I’ve never met the man, and I don’t mean this personally, but Florida Gov. Rick Scott is an idiot. Rather, more specifically, the way he has managed Florida’s Medicaid expansion, or lack thereof, is idiocy on the altar of political ideology and kneejerk Republican healthcare doctrine.
Other governors are fighting Medicaid expansion, of course. It’s a major battleground in the implementation of the Affordable Care Act (ACA). But Scott, 62, and governor since 2011, has raised his resistance to the level of high political theater that defies commonsense and hurts Florida residents.
If you haven’t been following this lately, here’s a quick recap: In April, Scott filed suit against the federal government (HHS) over federal funding for a special Florida program, launched in 2005, called the Low Income Pool (LIP). The funding—due to be about $1.3 billion in 2015-16 and combined with about $1 billion in state funds—compensates safety-net hospitals for care of low-income, uninsured people. It’s set to expire on June 30 and must be reauthorized by HHS.
Scott and Florida claim in the suit that HHS is trying to force the state to expand Medicaid against its will and in violation of federal law—that law being the now-famous 2012 Supreme Court decision that gave thumbs up to constitutionality of the ACA but nixed the law’s mandate requiring states to expand Medicaid. Medicaid expansion is thus voluntary. (A half dozen or so Republican governors who were initially opposed to Medicaid expansion have relented; the most recent are in Utah and Missouri. To date, 29 states plus DC have expanded Medicaid under the ACA and 17 have not. In four states, including Fla, it’s being debated.)
The Obama Administration denies that its actions in Florida are tantamount to bribery. Instead, the White House and HHS say their approach is legal and based on the judgment that the LIP program is now an inefficient use of taxpayer dollars—essentially compensating hospitals twice (via Medicaid and LIP) for money they lose on treating the uninsured, illegal immigrants, and Medicaid recipients. HHS does not deny, however, that it would strongly prefer that Florida look at the facts and conclude that Medicaid expansion would reap more federal dollars for the state and expand access to coverage and care to more Floridians at reasonable cost to the state.
The stand-off and lawsuit threw the state’s budget process into disarray, since Scott’s budget counted on the LIP funds. The budget was due May 1. But the state’s lawmakers couldn’t agree on the Medicaid expansion and Scott’s approach. The state Senate supports it and wants Scott to back down; the House opposes it and supports Scott. That forced Florida lawmakers to call a special session, to start June 1, to hammer out a budget and Medicaid compromise by June 30. The stand-off also forced Scott to order state agencies to develop contingency plans for a government shutdown.
Faced with tough criticism from the state’s hospitals and advocacy groups for the poor, Scott also quickly convened a commission to study whether hospitals were using federal and state funds efficiently. The commission, made up mostly of business leaders and Republican donors, held its first meeting on May 20. It concluded that a truly informed judgment on the issue could not be rendered before the June 30 deadline.
Then, in an unexpected move on May 21, HHS announced preliminary approval of a $1 billion LIP program for fiscal 2015-16, less than half of what the state wants and hospitals say they need. In 2016-17 and beyond, the program would be authorized to spend no more than $600 million in total, combining fed and state finds, HHS said. In addition, the feds told Florida Medicaid regulators they could not use the funds to compensate for care of people who could be covered by a Medicaid expansion. “Coverage rather than uncompensated care pools is the best way to secure affordable access to health care for low-income individuals, and uncompensated care pool funding should not pay for costs that would be covered in a Medicaid expansion,” the HHS/CMS letter to Florida officials says.
How these requirements will play out politically and legally is not yet clear. Also unclear at this writing is whether Scott will drop the lawsuit or continue to press his case. HHS’s action—which some are calling a significant concession—would seem to resolve the immediate budget crisis, but only if Scott agrees and the state and HHS reach an agreement. (We’ll update this post in the days ahead as needed.)
Several relevant facts as this story develops:
Florida has one of the highest uninsured rates in the nation, with about 25% of people under age 65 lacking coverage.
Medicaid expansion in the state would cover an estimated 800,000 people; 90% of the cost would be picked up by the feds under the ACA.
Florida was one of the chief plaintiffs in the Supreme Court challenge to the ACA’s constitutionality, the case that led to the 2012 decision on Medicaid. Scott led the charge.
Scott was a hospital executive from 1987 to 1997. He resigned as CEO of Columbia/HCA, one of the nation’s largest for-profit hospital chains, in 1997 amid controversy over Medicare billing. While Scott was never personally charged with wrong doing, the company copped to 14 fraud violations and agreed to repay $600 million, then the largest healthcare fraud settlement in history. Scott’s net worth in 2013 was put at $132 million.
Jeb Bush, then governor of Florida and now presumed presidential candidate, initiated the LIP program in 2005. He recently said he hoped Florida lawmakers could reach a compromise on Medicaid expansion.
Marco Rubio (R-Fla), a presidential candidate, and other Florida Republican lawmakers sent a letter to the White House on May 20 supporting Scott’s approach and demanding full LIP funding. A House hearing is planned.
Apart from his staunch anti-federal government/state’s rights beliefs, Scott has argued that Medicaid is not the best way to expand health insurance coverage among low-income people in Florida and that doing so would risk busting Florida’s budget in the future. He has never produced evidence of either, and he has never proposed an alternative path to coverage expansion in the state.
In the debate over the LIP, Scott claimed that families covered under the program are a different population than that covered by Medicaid. PolitiFact Florida took a look at this statement and on May 11 said: Not so. Quoting Harvard health policy professor Ben Sommers, PolitiFact Florida said, “Chances are that most of the uninsured making these uncompensated ER visits are the poorest patients [that is, people who would qualify for Medicaid]….in broad strokes, the main people who benefit from the LIP would benefit even more from the Medicaid expansion and ACA Marketplace coverage.” 
On May 15, the Tampa Bay Times opined: “If this is leadership, Gov. Rick Scott should skip Tallahassee to find another Wawa to open….he has taken a smoldering fire and poured on the gasoline.” In an op-ed yesterday, the paper called for Scott to accept the state Senate’s approach and negotiate a deal with HHS. I agree. 
Republicans in Florida and nationwide should reconsider their ideologically-driven resistance to Medicaid expansion. Medicaid is far from a perfect program, and states are going to have to plan carefully as they expand the program; more Medicaid managed care will likely be required, a shift Florida made several years ago. But the numbers to date are clear: 6.5 million people who were previously uninsured are now covered under Medicaid, about half the 12 million new Medicaid enrollees since the ACA became law.
As for Scott, the days ahead will tell if he cares more about scoring political points or helping low income people in his state.
Steven Findlay is an independent journalist who covers medicine and healthcare policy and technology.