One of the biggest loss leaders in Florida's deteriorating budget is Medicaid, but, as of now, lawmakers are reluctant to pursue reforms that could save the state billions of dollars.
Senate President Mike Haridopolos is leading the charge against the new federal health-care law, saying, "I don't think there is anything more important than balancing the budget and health care. We're going to fight for what is right."
Last week, the Senate Health Regulation Committee voted to block a portion of the federal health-care mandate requiring individuals to buy health insurance or face penalties. The full Senate is expected to pass Haridopolos' measure when lawmakers convene next year. But the Senate president's resolution also requires a vote of the people, which would not take place for two years.
Meanwhile, Florida's costs for Medicaid, the indigent-care program, are expected to rise from $21.3 billion to $23.3 billion in 2011. Expenses will climb even higher as the federal health-care law moves more Floridians into Medicaid.
"The number is going to be big," state budget analyst Amy Baker warned.
To stanch the fiscal hemorrhage, the conservative Heritage Foundation says Florida could save $28 billion over five years by simply opting out of Medicaid. Though that might sound like a radical move, it dovetails philosophically with Attorney General Bill McCollum's lawsuit challenging the constitutionality of Obamacare.
Opting out also matches legislators' determination to pass a constitutional amendment to prevent the federal government from compelling people to participate in any health-care system. Both the House and the Senate have listed the resolution -- AJR 1 and SJR 1 respectively -- as their first order of business in 2011.
THE BENEFITS OF OPTING OUT
Starting in 2014, Medicaid is scheduled to expand to include anyone with incomes up to 133 percent of the federal poverty level, which is $29,327 for a family of four in 2010.
Heritage analyst Edmund Haislmaier says that in states which drop Medicaid, the program's low-income clients would instead receive federal subsidies to buy private insurance through state exchanges, also due to take effect in 2014.
States opting out of Medicaid would become wholly responsible for remaining Medicaid patients who require nursing homes and other long-term care, for premiums and other Medicaid costs for Medicare beneficiaries.
But Haislmaier says that would be a net gain for Florida because everyone else would go into the insurance exchanges.
"Florida would save up to $3.8 billion in 2014 and save $28 billion over the first five years," he projects, contingent on how the plans are designed.
Texas, whose five-year savings are pegged at $45 billion, is among the states actively considering quitting Medicaid.
Incoming Gov. Rick Scott, a former health-care executive, may be amenable to such surgery in Florida.
But Joe Negron, chairman of the Senate Health and Human Appropriations Budget Committee, says the opt-out option isn't on the table. Instead, his panel is exploring a host of reforms that he believes will make the existing system more cost-efficient.
Declaring that he and other senators are starting with a "blank page," the Stuart Republican said he is, among other things, looking at Arizona's use of performance bonds to cut Medicaid costs.
Negron said lawmakers also are zeroing in on optional medical services covered by Medicaid. He declined to specify which "soft services" might be on the chopping block, but said, "If you're not feeding, housing or providing medical care to someone, we can't afford to do what you're doing.
"In other words, if you're in the advice and guidance business, and you're giving out information and hectoring and lecturing the citizenry, we can't afford your programs and there's a number of them like that," Negron explained.
NURSE PRACTITIONERS HAVE A PRESCRIPTION
Alternatively, or additionally, Florida's 12,000 nurse practitioners say they can help the state reduce its Medicaid expenses -- if only the state would let them.
Citing a 1997 Tennessee study which reported millions of dollars in Medicaid savings through expanded use of nurse practitioners, the group's Florida association estimates that similar reforms in Florida could reduce this state's Medicaid bill by $1 billion a year or more.
Currently, Florida and Alabama have the strictest limits on the scope of care that can be provided by nurse practitioners. Widening their responsibilities to include the full range of prescription writing and the ability to commit mental-health patients would bring down costs while broadening access to care, the practitioners say.
"As time passes and more medical students graduate and become specialists in their chosen fields, the general public will still need a primary practitioner to oversee their general health care and preventative care.Nurse practitioners and physicians' assistants are able to tackle this," Cocoa-based nurse practitioner Terri Polito Jordan told Sunshine State News.
"If we work together, like so many other states, we all win.If patients can be seen at an earlier date or more convenient time, we have happier patients," Jordan said. (See previous Sunshine State News story here.)
Sen. Don Gaetz, a member of the health committee and a former hospital executive, is cool to the nurse practitioners' initiative, saying they have "attempted to expand their scope of duties on a number of justifications."
Gaetz, who chaired the Health Regulations Committee over the last two years, said, "I've heard testimony that costs would decrease. My guess is that even if costs would stay the same or increase, nurse practitioners would still like to expand.
"The doctor shortage in our state can only be resolved by keeping and attracting more physicians," the Niceville Republican said. "We cannot rely on the scope of nurse practitioners as a primary strategy."
Newly elected Sen. Rene Garcia, R-Hialeah, who chairs the Health Regulations Committee, did not return phone calls seeking comment.
PHYSICIANS, HOSPITALS AND 'MANAGED CARE'
The Florida Medical Association, which staunchly opposes an expansion of the nurse practitioners' duties, has a different approach to Medicaid and physician issues, which could complicate lawmakers' efforts to curb costs.
"We will continue to advocate for increasing the reimbursement rate for Medicaid to that of Medicare, or at the very least ensure that physicians have the opportunity to control the disbursement of Medicaid funds in any type of capitated system," said Erin VanSickle, spokeswoman for the FMA.
"The FMA also supports efforts to preserve patients access to care in Florida, including increasing state funding for residency slots and providing sovereign immunity to emergency-room physicians," she said.
On the other hand, VanSickle added, "The FMA opposes efforts to move Medicaid patients into Medicaid HMOs and will oppose any mandate to participate in Medicaid as a condition of physician licensure."
Bruce Rueben, president of the Florida Hospital Association, said his organization is committed to pursuing managed-care options for Medicaid and supports an extension of a federal waiver -- due to expire in June -- that allows the state to experiment with such programs.
Rueben notes that managed care doesn't necessarily mean commercial HMOs, but, rather, any groupings of organizations and patients seeking to contain Medicaid's spiraling costs.
Noting that pilot programs have yielded mixed results in Broward and Duval counties, Rueben said the FHA may seek to revive and tweak last year's House bill on managed care.
"We're looking at all options," Rueben said.
Editor's Note: This story is part 3 in a Sunshine State News series analyzing how the conservative swing in the Senate will affect policies, including tort reform, education and health.
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Contact Kenric Ward at kward@sunshinestatenews.com or (772) 801-5341.
