Florida health officials have received a letter from the Centers for Medicare and Medicaid Services (CMS) putting a halt to plans to significantly expand a pilot program that moves the state's Medicaid program into the private arena.
Medicaid provides medical coverage to low income individuals and families. In Florida, it covers nearly 3 million people (including almost 27 percent of the state's children) and costs about $20 billion annually. Its services are administered by Florida's Agency for Health Care Administration, but because costs are shared by the state and the federal government, modifications to the program require federal approval.
In 2006, then-Gov. Jeb Bush launched a pilot project that moved thousands of Medicaid recipients into managed care plans controlled by private insurance companies or medical provider networks. Since its inception, the project has been restricted to five of Florida's 67 counties: Baker, Clay, Duval, Nassau, and Broward. Now some lawmakers would like to see it go statewide. The CMS is saying, in effect, "not so fast."
Gov. Bush's plan received a speedy and favorable review by President George W. Bush's administration but the Obama administration may not prove as accommodating. CMS said in its letter that it needed details on how the state proposes to change the program before it issues a waiver (the pilot project currently is set to expire on June 30).
While the CMS stated that, "We require a plan to review before the additional authority can be granted," it does appear willing to work with the state to continue and perhaps expand the program. However, the details needed by CMS are stalled in disputes between the Florida House and Senate.
Florida Chambers Must Agree
The Republican-controlled House and Senate both have proposed Medicaid bills but they are far apart on language. They chambers agree that they would like the program to go statewide but beyond that there are major sticking points. Among the issues: The Senate has said that the state should withdraw from Medicaid if CMS does not allow the expansion, a criteria with which the House does not agree; the Senate also wants to divide the state into 19 managed care regions while the House wants only eight.
SB 1972, sponsored by Sen. Joe Negron, R-Palm City, was passed out of the budget committee on April 14 by a vote of 17-4. It includes a proposal that would cap the amount of money the state spends each year on Medicaid and force mid-year cuts if costs go up. The House Medicaid bills, HB 7107 and HB 7109, sponsored by Robert Schenck, R-Spring Hill, were approved by that chamber last month.
In addition to conflict between the chambers on legislative details, the two major political parties view the recent news from CMS far differently.
House Speaker Dean Cannon, R-Winter Park, remains hopeful and optimistic that the Legislature will pass a bill acceptable to federal officials by the end of the session.
Rep. Elaine Schwartz, D-Hollywood, the Democratic ranking member on the House Health & Human Services Quality Subcommittee, issued a statement calling the decision "a huge relief. With so many unemployed Floridians desperately needing health care and relying on Medicaid, this decision gives us confirmation that someone up there is watching out.
"Despite the state's attempts to cover up details and hide data about what has really occurred under the pilot Medicaid program, the feds have rightly taken notice that taxpayers' dollars have not been adequately accounted for and quality care has not been accessible to the most vulnerable citizens," Schwartz said.
"House Democratic Caucus members have repeatedly demanded evidence from state administrators about the performance of the pilot program," she continued. "In these pilot project counties, we are aware of many people, including those who are blind, disabled and suffering from mental illnesses, who have been unable to access needed care without jumping through needless bureaucratic hoops, and health providers have not always been compensated for the care and services that they have delivered."
Lawmakers need to reach consensus quickly. Florida's legislative session is set to end on May 6.
Problematic Program
The pilot program has been controversial from the start. Supporters said it would improve services and save money. Opponents said it simply placed another level of bureaucracy on an already burdened process and caused delays in medical services. Over the years, a number of providers in Broward County have pulled out of the project, claiming they could not make sufficient profits; provider plans representing two-thirds of the market share in 2008 are no longer participating in Broward. Patients have complained of difficulty in making appointments with specialists and of lapses in care.
In April, Georgetown University's Health Policy Institute released a report commissioned by the Jessie Ball duPont Fund that sought to assess the Florida plan. To the question, "Has the pilot program saved money?" the report stated, "The 2008 report noted that there was insufficient data available to draw conclusions. That still appears to be the case." The report also noted "significant turnover in participating plans in all counties" since 2008.
According to a synopsis provided by researchers, other key findings of the study include:
- There is no clear evidence that the pilot programs are saving money, and if they are whether it is through efficiencies or at the expense of needed care.
- Little data is available to assess whether access to care has improved or worsened under the pilot program.
- Children, parents and people with disabilities who rely on Medicaid have experienced enormous disruption as a result of plan turnover in Broward, Duval and surrounding counties. Patients appear to be "voting with their feet" and moving from HMOs to provider sponsored networks.
- Certain features of Medicaid reform, such as the opt-out program designed to encourage the use of employer-sponsored insurance and the enhanced benefits program designed to encourage healthy behaviors, lack evidence to suggest they are achieving their goals and may be an inefficient use of scarce funds.
CMS likely will need to be convinced that the plan has brighter prospects than those found in the Georgetown study.
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