Earlier this month the Florida Senate Health Policy Committee unanimously approved an alternative to the Medicaid expansion provision contained in the Affordable Care Act, dubbed the “Health Insurance Affordability Exchange (SBB7044).” And on Wednesday the bill was passed through it’s final committee hurdle (Appropriations), the last step towards being presented to the full Senate for a vote.
The legislation would expand health insurance coverage to low-income Floridians who currently fall into the coverage gap — defined as those who earn too much to qualify for existing Medicaid eligibility, but too little to qualify for subsidy assistance on the federal marketplace. Under the Senate proposal eligible residents would, with several strings attached, be able to purchase private insurance using public funding. In general it’s extremely similar to other plans from conservative states that were ultimately accepted by the Obama administration.
But at this point the particular details of SBB 7044 are not the most contentious element in this process. While passage by the full Senate body is probable, and Governor Rick Scott has previously stated that he’d sign an expansion bill if it hit his desk, the endeavor would have to be adopted by the very conservative and recalcitrant Florida House of Representatives. According to Scripps reporter Matt Dixon the sun isn’t exactly shining in that corner.
If you’ve been paying attention to the post-ACA health politics era then this might seem familiar too you because this scenario has played out before. In 2013 a more moderate Republican-controlled Senate passed a Medicaid expansion alternative and a more conservative Republican-controlled House of Representatives basically said “No, we’re not dealing with this.” Not wanting to start a bicameral fight, Republican Senators more or less passively watched the legislative session end with no action taken towards providing coverage for hundreds of thousands of low-income state residents.
The state House’s current stance is a repeat from that year, but the broader circumstances have changed significantly. This time there is a looming billion dollar budget hole from an existing agreement with the federal government that expires at the end of June, which conditionally provide funding to hospitals for treating uninsured patients through a Low Income Pool. The state was able to secure a one year extension for the Section 1115 Medicaid waiver that has been in place since 2005, but the Center for Medicare and Medicaid Services (CMS) has signaled that the demonstration project will not continue (indeed, the last renewal essentially came with the warning).
Governor Scott, Speaker of the House Crisafulli, and others would like to see that funding continued under a new deal, although as far as I know the state hasn’t submitted a new proposal. Rather, they seem to be awaiting CMS’ indication of what they’ll accept in lieu of the current agreement — as long as it isn’t called Medicaid. But it’s not difficult to see why the administration doesn’t want to renew the waiver: there is a more efficient, more comprehensive solution that happens to address this same problem of uncompensated care for indigent patients. It just also happens to be called Medicaid.
Despite their insistence that the state’s urgent need for federal LIP funding is a completely separate matter from their rejection of federal money to expand Medicaid (in a March letter to President Obama, Scott wrote that the state’s request is “not associated with Medicaid expansion in any way […],” and that the state won’t budget any contingency to make up the potential shortfall), both are lines of support that benefit the state’s public budget, the state’s health care industry, and the state’s low-income population. Beyond the merits of efficacy and scope, the most prominent difference is that LIP funding doesn’t hold the same political stigma as Obamacare.
Senate Republicans, on a practical level, are admitting this cognitive dissonance. Their governing response to losing federal contributions for indigent care is to gain a greater amount of federal contributions for indigent care. They also understand that, in the process, a compromise can be had that results in a more conservative health policy outcome. The game now is to convince Crisafulli and others that they have the ideological and political cover to go along. One could see this on display Wednesday, as although the Committee’s affirmative vote was never in doubt the panel spent the entire allotted debate time essentially subtweeting the House.
And it is very important that House Republicans recognize all of this, because the consequence of their current choice is to just suffer the budgetary and humanitarian fallout. For everyone else that outcome is unacceptable. As Senator Don Gaetz (R) remarked at one point, “‘No’ is not a health care policy for some 800,000 Floridians.”