As we move thru 2011, many states are eagerly progressing with implementation of the Affordable Care Act (ACA). We have many Early Innovators that are leaders in setting up the state based exchanges. These states are Kansas, Maryland, New York, Oklahoma, Oregon, Wisconsin and a multi-state entity led by the University of Massachusetts Medical School that consists of Connecticut, Maine, Massachusetts, Rhode Island, and Vermont. Furthermore, Vermont is poised to pass the country’s first state-wide single payer system.
You can imagine when I look in my own back yard I get a bit depressed. Despite our 80 degree sunny weather, our state is leading the charge to overturn the ACA. Our newly elected governor, Rick Scott (the past CEO of Columbia/HCA when the company pleaded guilty to MCR fraud and paid $1.7 bil fine) is singularly focused on not implementing the ACA in Florida. As the months go by and other states move forward, we continue to move backwards.
As expected, it is the poor and sick that continue to suffer the most. The current assault occurring in Florida is on Medicaid. Medicaid currently covers close to 3 million Floridians (nearly 15% of the population) at a cost of nearly $19 billion dollars. The cost of each state Medicaid program is a burden shared jointly by the states and the federal government. For every $1 spent by the state, the federal government matches $1.84. Florida Medicaid already has one of the most restrictive eligibility criteria in the country, such that the only people who can qualify for Florida Medicaid are: 1) low-income infants, toddlers, preschool-age children, and pregnant women; 2) extremely low-income school-age children, seniors, people with disabilities; and 3) parents of children in deep poverty. 60% of FL Medicaid recipients are children.
So this so called ‘safety-net’ has some gaping holes in it. It leaves the working poor with no insurance options. The ACA calls for an expansion of Medicaid eligibility so that poor who make less than 133 percent of the federal poverty level would become eligible. Currently, that means a single person who makes $14,404 or less, and a family of four that has income of less than $29,327 could be on Medicaid. Instead of trying to strengthen this safety net and help insure more Floridians, the governor and legislature has stated that the cost of expanding Medicaid is a burden our state cannot handle. They may not be aware that during this expansion, the federal government would match the spending initially at 100% and then drop to 90% by 2019. This would offer coverage to 1.5 million previously uninsured Floridians by 2019 at a cost of between $149 million in 2014 and $1.1 billion in 2019
The state of Florida has instead chosen to press forward with a plan to privatize Medicaid. In 2005, then Gov. Jeb Bush began a pilot program to privatize Medicaid plans in 5 counties. This plan has been met with much criticism both from providers and beneficiaries. Concerns were raised back in 2007 by AHCA Inspector General Linda Keen regarding the plan’s success. Georgetown University researchers raised issued and noted that some doctors couldn’t afford to provide care to Medicaid patients under these plans. The University of Florida released an analysis of the pilots in 2009 that revealed some modest cost savings but made no analysis of quality or accessibility of care.
These plans reimburse physicians at 58% of Medicaid reimbursement rates. Some of my colleagues find that seeing these patients actually costs them money. This has obviously led to low acceptance and participation by providers.
I currently participate in 5 private Medicaid plans. Four of them require paper claims for reimbursement as well as onerous authorization procedures. I currently care for a 4 year old child with recurrent seasonal wheezing that has concomitant growth delays. I have attempted to treat her with a leukotriene modifier drug. Her private Medicaid provider denied my request, insisting that I use a generic nebulized steroid preparation. I engaged in a peer-to-peer review to try and get approval (that lasted 15 minutes over the phone), after exhausting 3 levels of paper prior authorizations. The friendly doctor I spoke with apologized that the drug could not be approved and when pressed for a reason, his answer was clear- COST. My patient will have to be placed on a medication that could further stunt her growth when a safer option is available, because her privately administered Medicaid insurance plan needs to make more profit.
I am amazed at how history repeats itself. Did we learn nothing from the failed experiment of privatizing Medicare? As a reminder, Medicare Advantage programs cost taxpayers 14 percent more than traditional, fee-for-service Medicare. This additional cost did not contribute to better care for seniors. It surely lined the pockets of the insurers with big profits. The same thing will happen in Florida if we agree to let Medicaid become a private endeavor. And millions of Floridians will again be left poor, sick and uninsured.
We will fight to implement the ACA because it will benefit Floridians. Amazingly, doctors are united in their push back against the plan to privatize Medicaid. I take some solace in that, and will continue to vicariously enjoy the improvements being made in other states across the country.