Last week the Florida legislature began its regular session – scheduled to end in the first week in May. As regular readers of Say Ahhh!! know, I have been expecting a more robust debate there this year due to the expiration of the Low Income Pool funding that Florida receives through its Section 1115 waiver on June 30, 2015. But I have been surprised by how aggressively the Senate has moved ahead on expansion so far!
With coverage for up to one million Floridians on the line, and the state currently passing up $10 million in federal funds every single day, this is an enormously consequential debate.
In his opening speech Senate President Andy Gardiner said, “We have an obligation to look at this issue.” The next day the Health Care Policy Committee held a hearing on the issue – hearing testimony from the architects of Indiana’s recently approved proposal and now a bill has been released which passed the committee unanimously today. So things are moving quickly in the Senate.
Lets take a look at the bill (SPB 7044) that passed. It would certainly require a waiver. And there are issues where compromises will be needed. But if there is a willingness to negotiate on both sides I see this proposal as being in the ballpark.
First question that I have gotten a few times since last week’s hearing – is this the Indiana proposal?? Well, no, there are some elements of Indiana here, but like every waiver proposal we have seen this is uniquely Floridian and pulls in elements from other states as well as some new twists. And as always there are many details that would have to be fleshed out in the waiver negotiations and questions that can’t be answered by reading the bill.
How would coverage be provided? The bill provides for a phased in implementation starting very quickly on July 1st of this year through the existing Medicaid managed care system for the first six months. A la New Hampshire the state would aim to get this coverage opportunity up as quickly as possible while negotiating the waiver agreement for Phase 2.
Phase 2, which would start January 1, 2016 (ambitious timeline here!) and this is where the waiver piece would come in. The Senate’s plan is to have beneficiaries enroll in and receive coverage through the Florida Health Choices (FHIX) marketplace, a very small (think approximately 50 people now) state-based exchange that predates the ACA marketplaces. So this is a new twist on an Arkansas style approach. I don’t see CMS objecting to that approach on its face value – though there will be lots of details to work out.
What kind of coverage would be on offer? The bill mentions ACA compliant plans (at least two) being offered to newly eligible folks. I read this to mean compliant with Essential Health Benefit rules. There are no explicit benefit waiver requests in the bill that passed – but mention of a range of different kinds of coverage (employer-sponsored, other private insurance plans) that might be offered to enrollees.
With respect to cost sharing the bill includes two areas – first and clearly falling into the would need to be negotiated bucket – premiums for all starting at 0% of the poverty line. As we learned from Indiana, Iowa and Michigan CMS has not been willing to approve enforceable premiums below poverty, (for good reason – they are a clear barrier to coverage) but they have been willing to approve very complicated cost-sharing arrangements which have differed in each of those states.
And in a clear nod to Indiana, the bill includes a 6-month lockout for those who don’t pay their premiums, something which I think is very bad health policy but which CMS did unfortunately approve but only for those above the poverty line. Finally in another tip of the hat to Indiana the bill includes a copay of $25 for those who use the ER inappropriately two times in a row. CMS did approve this through 1916f waiver authority in the Indiana agreement.
What are the other important features of the bill? In another reoccurring theme, the bill includes a work, job training, or educational opportunities requirement for parents of 20 hours weekly and for childless adults of 30 hours weekly. As veteran watchers of the Medicaid expansion debate this issue arose in Pennsylvania where the Governor included a request in his original proposal but by the end of the negotiations was removed. Utah’s Governor was also negotiating on this issue with CMS. Conditioning eligibility on work or job training is not going to pass muster, but thinking through linkages to job training resources and programs and perhaps in a new twist educational opportunities may.
In response to opponents’ argument that federal dollars are not reliable, the bill also includes a trigger provision which states that the program will automatically be terminated at the end of any state fiscal year in which the federal Medicaid matching rate falls below 90% or the levels specified in the Affordable Care Act.
Finally there is mention of health saving accounts similar to Indiana’s and linked to rewards for participation in healthy behaviors also similar to Iowa’s waiver. But not a lot of detail here on how these would work. So I guess we will have to stay tuned on that one.
One more note on the sequencing here, the bill also talks about a phase 3 in which all of Florida’s CHIP kids (i.e. Healthy Kids program) would also go into the new beefed up marketplace as of July 1, 2016 – certainly we at CCF would have a fair amount to say about that but that strikes me as very far down the road at this point. Arkansas initially indicated they would eventually move all of their CHIP kids into the private option, but this policy has recently been reversed before it actually happened.
So certainly this proposal would require some compromises on both sides to get to yes. And the future of the Low Income Pool funding will no doubt be on everyone’s mind – even though not mentioned in the bill. But it’s exciting news that there appears to be considerable momentum in the Florida Senate to move this issue forward.
