During the heated debate in Florida’s legislature over the expansion of Medicaid, children’s health advocates contend that the precarious status of the state’s uninsured children was slighted.
They vow not to let that happen again.
The legislative session, which ended in May, left the state as one of 20 that decided to forgo increased federal funding. Had the Medicaid expansion been enacted in Tallahassee, it is estimated that more than 1 million Floridians would have been provided access to health care through the $51 billion the state would have received for the program over 10 years.
“The energy was really focused, and rightly so, on Medicaid expansion, but lost in the maze of rhetoric was the importance of getting that passed, not only for low-income individuals and families, but for children,” said Linda Merrell, coordinator of the Florida Child Healthcare Coalition.
This summer, as advocates work on “getting Medicaid expansion back on the table,” she emphasized that time will “be devoted to raising significant awareness that this [Medicaid expansion] is about closing gaps for children as well.”
Despite Gov. Rick Scott’s endorsement of Medicaid expansion after avowing to oppose it, his party’s Republican-dominated Florida House successfully shut down enactment of the law that would have raised the eligibility ceiling for Medicaid for individuals up to 133 percent of the Federal Poverty Level.
One concern voiced by opponents is that the expansion would have allowed single, childless men – a cohort not eligible under the state’s current program – to become covered under the new expansion criteria. Little discourse, however, was directed at the consequences for children in the decision to decline the federal funds.
Florida ranks second in uninsured children
Ranking second in uninsured children, Florida has an estimated 500,000 children, or 12 percent of the state’s population, who are uninsured. The predictable result is that those children receive less primary care and have a higher mortality rate than their insured peers. Taxpayers are paying skyrocketing costs to cover the uncompensated care expenses hospitals incur from attending to the medical needs of children in emergency rooms when their parents cannot afford to pay those bills.
The current situation is an irony not lost on Merrell. Her involvement in children’s issues reaches back to 1998, when Florida was one of three states chosen to launch a federal pilot project for what would become the State Children’s Health Insurance Program (SCHIP), which had been enacted the previous year.
She recalled the federal law as a bipartisan deal successfully brokered by Senators Ted Kennedy, a Democrat, and Utah’s Republican Orrin Hatch. Merrell explained that the current structural complexity of Florida’s children’s health program, now known as Florida KidCare, was also the result of political compromises; each state was allowed to fashion its own version of the law to qualify for federal funds.
Of state versions of SCHIP, Merrell asserted, “We have the most complex law for it in the nation.” She said the program has been administered by four different state agencies which, even when operating with good intentions, are often hamstrung by internal administrative procedures and systems that have yet to be reconciled, although some improvements have been made over time. Merrell argued that one key benefit of Medicaid expansion for children would be leveling of the bureaucratic obstacles of these “stair-steps” as more parents are brought into coverage.
States, collectively, seem to face a universal problem of identifying children who are eligible for health care coverage. School enrollments are an obvious source of obtaining records, but Merrell pointed out that even once identified, retention of those children in a treatment regimen is also problematic.
“Even if children have coverage, unless the parents are covered, they are less apt to bring them in for appointments,” she said.
“What we know and what the research shows is that uninsured children are more likely to become insured when their parents become insured,” agreed Nicholas Duran, health care coordinator with The Children’s Movement of Florida.
Duran, who is leaving his position to work for Enroll America, a non-partisan organization that will focus on educating the public about the state’s federally mandated health insurance exchange, thinks he will be able to leverage public support for Medicaid expansion in his new role. Translating public awareness into civic action, he says, will be crucial to ramping up pressure for enactment of Medicaid expansion when the legislature reconvenes in 2014, or if they are called into a special session.
“Many people don’t know what to do, but ask, ‘How can I help?’” Duran said. “The answer is constituents going to their elected officials and letting them know how this policy impacts their lives. The people have to realize that their voice does count.”
Leah Barber-Heinz, advocacy director of Florida CHAIN, also views the run-up to the looming Oct. 1 medical insurance exchange as an ideal time to better inform the public about Medicaid expansion. She said a more engaged public could provide the push needed to move the legislature forward. Barber-Heinz noted that the Republican-controlled Senate had passed a bill in support of expansion.
“Sen. Joe Negron’s bill was just what we needed and would have provided the state funds to draw down federal money,” she said, referring to the money Florida would have had to commit in three years after receiving 100 percent of federal funding for Medicaid expansion in 2014 through 2016.
While Democrats rallied to support enactment in both chambers, even on the House side, Barber-Heinz said her organization also was pleased to recognize Republican state Rep. Mike Fasano as a champion of Medicaid expansion.
Impact of term limits
Yet Fasano’s very presence in the legislature speaks to one of the obstacles health care advocates in Florida encounter: the impact of term limits. First elected to the Florida House, Fasano was later elected to the Senate. Term-limited after two four-year stints, he ran for and won his old House seat in 2012.
Typically, however, unlike the experience Fasano brings to the legislative process, the institutional memory about a policy issue follows term-limited legislators out the door. When term limits occur, “you have to start over with the education of new legislators,” observed Barber-Heinz. “There’s a great deal of education that goes into public policy, especially in health care because it’s very complicated.”
Karen Woodall, executive director of Florida Center for Fiscal and Economic Policy, agrees. “Term limits have damaged the process because the legislators want to become leaders,” she explained, but with an eight-year cap, the path to leadership is through toeing the line of the incumbent leadership’s expectations, not through developing a mastery of policy. She added that outside money flowing into the state to fund anti-Medicaid expansion efforts has helped impede the process.
Woodall has a great appreciation for the protracted and often tortuously cumbersome task of passing state legislation. “It took 10 years to pass the breakfast program in Florida,” she said, referring to an initiative similar to Medicaid expansion in that most of the funding came from federal funds, with a smaller state funding match. “It takes three to five years to pass anything good.”
Nevertheless, the child health care advocacy community feels emboldened that Medicaid expansion will occur in a shorter timeframe. Merrell notes that the legislature came close to passing a law that would have lifted the state’s current five-year ban on lawfully residing immigrants from receiving Medicaid benefits. “These children are here lawfully and deserve to get coverage,” she exclaimed. “Even in the midst of the debate over immigration reform, people want to see these children covered.”
Observers are skeptical that a special session on Medicaid expansion will be called, but note that legislative committees begin evaluating and developing policy options and strategies well before the next session convenes in March 2014.
Woodall added that public pressure on legislators cannot be underestimated. “In order to expand Medicaid,” she said, “it’s going to take people going to their representatives’ offices and saying, ‘What are you doing? How could you not pass a law that’s going to benefit a million people?’”
This article is part of ongoing coverage by New America Media on the Affordable Care Act, supported by The Atlantic Philanthropies.
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