DeSantis signs bills aimed at health care access, but they do little to help uninsured

TALLAHASSEE — Gov. Ron DeSantis signed on Thursday the first four of six bills from a $1.1 billion package that improves health care for most Floridians who already have insurance but does little to provide treatment for the state’s quarter-of-a-million-plus uninsured patients.

The legislative package, Live Healthy, invests in growing Florida’s health care workforce so that patients can get care faster and more easily; improves services for disabled, mental- and maternal-health patients; and makes it easier to shop around for care and harder for hospitals to sue patients over medical debt.

“We’ve done a lot in Florida to really lead” on health care, DeSantis said at the Bonita Springs bill signing on Thursday, highlighting the Live Healthy provisions focused on building up the number of health care workers in the state and improving access to mental health treatment.

“You’re talking about underserved areas, you’re talking about low-income areas, you’re talking about having more flexibility for health care providers to be able to come and serve our residents,” DeSantis said.

Tampa General Hospital President and CEO John Couris said the legislative package would improve “access to health care in a reliable, reproducible, sustainable kind of way.”

But while the Live Healthy package aims to modernize Florida’s understaffed and overburdened health care system, it does little for the uninsured, with Florida’s state leaders focusing largely on improvements for those who already have coverage and rejecting the one move that many advocates say would dramatically improve health care for hundreds of thousands of Floridians: expanding Medicaid.

Making Medicaid more widely available by raising the income threshold for government-provided health insurance largely remains anathema among Florida Republicans, though some experts say their legislative agenda this session would be helped by expanding the program and drawing down billions of dollars in federal assistance.

“I detect no appetite in the Florida House to revisit that conversation,” incoming House Speaker Daniel Perez, R-Miami, told the Times/Herald in a statement. “We need to focus on expanding opportunities for people to improve their economic circumstances and access quality, affordable health care. Adding able bodied adults without dependents to the Medicaid rolls is a band aid not a solution.”

Though Perez’s Republican counterpart in the Senate has said he’s “open-minded to the discussion” of expanding Medicaid, Perez told the Times/Herald during the final week of this year’s legislative session that he believed “the Medicaid expansion debate was fully litigated by the Legislature several years ago.”

Perez’s position has been status quo in Florida for nearly a decade.

Medicaid expansion was once a red versus blue war, with most liberal states expanding after the 2012 Supreme Court’s ruling that the Affordable Care Act would stand but expansion would be up to states’ discretion. Most conservative states, like Florida, declined. Since then, holdouts have slowly come aboard, leaving Florida as one of 10 states where income restrictions leave a combined 1.5 million people — 19% of them in Florida — ineligible for both Medicaid and Affordable Care Act marketplace subsidies that would enable them to afford health insurance on their own.

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Florida’s insistence on not expanding access to Medicaid despite proof of its positive impacts reflects an evolving war over who deserves to have health care — the people who can afford to pay for it or everyone, said Joan Alker, the executive director for the Center for Children and Families at Georgetown University.

“This is a fight within the Republican party,” said Alker, “where ideological extremists … are going to keep fighting this.”

They are in “a fight with the more pragmatic Republicans,” she said.

The coverage gap: unsubsidized, unable to buy

There are 570,000 Floridians who would qualify for Medicaid if Florida lawmakers expanded the government-subsidized health insurance program to those who make up to 138% of the federal poverty level, which translates to $20,783 for an individual.

Of these, roughly half don’t qualify for federal subsidies to purchase their own health insurance in the Affordable Care Act marketplace. They make less than the federal poverty level, but not so little that they are eligible for Medicaid in Florida without expansion. A family of three must make less than $7,746 a year, for instance, for non-pregnant parents to qualify for Medicaid in Florida.

They are in what is called the “coverage gap.”

While Live Healthy expands access to free and low-cost primary health care and testing clinics, it leaves those in the coverage gap without treatment options if they find they have something, like cancer, at one of those clinics.

“Having health insurance is the top indicator of whether somebody survives cancer,” Florida Cancer Action Network lobbyist Susan Harbin said in an interview. “While there are some pieces of this bill that will benefit uninsured cancer patients, there’s definitely solutions out there on the table that we would love for the Florida Legislature to start talking about again in earnest: Medicaid expansion, closing the coverage gap, doing a Florida-style solution.”

Harbin added: “We’re really hopeful that they’ll start to have those conversations again next session.”

The Florida Senate in 2015 passed a Medicaid expansion bill including conservative policies like work requirements, but it was defeated in the House. The debate has gone nowhere since.

Currently, people eligible in the state for Medicaid include those who have met the low-income requirement and are either pregnant, have kids younger than 18, are blind, have or live with someone who has a disability or are at least 65. (Pregnant women have a higher income threshold.) Expanding Medicaid would make Medicaid eligibility based on income alone, and would raise the income threshold in general, allowing more people, including adults who don’t have children, to be eligible for the insurance.

Though state leaders have dismissed its effectiveness, health care experts widely say that states that have expanded Medicaid — with most of the cost picked up by the federal government — have found it to benefit low-income patients as well as workers in and outside of health care.

Professor John McDonough at Harvard’s T.H. Chan School of Public Health said people with insurance are more likely to go to their regular doctor instead of the emergency room. He also said Medicaid expansion invigorates the health care workforce and increases workers across the economy because uninsured people suffering from chronic health conditions could now tend to them and return to work.

“That’s what’s been found in all of the states that have expanded already,” said McDonough. “So, if the concern is we need more workers, we need more people working, we need more people working in the health care workforce and outside of the health care workforce, Medicaid expansion is a proven-tested formula to advance that goal, which is why no state that’s expanded has even looked at going back.”

McDonough summarized: “Medicaid expansion could actually be an important asset in helping to make the Senate president’s agenda successful.”

But Senate President Kathleen Passidomo, a Naples Republican who championed Live Healthy, said prior to the end of the legislative session that she didn’t believe experts like McDonough about Medicaid expansion increasing the workforce or helping to divert patients from emergency rooms, two main goals for her package.

“There are a lot of experts all over the place,” Passidomo said. “Whether you have insurance or not, at two o’clock in the morning, your primary care doctor is not available. Nobody’s available … There’ll just be more people showing up in the emergency room.”

“Resisting the wave”

Florida’s senior Republicans have their own medical experts, with a Paragon Health Institute report floating around the Florida Capitol backing up many of their policy arguments.

Titled “Resisting the Wave of Medicaid Expansion: Why Florida is Right,” the report largely cites as its evidence an October 2023 study regarding Medicaid expansion by the actuarial consulting firm Milliman that was created for the Florida Agency for Health Care Administration, which regulates Medicaid.

The Milliman study found that Medicaid expansion in Florida would cost between $78 billion and $176.2 billion over 10 years, with Florida paying up to $17.2 billion of that. The report also estimates that expansion enrollment would be much higher than anticipated, up to 2.5 million people by 2027.

“Medicaid expansion would have harmful health care effects in addition to the deleterious fiscal effects. Expansion would lead to great health care access challenges for existing enrollees,” states the report, written by Paragon President Brian Blase, a health care adviser to former President Donald Trump, according to Stat News, and former right-leaning Heritage Foundation data analyst Drew Gonshorowski.

“Recent research demonstrates that expansion has resulted in states shifting resources from traditional Medicaid enrollees, such as children and people with disabilities, and toward able-bodied, working-aged adults while creating a disincentive to work.”

But Holly Bullard, chief strategy and development officer for Florida Policy Institute, one of the groups leading the effort to get Medicaid expansion on the 2026 ballot as a state constitutional amendment, told the Herald the Milliman study was “incomplete and misleading.”

The Milliman report excluded “hundreds of millions in savings,” Bullard said. She said her organization estimated that Medicaid expansion would in fact save Florida $200 million per year.

“It’s very concerning that a report commissioned by the state of Florida using taxpayer dollars would be so glaring in omitting so many of the well-known budget savings categories that the 40 states that have expanded Medicaid have benefited from. Florida’s budget spending on mental health services, corrections, substance abuse, people who have cancer or AIDs, and many other programs would see budget savings under expansion,” Bullard said in a statement. “This is Medicaid finance 101.”

Times/Herald Tallahassee reporter Romy Ellenbogen contributed to this story.