Florida's Republican-controlled Senate, defying a powerful conservative advocacy group, has passed a budget bill that includes a customized version of Medicaid expansion under the Affordable Care Act. The measure would extend coverage to as many as 800,000 lower-income adults.
Prospects for passage in the GOP-controlled House, where Republican leaders have expressed opposition, remain dubious despite strong pressure from business and hospital groups to pass it. Republican Gov. Rick Scott in the past has expressed support for Medicaid expansion. The governor will review the final budget when it reaches his desk, a spokesman said.
But Florida's congressional Democrats say that if the state wants to win renewal from the Obama administration of $2.2 billion in federal funding to help hospitals serve the poor and uninsured, it will have to expand Medicaid. Federal officials have temporarily suspended negotiations with the state over the so-called low-income pool. U.S. Rep. Debbie Wasserman Schultz (D-Fla.) told the Miami Herald that Obama administration officials have indicated that it's less likely the low-income pool will be renewed if Medicaid is not expanded.
Meanwhile, there's some momentum in other Republican-controlled states for Medicaid expansion. The Montana Senate just passed an expansion bill, and an expansion bill was approved this week by an Alaska House panel. Still, Florida, with its huge uninsured population, is one of the two big prizes, along with Texas, for Medicaid expansion advocates.
On Wednesday, the Florida Senate unanimously passed budget bills that included expansion of coverage for adults with incomes up to 138% of the federal poverty level. The bill would transform the state's private exchange, Florida Health Choices, into a Medicaid plan exchange called the Florida Health Insurance Affordability Exchange. The federal Medicaid expansion dollars would be used to buy private coverage for qualifying residents. Beneficiaries would have to pay premiums ranging between $3 and $25 based on income. Nonpayment would result in individuals being moved to inactive status, and they could not regain coverage for six months. The bill also sets work requirements.
If the bill is enacted, the CMS would have to decide whether to approve it. So far the Obama administration has not approved other state proposals to require employment or job searches as a prerequisite for Medicaid coverage. But it has allowed some flexibility in requiring beneficiaries to pay premiums, particularly for those above the poverty level.
Despite the bill's conservative-friendly features, the conservative advocacy group Americans for Prosperity, financed by the billionaire Republican heavyweights Charles and David Koch, has mounted an aggressive campaign against the legislation, targeting key Senate Republicans who support it.
The group's lobbying campaign was denounced by some Senate Republican leaders. “ 'No' is not a solution, and I am grateful to my colleagues for working together to develop a comprehensive plan for Medicaid sustainability that uniquely suits the needs of Floridians,” Republican Senate President Andy Gardiner said in a written statement.
Americans for Prosperity also is lobbying heavily against Medicaid expansion in Montana, where the state Senate passed a Medicaid expansion bill on March 27. The group recently helped kill Republican Gov. Bill Haslam's Medicaid expansion bill in Tennessee.
Florida's Republican House leaders have said they have no intention of addressing Medicaid expansion this year. But House leaders face pressure to close a big budget deficit, which the Senate does by including $5 billion in federal funds for Medicaid expansion and the low-income pool.
“We're proud the House is standing strong in not putting able-bodied adults into a bloated and inefficient system,” said Americans for Prosperity spokesman Andres Malave.
Florida-based Republican strategist J.M. "Mac" Stipanovich said Americans for Prosperity has clout with GOP lawmakers because it has deep pockets. “I would say anybody who has a billion dollars and has a conservative agenda and supports conservative candidates that need help getting elected matters,” he said.
Others downplayed the group's influence. “The Koch bothers didn't elect any legislators in the state, though they may have helped fund the campaigns for some of them,” said Karen Woodall, executive director of the Florida Center for Fiscal and Economic Policy, a group which advocates for low-income people. “Ultimately, they answer to their constituents.”
Healthcare providers, patient advocates, and Florida Chamber of Commerce all have backed the Senate's Medicaid expansion bill. “Every day, more business leaders, more hospitals and more patients are coming forward and saying we need to close the coverage gap,” said Athena Smith Ford, advocacy director for the Florida Community Health Action Information Network.
In addition to expanding coverage, the Florida Senate bill would establish a new form of the low-income pool to help the state's hospitals with uncompensated-care costs. The state's current pool, funded by the CMS, expires in June. The CMS announced in February it would not renew the waiver in its current form.
Since 2005, the state had been receiving $1 billion to $2 billion annually to support safety net providers. The Senate bill would restructure the low-income pool to distribute funds more broadly so more hospitals benefit, Gardiner said.
The fact that the CMS has suspended negotiations on renewing the low-income pool has raised doubts if the agency will renew it in any form if the state does not also expand Medicaid, Gardiner said.
“It appears the federal government sent a clear message to our state. Both Sen. Bill Nelson, our state's senior United States senator, and Florida Congresswoman Debbie Wasserman Schultz, the chair of the Democratic National Committee, came to Tallahassee and stated they are doubtful the federal government will continue (low-income pool) funding if Florida does not expand health care coverage,” he said. “By passing our budget, which included a comprehensive plan for Medicaid sustainability, the Senate likewise sent a clear message to Floridians about our willingness to bring ideas to the table and work towards solutions.”
Nelson told the Tampa Bay Times that HHS Secretary Sylvia Mathews Burwell considers the low-income pool “paying two times for the same thing” because states can receive federal Medicaid expansion funds to provide coverage for the same population.