(This is the second part of a series of stories previewing issues for the 2018 legislative session.)
Battles over health-care spending and regulation of Florida's vast health-care industry are likely to command a great deal of time and attention when the Florida Legislature convenes in January for its annual session.
Lawmakers are again expected to engage in a tug-of-war about what type of regulations should be in place for health-care facilities, but a main focus will be on Florida's strained safety-net health program at a time of tight state finances.
Florida's Medicaid program already costs $26 billion and covers an estimated 4 million people.
A July snapshot by the Kaiser Family Foundation estimated that Medicaid along with a major children's health-insurance program provide coverage to two out of every five low-income people in the state, half the state's children and more than three-fifths of all nursing home residents.
The bulk of money for Medicaid comes from the federal government, but this year more than $6 billion comes from general revenue, the state's main budget account funded primarily by sales taxes.
House Health Care Appropriations Chairman Jason Brodeur, R-Sanford, said hurricanes Irma and Maria put “a bit of a strain” on the budget he oversees, and as a result that could hamper any requests for new social-services spending.
“From the explicit costs of providing more health and human services to a larger than anticipated population, to the implicit costs of things like the overtime paid to our (state employees) who are in charge of registering and providing (benefits) to all those new enrollees, all of those costs must be paid for before we can start looking at new programs,” he said.
Nevertheless, Brodeur said members have filed more than 200 requests to fund local projects “which is the exact opposite of `small government.' ”
During the 2017 session, legislators agreed to change how the state pays nursing homes to provide care for the poor and seniors who rely on Medicaid. Lawmakers decided to scrap a longstanding system where nursing homes have been paid based on audited cost reports and agreed to implement a prospective payment system where payments are determined in advance, regardless of the intensity of the services provided.
While lawmakers agreed to change the payment methodology, they delayed implementation of the new system until 2018. Brodeur said the conversion “is our next step in efficiency.”
Senate President Joe Negron, though, wants the Legislature to do more than pull the trigger on the prospective-payment system. He wants to increase the amount of money the state directs to paying nursing homes.
“That's a very strong priority of mine,” said Negron who, quoting Sen. Lizbeth Benacquisto, notes that the average Medicaid-funded nursing home resident in Florida is an 85-year-old woman.
“These are the women who shaped our communities. We have a responsibility to give them the highest level of care,” Negron said.
The Stuart Republican also said he would like to help the industry offset the costs of generators that Gov. Rick Scott has mandated for nursing homes after deaths at a Broward County nursing home following Hurricane Irma. Negron predicted that the generators “will ultimately be a shared endeavor between the state and the industry.”
But Negron's push to increase reimbursement for nursing homes and offset the costs of generators also comes at a time when two state agencies are requesting funding to help plug deficits.
The Agency for Persons with Disabilities is asking for $34 million in general revenue to help cover a $89 million deficit in a Medicaid waiver program that enables developmentally disabled people to live in communities instead of institutions. Also, the Department of Health is requesting $25 million to plug a shortfall in the Children's Medical Services program, which pays the health care costs for medically complex children covered by Medicaid.
Negron downplayed the deficits in the programs and the effects they could have on new funding requests during the 60-daysession, which starts Jan. 9.
“You have to make difficult decisions,” Negron said of crafting the state budget. “That's why I think the budget process is fascinating.”
While the annual budget is the only bill the Legislature is required to pass when it meets, it isn't the only piece of health-care legislation that members will focus on.
Indeed, there are hundreds of bills filed for consideration, from requiring birth centers to report adverse events to state health care regulators (SB 510 and HB 673) to authorizing new needle-exchange programs to try to prevent the spread of infectious diseases (SB 800 and 579).
The Legislature will once again consider passing a bill that would allow ambulatory surgical centers to keep patients overnight. Florida law currently requires the surgical centers to release patients the same day they are admitted and cannot keep patients overnight.
“It's silly that people have to be discharged the `same work day' and not 24 hours. The marketplace could open up for consumers if they could adjust their schedules for the 24-hour standard,” Brodeur said.
The legislation (HB 23) is already ready for the House floor. While the House bill also would authorize and license so-called “recovery care centers,” to provide post-surgical and post-diagnostic care to patients for up to three days, the Senate version (SB 250) would only authorize overnight stays at ambulatory surgical centers.
Sen. Greg Steube, a Sarasota Republican sponsoring the Senate version, said he does not plan to take the House bill as it has been drafted. “It's my intention just to get the 24-hour piece done,'' he said.
The House also is poised to vote on a measure (HB 27) that would eliminate a controversial regulatory program for hospitals that's known as certificate of need. Bill sponsor Rep. Heather Fitzenhagen, R-Fort Myers, said ending the regulations would remove “barriers to entry” and increase competition in the hospital industry.
“I think competition is healthy in almost all settings,” she said.
But critics have raised questions about how lifting the regulations, which require state approval of new facilities and programs, would affect older public hospitals that provide a wide array of services.
And while the legislation is touted as eliminating artificial barriers that impede competition, the bill would only eliminate so-called CONs for hospitals. New nursing home beds and facilities would still be regulated by the CON program.
The Florida Health Care Association, a statewide nursing-home group, has lobbied against legislative efforts to eliminate CONs for long-term care providers.
House Health Quality Subcommittee Chairman Rep. James Grant said he supports eliminating CONs for hospitalsÂ and nursing homes but said he won't vote against Fitzenhagen's bill for not including nursing homes.
“Some repeal is better than no repeal,” Grant, R-Tampa, said.
The Senate does not have a companion bill, though, and the potential CON elimination is opposed by much of the powerful hospital industry.
Florida Hospital Association President Bruce Rueben said certificate-of-need requirements have ensured that low-income communities and rural communities have access to inpatient, acute-care health services.
“CON deregulation would allow a proliferation of these services in affluent communities and undermine hospitals serving communities with high numbers of uninsured and underinsured Floridians,” Rueben said.