Millions of uninsured Florida families and healthcare providers are in a purgatory of sorts.
Gov. Rick Scott and the Republican-led Legislature want to privatize the state's Medicaid program, but need the Obama administration's permission. The Obama administration wants to make more low-income Floridians eligible for Medicaid, but needs Scott and the Legislature to agree.
The sides have been negotiating a package deal for more than a year and won't comment. Without a solution billions of federal dollars could go to other states and many uninsured Floridians will continue to receive their healthcare in emergency rooms—the most expensive, least effective place. Safety nets, like community health centers, say they don't have enough funding to keep up as more uninsured patients end up in their waiting rooms.
"So many states are in a bit of a holding pattern until after the election," said Joan Alker, co-executive director of the Georgetown University research center.
Florida's Medicaid program currently costs more than $21 billion a year, with the federal government picking up roughly half the tab. It covers nearly 3 million people—about half are children—and consumes about 30% of the state budget.
In an effort to cut costs, the state has been trying to privatize Medicaid—rather than having government insurance, patients would be assigned to for-profit insurance companies, which would receive a per-person fee from the state and decide what services and prescriptions to cover. A five-county pilot program showed little or no savings, however, but Scott and the Legislature still want to take a revamped version of the program statewide.
Meanwhile, Florida has some of the most stringent eligibility requirements in the country. A family of three with income of $11,000 a year makes too much and single residents are not covered. The Obama administration wants those requirements loosened so that an estimated 2 million uninsured Floridians could be covered by Medicaid. Feds will pick up 100% of the tab for the first three years and at least 90% after, along with extra funding for technology costs.
But Scott says Florida can't afford any additional costs.
State economists said Florida would pass up $2.1 billion in federal money while saving $3.9 million in the next budget year if everyone eligible for the expanded program participated. The state's share would increase over time, but even by the 2020-21 budget year Florida would pay $487 million compared to the federal government's $4.2 billion contribution.
Legislative leaders have mostly stayed quiet on the issue and it seems unlikely that Scott, a staunch conservative who forbid state agencies from accepting money tied to Obama's healthcare overhaul, will change his mind.
Carol Weissert, a political science professor at Florida State University, said despite Scott's strong political stance there's been relatively little backlash over his decision not to expand Medicaid.
"We have high uninsured populations in Florida and unfortunately they don't vote," she said.
Meanwhile, Sandra Bell, a 55-year-old single mother and school crossing guard from Miami, struggles to pay her $200 a month prescription costs for diabetes and hypertension. She makes too much to qualify for Medicaid during the school year, but qualifies for Medicaid during the summer.
Bell has made several trips to the emergency room in the past year because she ran out of insulin. More recently, she visited the ER to get a tooth pulled after developing a painful infection.
Florida hospitals admitted nearly 200,000 uninsured patients during fiscal year 2010-11 and their emergency rooms treated 1.8 million uninsured patients—that's about 1 in 5. Hospitals absorbed $2.8 billion in uncompensated costs, according to the Florida Hospital Association.
"We're not talking about spending a lot more money. We're talking about spending the money we're already spending differently," said Bruce Rueben, the association's president.
Sen. Joe Negron, who heads up healthcare, said he'd like to see Medicaid resemble private insurance where recipients choose from a list of commercial plans tailored toward patients with different needs, including HIV and diabetes.
"Rather than just saying, 'This is the government plan for Medicaid, here's your Medicaid card, you'll go where we tell you to go,' this frees people to be informed medical consumers, to shop around," said the Stuart Republican.
Negron said lawmakers may consider a program that Floridians can purchase if they don't qualify for Medicaid but can't afford private insurance.
"Perhaps there would be state involvement in that ... Right now, Medicaid is growing so fast in cost that it's really inhibiting our ability to try some creative things."
As state and federal negotiations continue, more patients are relying on safety nets like community health centers. Experts say the one-stop shop helps doctors better coordinate care for the patients by monitoring them over time, saving money by diverting them from emergency rooms for less-serious issues. Borinquen Medical Centers in Miami has a state-funded ER diversion program with three local hospitals.
Florida community health centers, including Borinquen, have received more than $111 million under the Obama healthcare plan: city and county governments are eagerly accepting the windfall, even if Scott won't.
The number of patient visits to Borinquen jumped from 15,897 in 2008 to 26,123 in 2011, a two-thirds increase. But funding only increased by $250,000 during that time, said CEO Bob Linder.
The center charges patients $25, even though the average visits costs about $140. More than half of those patients are uninsured. Thirty-five percent are Haitian—many who were displaced by the 2010 earthquake, he said.
Nineteen year-old Madochee Gregroire is ready to give birth any day and gets weekly pre-natal care even though she is unemployed and doesn't have health insurance. The teen moved to Miami from Haiti after the earthquake.
"When I came here people take care of you. They know that you need them."