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Imagining a Florida Without Medicaid

See also: Rick Scott's stranger-than-fiction smackdown of Obamacare and his defense of that decison.

In 2009, at least 2.45 million people in Florida were enrolled in Medicaid, according to data from government agencies. Another estimate pegs the number at more than 3 million. That's over a tenth of all people in the state and more than all of the people in the Tampa Bay area. All of those people are below the poverty line, and their health care is provided by a mix of federal and state funds.

But that huge population of the poor and vulnerable is now at the edge of a cliff. Republican Gov. Rick Scott is dead-set on shifting their health care to flat-rate, privatized care programs. And a portion of the Affordable Care Act that tried to build more padding into Medicaid eligibility landed with a thud in the U.S. Supreme Court chambers. Now, states are free to reject any expansion of Medicaid, as Scott did last week, when he vowed not to enforce Obamacare.

It's not too much of a stretch to imagine that the next step involves cutting Medicaid eligibility. The Affordable Care Act's proposed incentive was silly from the start: "If you don't expand Medicaid, we won't give you any money for Medicaid!"

Scott might have been OK with that. Then he'd have an excuse to divert poor folks to a private health-care market and save some state funds for corporate welfare or international vacations.

The part of the act that did survive the Supreme Court was the individual mandate, which (for all the Republican backlash right now) will effectively channel gazillions of dollars, under penalty of law, to large private health-insurance providers. Obamacare, as it turns out, represents a huge potential shift away from the remnants of single-payer that exist in Medicare and Medicaid and toward the "personal responsibility" of paying big corporations.

The Supreme Court decided that states can stay on the federal Medicaid dole even if they don't expand the ranks of the insured to those just above the poverty level. You're going to see a lot of Southern, Republican-led states turn down the money and maintain a fragile status quo. In 2009, Florida paid around 32 percent of an estimated $14,990,559,595 in Medicaid health-care costs.

Sixty-four percent of Floridians on Medicaid were on managed-care plans such as HMOs, like those favored by Scott and the Legislature, which last year passed two bills designed to reduce expenditures and pay more flat rates to for-profit managed-care providers.

"Medicaid in its current form is an out-of-control entitlement program which has become the single largest cost driver in our state's budget," said House Speaker Dean Cannon, who called Medicaid a "broken program." The Obama health-care reform assumed that states would step in line to keep their Medicaid funding. But with it so out of favor with those in charge and so full of bloated expenses, some might be dreaming of eliminating it.

What would a Florida with 3 million people who lost their health coverage look like? There are already signs of how private care sets up shop to generate healthy profits from sick, poor people.

On a PBS Frontline episode last week, reporters from the Center for Public Integrity delved into the records of for-profit dental clinics that serve children and adults with serious tooth decay who have slipped through the system without proper preventive care. Doctors are expected to meet quotas for numbers of patients served, more-expensive crowns are pushed on customers, and dentists are sometimes awarded bonuses for making more money. A lot of this, the report shows, channels funds from Medicaid programs. But there's another profit channel as well: good old American credit cards.

When a little old lady went into a dentist's office for repair work, she said she was conned into getting a "Hollywood smile" and shuttled off to sign up for a GM credit card that started accruing hefty interest the moment she signed on the dotted line, before the dentist started working on her teeth. For now, kids are protected by Medicaid and state-run CHIP plans, even if providers try to milk the system.

It's an inefficient way to pay for services, prone to manipulation at taxpayer expense. But what are the alternatives: Charity? Church fundraisers? Credit cards?

The U.S. government has failed to provide an enticing incentive that governors can turn around and sell to their mad-hatter right-wing voting blocs. Instead it was "expand the status quo or we won't give you the status quo." Medicaid is, as Speaker Cannon said, broken. But there's a thin layer of legislation between us and a world where there's no incentive to care for 3 million Floridians except for the opportunity to make a buck.

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Stefan Kamph
Contact: Stefan Kamph

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