, but it misrepresents the details of the federal plan and the observations of political analysts. Medicaid expansion will pay all costs for three years in Florida, and then 90 percent of all costs in perpetuity according to the current law.
The gravity of American history
But accurate or not, Sen. Rubio’s argument is part of a political debate that comes with a history.
And that history suggests that the federal government has been completely reliable when it comes to both Social Security and Medicare-Medicaid.
“When you look at the history of Medicaid, this important federal and state partnership, the federal government has been there every year since 1965,” explained U.S. Rep. Castor in a telephone conversation.
“Right now, Medicaid serves the disabled, children, and seniors in nursing homes. The expansion will cover our neighbors who are in poverty. This is a whole lot smarter than having everyone who has insurance pick up the tab for people who don’t have it. And it’s not fair to people who have insurance. You’re asking them to pay twice. First, to pay federal taxes, and then to pay again if Florida doesn’t recoup those taxes.”
Both Mr. Nathan at Lee Memorial and Dr. Weiss at NCH Healthcare have pointed out that caring for citizens too old, too young, too disabled or too poor to care for themselves has been an American social problem for only about 80 years, since President Franklin Roosevelt signed the Social Security Act in 1935.
That was one of three great changes in the way Americans take on care. The second came 30 years later, in 1965, when President Lyndon Johnson amended the Social Security Act by signing Medicare and Medicaid into law. Both are managed by the U.S. Department of Health and Human Services, but states establish their own guidelines for individuals who can qualify for Medicaid.
The third change came in 2010 when the Affordable Care Act was signed into law and confirmed as the constitutional right and responsibility of Americans by the Supreme Court.
“I see this as the third pillar of economic security in America,” said Rep. Castor. “First, Social Security, then Medicare and Medicaid, and now health-care reform.”
Medicaid expansion was designed to work in tandem with the Affordable Care Act. While every state must now comply with the tenets of ACA, each state may decide for itself whether to accept Medicaid Expansion.
But as of this month, 23 have not, including Florida. ¦