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The Florida Health Care Landscape

On January 1, 2014, the Affordable Care Act (ACA) goes into full effect and ushers in health insurance reforms and new health coverage options that will impact Americans across the country. Florida, like other states, will experience changes to its health care delivery system. This fact sheet provides an overview of the health, health coverage, and health care in Florida today, as well as health reform efforts and opportunities looking forward to 2014.

Demographics

Figure 1: Florida State Demographics, 2011

Figure 1: Florida State Demographics, 2011

Florida has a large and diverse population. Home to over 18 million residents, Florida is the fourth most populated state in the U.S. In 2011, 59% of Floridians identified as White, 22% identified as Hispanic, and 15% identified as Black (Figure 1).1,2 Florida has a higher share of individuals ages 65 and older than any other state, reaching 18% of the state’s population, or over 3 million people.3 Over 19% of Florida’s population was foreign-born in 2011, although 91% of Floridians are U.S. citizens.4 Over ¼ of the population (28%) speaks a language other than English at home.5 Aligned with the national average, 20% of the state’s population, or nearly 4 million people, were living in poverty in 2011 (Figure 2). However, like in other states, poverty in Florida is not equally distributed by race or age. Thirteen percent of those living in poverty identified as White, while 29% identified as Hispanic and 36% identified as Black. In addition, 28% of those living in poverty were children 18 or under, while 20% were adults 19-64 and 14% were 65 or older.6

Figure 2: Distribution of Total Population by Federal Poverty Level, 2011

Figure 2: Distribution of Total Population by Federal Poverty Level, 2011

Population Health

The total population health of Floridians is ranked below the national average. Florida ranked 34 among the 50 states for total population health in the United Health Care Foundation’s report, America’s Health Rankings 2012.7 Florida’s rates of infant mortality, obesity, and diabetes are slightly higher than the national average,8 while the state’s smoking rates are lower.9 Average life expectancy in Florida is above the national average.10 While the prevalence of asthma among Floridians is lower than the national average, the prevalence of asthma among Hispanics in Florida is well above the national average and ranked the 12th highest in the U.S.11

Disparities in health and health care access are faced by Florida residents. In 2012, 21% of White nonelderly adults had no health care provider, compared to 25% of Blacks and 43% of Hispanics.12 In addition, White adults, including the elderly population, reported being in good health more frequently than Black and Hispanic adults.13 Population health also varies across Florida’s 67 counties, with many rural counties, such as those in the panhandle, faring worse than urban ones. Disparities exist among measures of health outcomes, such as morbidity and mortality, and across health behaviors and health care access and utilization.14

Figure 3: Health Insurance Coverage of the Total Population, 2011

Figure 3: Health Insurance Coverage of the Total Population, 2011

State and local initiatives are aimed at addressing existing health disparities and improving the health of the state’s population. Florida’s Office of Minority Health within the Department of Health has a “Closing the Gap” grant program to reduce racial and ethnic health disparities and promote disease prevention across the state.15 The Department of Health has also developed a Statewide Health Improvement Plan (SHIP) to improve the health of Floridians through improvement of key health and health access indicators.16 Population health is being addressed on a local level through the development of Community Health Improvement Plans across several Florida counties, such as the Alachua, Charlotte, and Gulf Counties.17 Community-based partnerships, such as Healthy Central Florida (HCF), are also working to promote healthier behaviors throughout their communities.18

Coverage

Figure 4: Characteristics of the Nonelderly Uninsured in Florida, 2011

Figure 4: Characteristics of the Nonelderly Uninsured in Florida, 2011

Over 3.8 million people, or 20% of Florida’s population, were uninsured in 2011. This is the fourth highest uninsured rate of any state and it exceeds the U.S. average of 16% (Figure 3). Eight percent of the nation’s uninsured live in Florida. As shown in Figure 11 (Appendix), the nonelderly uninsured in Florida are not equally distributed across the state’s counties. As in other states across the U.S., the majority of nonelderly uninsured have at least one full-time worker in their households, have incomes below 250% of the Federal Poverty Level (FPL), and are under age 55 (Figure 4).19

Among the 80% of Floridians with health insurance, the largest share were insured through employer-sponsored coverage (53%), followed by Medicare (21%), Medicaid (18%), and individual insurance (6%).20

Medicaid

Figure 5: Florida State General Fund Expenditures, SFY 2011

Figure 5: Florida State General Fund Expenditures, SFY 2011

Florida’s Medicaid program covers nearly 2.7 million low-income individuals, for whom the state spent about 16% of its general revenue funds during the 2011 state fiscal year (Figure 5).21 Of those enrolled in 2010, 51% were children, who accounted for 20% of expenditures (Figure 6). Meanwhile, 28% were elderly or disabled, who accounted for 66% of total costs.22 The combined federal and state costs for Florida Medicaid were $18.3 billion in FY 2011.23 Average state and federal spending per beneficiary was $4,434, which was lower than the national average of $5,563 (Figure 7).24 This fiscal year, the federal government will pay 58.o8% of the cost of Medicaid in Florida; therefore, for every $1.00 that Florida spends on Medicaid, the federal government will send $1.39 to the state in matching funds.25 Florida also provides coverage for certain groups of children up to 200% FPL through three separate CHIP-funded programs: Healthy Kids, MediKids, and the Children’s Medical Service Network.26

Figure 6: Medicaid Enrollment and Expenditures, FY 2010

Figure 6: Medicaid Enrollment and Expenditures, FY 2010

Almost half (47%) of Florida’s Medicaid beneficiaries are enrolled in managed care arrangements.27 However, managed care penetration varies by region, from 28% to 66%.28 In October 2005, the Centers for Medicare & Medicaid Services (CMS) approved a Section 1115 Medicaid demonstration waiver, entitled Medicaid Reform, that piloted a new managed care program in 5 Florida counties.29 The program was designed to promote consumer choice and market competition among private health plans, while reducing the rate of spending growth.30,31  Participating health plans were allowed to offer customized benefits and reduced cost sharing and a cap was placed on annual benefits for beneficiaries. The waiver also established Enhanced Benefits Accounts, through which beneficiaries accrue credits for healthy behavior, and a Low Income Pool (LIP) that distributed $1 billion annually to support the state’s safety net providers. Concerns were raised two years after the waiver’s implementation about the effect it was having on beneficiary access to services and continued provider participation due to increased administrative burdens, in addition to questions about whether the waiver is cost-saving.32  Caps on annual benefits and limits on children’s benefits have been eliminated and the waiver was renewed for three years on December 15, 2011.

Figure 7: Average State Medicaid Spending per Beneficiary, 2010

Figure 7: Average State Medicaid Spending per Beneficiary, 2010

Florida has received approval to expand Medicaid managed care statewide. In June 2013, CMS approved an amendment to Florida’s Medicaid Reform waiver, now re-named the Managed Medical Assistance Program, for a statewide expansion of managed care for nearly all Medicaid beneficiaries, including dual eligible beneficiaries or those eligible for both Medicaid and Medicare.33 Along with approving the amendment, CMS included some unprecedented consumer protections, including a medical-loss ratio (MLR) requirement of 85% for participating plans (this is the first time CMS has required a MLR as part of a waiver agreement).34 The waiver agreement also requires that participating health plans commit to participating in the program for five years; the state must create annual consumer health plan report cards for plans on quality-of-care metrics (with a target of the 75th percentile among Medicaid plans nationally; this is a unique requirement of this waiver); and there are more stringent requirements for consumer input through the Medicaid Medical Care Advisory Committee (MCAC). The managed care transition is scheduled to be phased in throughout Florida’s 11 regions. By October 31, 2013, Florida must submit an implementation plan to the federal government that includes the state’s plans for assessing plan readiness and network adequacy, among other things. Enrollment is scheduled to begin in early 2014.35,36 Although it was just approved this past June, the waiver is scheduled to expire at the end of June 2014, three years from when it was originally submitted to CMS. Florida, therefore, must start seeking an extension of the amendment prior to the completion of the managed care transition.     

Florida will transition many elderly and disabled Medicaid beneficiaries to managed care. Florida received approval from CMS in February 2013 for a three-year combined Section 1915(b)/(c) waiver to transition Medicaid beneficiaries using long-term services and supports (LTSS) to managed care.37 The Florida Long-Term Care Managed Care program will require mandatory managed care enrollment for most Medicaid beneficiaries ages 65 and older and ages 18 to 64 with physical disabilities. Through a phased implementation by geographic region, nearly 100,000 beneficiaries will be notified and transitioned to managed care from April 1, 2013 through March 1, 2014. Florida’s dual eligible beneficiaries, in addition to other high-need beneficiaries, will be impacted by both of these waiver managed care transitions. Florida is not one of the 9 states participating in CMS’ demonstration project to integrate Medicaid and Medicare for dual eligible beneficiaries.38

Safety Net

Florida’s safety net delivery system plays an important role in delivering health care to the state’s vulnerable populations. Florida’s community health centers and safety-net hospitals provide access to needed primary, preventive, and acute care services for low income and underserved residents. The state is home to 48 federally qualified health centers (FQHCs), which each have between one to 25 access sites around the state.39 During 2011, these health centers provided more than 4.1 million patient visits.40 Florida is also home to 14 safety net hospital systems that operate 23 hospitals throughout the state. Although safety net hospitals account for only 10% of the state’s hospitals, they see a quarter of all hospital admissions, including 100% of all Level I Trauma Center and Pediatric Trauma Care admissions. Forty percent of all Medicaid hospital days are spent in safety-net hospitals and they provide over 40% of the uncompensated care in the state.41 Despite the existing care capacity of Florida’s health care safety net, there are still high levels of unmet health care needs, in part due to provider shortages. Florida has 253 primary care health professional shortage areas (HPSAs), 218 dental HPSAs, and 140 mental health care HPSAs. Across each of these measures, less than 60% of the need for care is currently being met.42

Health Reform

Figure 8: Income of Nonelderly Uninsured Population in Florida, 2011

Figure 8: Income of Nonelderly Uninsured Population in Florida, 2011

Florida has been a leading opponent of the Affordable Care Act (ACA). On March 23, 2010, the day that President Obama signed the ACA, the state of Florida filed a lawsuit in federal district court challenging the constitutionality of the individual mandate and the Medicaid expansion.43 Florida was joined by 25 other states. The case was considered by the Supreme Court, combined with the case by another group of plaintiffs, including the National Federation of Independent Businesses (NFIB). On June 28, 2012, the Supreme Court ruled that the individual mandate was constitutional, but that the Medicaid expansion was unduly coercive, effectively making it a state option.

Florida is not expanding Medicaid coverage at this time. The Medicaid expansion is one of the major vehicles for expanding health insurance coverage under the ACA, expanding coverage to nearly all adults with incomes at or below 138% of the federal poverty level (FPL)($15,856 for an individual in 2013). The state of Florida estimated that just over 1 million Floridians would be eligible to enroll in Medicaid under the Medicaid expansion, primarily parents and other low-income adults (Figure 8).44 If Florida took up the Medicaid expansion, the federal government would pay 100% of the cost of coverage for 2014 through 2016, and then phase down to 90% in 2020 and beyond.

Figure 9: Medicaid Income Eligibility in Florida as a Percent of the Federal Poverty Level, Beginning January 2014

Figure 9: Medicaid Income Eligibility in Florida as a Percent of the Federal Poverty Level, Beginning January 2014

Despite prior opposition, Florida Governor Rick Scott announced on February 20, 2013 that he supports a three-year Medicaid expansion, with legislative approval.45,46 State Senator Joe Negron introduced SB 1816 this past legislative session to expand Medicaid through a privately administered managed care plan.47 This proposal, which was supported by Governor Rick Scott, projects state budgetary savings over the first 10 years of the expansion.48,49 In addition, some state estimates show that the influx of new federal funds would positively impact the state economy, by increasing general revenues, premium taxes, and provider taxes and fees.50  Ultimately, the Florida Legislature passed a limited health care bill that did not include the Medicaid expansion before adjourning the legislative session, which was signed into law in June 2013.51,52 As of September 30, 2013, Florida is one of 25 states not moving forward with the Medicaid expansion at this time.53 Regardless of a state’s Medicaid expansion decisions, all states must implement new eligibility and enrollment processes under the ACA, including a transition to determining income eligibility for most groups using Modified Adjusted Gross Income (MAGI)(Figure 9).54,55 Under the new MAGI eligibility rules, the eligibility level will be 210% FPL for children, 191% FPL for pregnant women, and 35% FPL for parents.56

Figure 10: Nearly 764,000 Poor Nonelderly Uninsured Adults in Florida Will Be in the ACA Coverage Gap in 2014

Figure 10: Nearly 764,000 Poor Nonelderly Uninsured Adults in Florida Will Be in the ACA Coverage Gap in 2014

Nearly 764,000 poor uninsured Floridians could be left without access to new health coverage options (Figure 10).57 Beginning in January 2014, citizens with incomes between 100% – 400% FPL will be eligible for tax subsidies to purchase health insurance in the Health Insurance Marketplace (undocumented immigrants are ineligible to receive subsidies to purchase coverage in the Marketplace, regardless of income). In Florida, nearly 1.6 million individuals will be eligible for premium tax credits.58 However adults with some of the lowest incomes (parents between 35% and 100% FPL and all childless adults < 100% FPL), will not have access to new coverage options. This will leave nearly 764,000, or 27% of the state’s nonelderly uninsured adults, including 91% of the nonelderly uninsured adults with incomes up to 100% FPL, without affordable health coverage options. Further, safety net clinics and hospitals that have traditionally served the uninsured population will continue to be stretched in Florida, especially safety net hospitals as their uncompensated care funding is likely to drop, while many remain uninsured.

Florida has defaulted to a federally-facilitated Health Insurance Marketplace. In December 2012, Governor Scott announced that Florida will not pursue a state-based Marketplace and, instead, will default to a federally-facilitated Marketplace. Florida is one of 27 states in which the federal government has set up and will run their Health Insurance Marketplace.59 Eleven insurance providers are participating in Florida’s Marketplace, although only Blue Shield of Florida is offering plans throughout the state.60 Floridians will have an average of 102 Qualified Health Plans (QHPs) per region, although the number of available QHPs is much lower in many of the state’s rural counties. The Marketplace will offer Bronze to Platinum level plans, all of which cover the Essential Health Benefits.61 Individuals can sign up for coverage by visiting www.healthcare.gov and those who have incomes between 100% and 400% FPL may qualify for sliding-scale premium tax credits to lower the cost of coverage.

Florida is pursuing its own marketplace for small businesses, called Florida Health Choices.62 The initiative, which began in 2008 with the enactment of SB 2534, will include a web portal where employers with 50 or fewer employees and some individuals, such as state retirees, can shop for health plans offered in their county.63 Florida Health Choices is a separate state initiative and does not comply with ACA requirements for the marketplace, such as providing subsidies to assist eligible low-income individuals with purchasing insurance or mandating that all health plans sold through the marketplace cover the Essential Health Benefits. The state provided $1.5 million for start-up funding in 2008 and an additional $900,000 in 2013. Florida Health Choices is intended to be self-sustaining with ongoing support provided through a fee of 2.5% of the premium for every policy sold through the marketplace paid by participating health plans and a $300 annual payment from agents who sell policies through the marketplace. Florida Health Choices has appointed a Board of Directors, hired staff, and appointed two steering committees to advise the Board – one for vendors and another for agents. In May of 2012, Florida Health Choices identified a third party administrator to provide a web portal, online plan selection tools, and a statewide customer contact center and, in September 2012, the state began beta testing the web portal.64,65 Thus far, Florida Blue, and its affiliate Florida Health Care Plans, has agreed to offer health plans, and Liberty Dental and Argus Dental have agreed to offer dental plans.66 Florida Health Choices is scheduled to become operational in early 2014 and it is unclear whether it will be amended to comply with the ACA.67

Florida has returned ACA grant funding, accepting less per capita than other states. Florida is one of two states (along with Alaska) that have not accepted any federal grant money for their Health Insurance Marketplaces.68 In 2010, Governor Rick Scott returned the state’s $1 million Exchange Planning Grant and, together with Louisiana and New Hampshire, is one of three states that have returned all or part of their Exchange Planning Grant funds.69 Although Florida has been awarded over $82 million in federal ACA grant funding, including a $2.3 million Consumer Assistance Program Grant to the Department of Elder Affairs in 2012, Florida has accepted less money per capita than other states.70 As of 2012, Florida had accepted $15.24 per capita in grant funds, the least amount of any state across the country and much lower than the national average of $40 per capita.71

The state is imposing barriers to ACA outreach and enrollment efforts. Outreach and enrollment efforts will be important to educating individuals about their new coverage options and assisting them with successfully enrolling in coverage. The federal government has provided $7.9 million in grant funding to eight organizations in Florida that will serve as Navigators who will facilitate enrollment in QHPs in the state’s federally-facilitated Marketplace.72 On May 31, 2013, Florida passed legislation to establish certifications and registration requirements for Navigators that go beyond the federal requirements.73 In mid-August, Florida raised concerns over the ability of Navigators to protect sensitive consumer information by joining 12 other states in an August 14, 2013 letter sent to HHS Secretary Kathleen Sebelius.74 A month later, Florida’s Deputy Health Secretary issued guidance for county health departments, stating that Navigators will not be able to inform individuals of the coming health care changes in county health departments.75

There is much to watch in Florida over the upcoming months, as the state’s waivers continue to be implemented and the ACA goes into full effect in January 2014. Opportunities exist to improve coverage and care for low-income and uninsured Floridians; however, without expanding Medicaid, many of Florida’s low-income adults will remain without affordable health coverage options.

Appendix

Figure 11: Florida Nonelderly Population by County, 2011

Figure 11: Florida Nonelderly Population by County, 2011

Figure 12: Florida Nonelderly Uninsured by County, 2011

Figure 12: Florida Nonelderly Uninsured by County, 2011

Endnotes
  1. Urban Institute (UI) and Kaiser Commission on Medicaid and the Uninsured (KCMU) estimates based on the Census Bureau's March 2011 and 2012 Current Population Survey (CPS: Annual Social and Economic Supplements).

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  2. UI and KCMU estimates based on Census Bureau's March 2011 and 2012 Annual Social and Economic Supplements to the CPS.

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  3. UI and KCMU estimates based on Census Bureau's March 2011 and 2012 Annual Social and Economic Supplements to the CPS.

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  4. Migration Policy Institute. “Florida Social & Demographic Characteristics” (2013), http://www.migrationinformation.org/datahub/state.cfm?ID=FL#3 and UI and KCMU estimates based on Census Bureau's March 2011 and 2012 Annual Social and Economic Supplements to the CPS.

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  5. U.S. Census Bureau. 2012 American Community Survey 1-Year Estimates: Characteristics of people by language spoken at home, http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_12_1YR_S1603&prodType=table.

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  6. UI and KCMU estimates based on Census Bureau's March 2011 and 2012 Annual Social and Economic Supplements to the CPS.

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  7. United Health Care Foundation. America’s Health Rankings: State Ranking Overview (2012), http://americashealthrankings.com/FL/2012.  Full report available at: http://reportgenerator.americashealthrankings.org/Report/Create/Print/RankingsPreview/ALL/2012/false

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  8. Between 2007 and 2009, the infant mortality rate in Florida was 7.10% compared to the national average of 6.6%; in 2011, the percent of adults who had ever been told by their doctor that they have diabetes in Florida was 10.4% compared to the national average of 9.5%; in 2011, the percent of adults who are overweight or obese in Florida was 63.4% compared to the national average of 63.3%. All data is available on Florida’s page at www.statehealthfacts.org.

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  9. In 2011, the percent of adults who smoked in Florida was 19.1% compared to the national average of 20.1%. Data is available on Florida’s page at www.statehealthfacts.org.

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  10. In 2010, the life expectancy of a Floridian was 79.4 years compared to the national average of 78.9 years. Data is available on Florida’s page at www.statehealthfacts.org.

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  11. In 2010, the prevalence rate of adult self-report current asthma in Florida was 8.3% compared to the national average of 8.6%; in 2010, the prevalence rate of adult self-report current asthma among Hispanic Floridians was 9.9% compared to the national average of 7.2%. All data is available on Florida’s page at www.statehealthfacts.org.

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  12. This data is from a 2 year merge (2011-2012) but is referred to by the second year, 2012. Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data, 2011-2012.

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  13. In 2012, 83.4% of adult Whites claimed that they had good or better health compared to 76% among Black adults and 75.2% among Hispanic adults. This data is from a 2 year merge (2011-2012) but is referred to by the second year, 2012. Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data, 2011-2012.

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  14. Roderick King. County Health Rankings & Roadmaps: Florida (University of Wisconsin Population Health Institute, 2013), http://www.countyhealthrankings.org/app/florida/2013/rankings/outcomes/overall/by-rank.

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  15. Florida Department of Health, Office of Minority Health. “Closing the Gap” (August 5, 2013), http://www.doh.state.fl.us/minority/CTG/.

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  16. Florida Department of Health. Florida State Health Improvement Plan 2012 -2015 (Tallahassee, Florida: Florida Department of Health, April 2012), http://www.doh.state.fl.us/planning_eval/strategic_planning/SHIP/FloridaSHIP2012-2015.pdf.

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  17. Alachua County Health Department. Alachua County Community Health Improvement Plan (November 212), http://www.doh.state.fl.us/chdalachua/docs/alachuaCHIP.pdf; Charlotte County Health Department. Charlotte County, Florida Community Health Improvement Plan (August 2012), http://www.doh.state.fl.us/chdcharlotte/Resources/CCHD_CHIP-web.pdf; Gulf County Department of Health. Gulf County 2013 Community Health Improvement Plan Report (September 2013), http://www.gulfchd.com/forms/GULF_CHIP_Report.pdf.

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  18. Healthy Central Florida website: http://www.healthycentralflorida.org/.

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  19. UI and KCMU estimates based on Census Bureau's March 2011 and 2012 Annual Social and Economic Supplements to the CPS.

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  20. UI and KCMU estimates based on Census Bureau's March 2011 and 2012 Annual Social and Economic Supplements to the CPS.

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  21. National Association of State Budget Officers. State Expenditure Report: Examining Fiscal 2010-2012 State Spending (Washington, D.C.: 2012), http://www.nasbo.org/sites/default/files/State%20Expenditure%20Report_1.pdf.

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  22. UI and KCMU estimates based on data from FY 2010 MSIS.

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  23. Urban Institute Estimates based on data from 2011 CMS, Form 64 (August 2012).

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  24. Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on data from FY 2010 MSIS and CMS-64 reports.

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  25. Federal Register, November 30, 2011 (Vol 76, No. 230), pp 74061-74063, at http://www.gpo.gov/fdsys/pkg/FR-2011-11-30/pdf/2011-30860.pdf.

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  26. Martha Heberlein, Tricia Brooks, Joan Alker, Samantha Artiga, and Jessica Stephens. Getting into Gear for 2014: Findings from a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost-Sharing Policies in Medicaid and CHIP, 2012-2013 (January 2013), http://www.kff.org/medicaid/report/getting-into-gear-for-2014-findings-from-a-50-state-survey-of-eligibility-enrollment-renewal-and-cost-sharing-policies-in-medicaid-and-chip-2012-2013/.

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  27. Florida Agency for Health Care Administration. Medicaid Managed Care Enrollment Reports. (August 2013), http://ahca.myflorida.com/mchq/managed_health_care/MHMO/med_data.shtml.

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  28. Florida Agency for Health Care Administration. (August 2012).

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  29. The pilot began in Broward and Duval Counties on July 1, 2006 and expanded to Baker, Clay, and Nassau Counties on July 1, 2007.

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  30. “Florida Medicaid Reform Pilot,” Florida Department of Health, http://ahca.myflorida.com/medicaid/medicaid_reform/index.shtml, 2011.

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  31. Samantha Artiga. Florida Medicaid Reform Waiver: Early Findings and and Current Status (Kaiser Commission on Medicaid and the Uninsured, Kaiser Family Foundation, October 2008), http://www.kff.org/health-reform/issue-brief/florida-medicaid-reform-waiver-early-findings-and/.

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  32. Georgetown University Health Policy Institute. Florida’s Experience with Medicaid Reform: What has been learned in the first two years? (October 2008), http://hpi.georgetown.edu/floridamedicaid/pdfs/briefing7.pdf.

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  33. Florida’s Managed Medical Assistance Program approval documents, http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/fl/fl-medicaid-reform-ca.pdf.

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  34. Medical Loss Ratio (MLR) quantifies the percentage of health care funds that must be spent on medical care, as opposed to overhead, executive salaries, or marketing. Starting in 2012, the ACA requires insurance companies to spend at least 80% to 85% of premium dollars on medical care and to provide rebates to consumers if they do not meet those standards.

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  35. Joan Alker. Florida’s Medicaid Managed Care Waiver Receives Final Approval: Some Strong Consumer Protections Included, Oversight Will Be Critical (Georgetown University Center for Children and Families, June 14, 2013), http://ccf.georgetown.edu/all/floridas-medicaid-managed-care-waiver-receives-final-approval-some-strong-consumer-protections-included-oversight-will-be-critical/.

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  36. Joan Alker and Jack Hoadley. Medicaid Managed Care in Florida: Federal Waiver Approval and Implementation (Georgetown University Health Policy Institute, October 2013), http://hpi.georgetown.edu/floridamedicaid/.

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  37. CMS. Approval letter for “Florida Long-Term Care Managed Care” 1915(b)/(c) waiver (February 1, 2013), http://ahca.myflorida.com/medicaid/statewide_mc/pdf/Signed_approval_FL0962_new_1915c_02-01-2013.pdf.

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  38. Nine states currently have MOUs signed with CMS, but this number keeps changing as CMS approves demonstrations on a rolling basis. For more information about the Demonstration projects, please see CMS. “Financial Alignment Initiative” (updated September 26, 2013), http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialModelstoSupportStatesEffortsinCareCoordination.html.

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  39. Florida Association of Community Health Centers. “Florida’s Federally Qualified Health Centers”, http://www.fachc.org/about-member-centers.php.

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  40. State Health Facts. “Federally-Funded Federally Qualified Health Centers Patient Encounters or Visits, 2011” (Kaiser Family Foundation, March 2013), http://www.kff.org/other/state-indicator/total-fqhc-encounters-or-visits/.

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  41. Safety Net Hospital Alliance of Florida website: http://safetynetsflorida.org/.

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  42. Bureau of Clinician Recruitment and Service. “HRSA Data Warehouse: Designated Health Professional Shortage Areas Statistics, as of July 29, 2013” (Health Resources and Services Administration, July 2013), http://ersrs.hrsa.gov/reportserver/Pages/ReportViewer.aspx?/HGDW_Reports/BCD_HPSA/BCD_HPSA_SCR50_Smry_HTML&rs:Format=HTML4.0.

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  43. MaryBeth Musumeci. A Guide to the Supreme Court’s Affordable Care Act Decision (Kaiser Family Foundation, July 2012), http://www.kff.org/health-reform/issue-brief/a-guide-to-the-supreme-courts-affordable/.

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  44. Florida Office of Economic and Demographic Research. Social Services Estimating Conference. Estimates Related to Federal Affordable Care Act: Title XIX (Medicaid) & Title XXI (CHIP) Programs (March 7, 2013), http://edr.state.fl.us/Content/conferences/medicaid/FederalAffordableHealthCareActEstimates.pdf.

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  45. Office of Governor Rick Scott. “Florida Won’t Implement Option Portions of Obamacare” (July 1, 2012), http://www.flgov.com/florida-wont-implement-optional-portions-of-obamacare/.

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  46. Office of Governor Rick Scott. “Governor Rick Scott: We Must Protect the Uninsured and Florida Taxpayers with Limited Medicaid Expansion” (February 20, 2013), http://www.flgov.com/governor-rick-scott-we-must-protect-the-uninsured-and-florida-taxpayers-with-limited-medicaid-expansion/.

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  47. Legislative actions for SB 1816, http://www.flsenate.gov/Session/Bill/2013/1816.

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  48. Fiscal analysis of Negron’s Healthy Florida proposal, http://ahca.myflorida.com/Executive/Communications/Press_Releases/archive/docs/2013/ProposalComparison.pdf.

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  49. There have been many economic impact analyses of the Medicaid expansion on Florida. The state’s Social Services Estimating Conference has released a series of such analyses. The latest, released on March 7, 2013, projects that the Medicaid expansion would draw down $51.5 billion in federal funds over from 2014 – 2023, costing the state $3.5 billion over the same time period (Florida Office of Economic and Demographic Research. Social Services Estimating Conference. Estimates Related to Federal Affordable Care Act: Title XIX (Medicaid) & Title XXI (CHIP) Programs (March 7, 2013), http://edr.state.fl.us/Content/conferences/medicaid/FederalAffordableHealthCareActEstimates.pdf).

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  50. Stan Dorn, John Holahan, Caitlin Carroll, and Megan McGrath. Medicaid Expansion Under the ACA: How States Analyze the Fiscal and Economic Trade-Offs (Urban Institute, June 2013), http://www.urban.org/UploadedPDF/412840-Medicaid-Expansion-Under-the-ACA.pdf.

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  51. Florida Chapter Number 2013-110 (June 6, 2013), http://laws.flrules.org/2013/110.

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  52. The Florida House of Representatives did introduce a bill on April 11, 2013 for a program called “Florida Health Choices Plus+”, that would be an alternative to the Medicaid expansion. If this program is adopted, the state would give each participant $2,000 per year to help them purchase coverage and enrollees would pay a $25 monthly premium.  Nondisabled enrollees would be required to work at least 20 hours per week.  Florida House Majority Office. Florida Health Choices Plus+ (April 2013), http://www.myfloridahouse.gov/Handlers/LeagisDocumentRetriever.ashx?Leaf=housecontent/HouseMajorityOffice/Lists/Other%20Items/Attachments/6/Florida_Heath_Choices_Plus.pdf&Area=House.

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  53. State Health Facts. “Status of State Action on the Medicaid Expansion as of October 22, 2013” (Kaiser Family Foundation, October 22, 2013), http://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/.

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  54. Medicaid.gov. “Medicaid and CHIP Eligibility Levels” (September 30, 2013), http://medicaid.gov/AffordableCareAct/Medicaid-Moving-Forward-2014/Medicaid-and-CHIP-Eligibility-Levels/medicaid-chip-eligibility-levels.html.

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  55. Kaiser Commission on Medicaid and the Uninsured. Medicaid Eligibility for Adults as of January 1, 2014 (Kaiser Family Foundation, October 2013), http://www.kff.org/medicaid/fact-sheet/medicaid-eligibility-for-adults-as-of-january-1-2014/.

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  56. For current child and adult Medicaid eligibility levels, please see: Martha Heberlein, Tricia Brooks, Joan Alker, Samantha Artiga, and Jessica Stephens. Getting into Gear for 2014: Findings from a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost-Sharing Policies in Medicaid and CHIP, 2012-2013 (Kaiser Commission on Medicaid and the Uninsured, Kaiser Family Foundation, January 2013), http://www.kff.org/medicaid/report/getting-into-gear-for-2014-findings-from-a-50-state-survey-of-eligibility-enrollment-renewal-and-cost-sharing-policies-in-medicaid-and-chip-2012-2013/.

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  57. Kaiser Commission on Medicaid and the Uninsured. The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid (Kaiser Family Foundation, October 2013), http://www.kff.org/health-reform/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/.

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  58. Gary Claxton, et al. State-by-State Estimates of the Number of People Eligible for Premium Tax Credits Under the Affordable Care Act (Kaiser Family Foundation, November 2013), http://kff.org/health-reform/issue-brief/state-by-state-estimates-of-the-number-of-people-eligible-for-premium-tax-credits-under-the-affordable-care-act/.

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  59. State Health Facts. “State Decisions for Creating Health Insurance Marketplaces” (Kaiser Family Foundation, May 28, 2013), http://www.kff.org/health-reform/state-indicator/health-insurance-exchanges/.

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  60. For a list of participating health insurers, see: Florida Office of Insurance Regulation chart,  http://www.floir.com/siteDocuments/Avg_Costs_PPACA.pdf.

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  61. Center for Consumer Information and Insurance Oversight (CCIIO). Additional Information on Proposed Essential Health Benefits Benchmark Plans, http://www.cms.gov/CCIIO/Resources/Data-Resources/ehb.html.

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  62. Florida Health Choices website: http://myfloridachoices.org/.

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  63. SB 2534 (Chapter 2008-32). Florida act related to health insurance and Cover Florida Health Care Access Program. 2008, http://laws.flrules.org/files/Ch_2008-032.pdf.

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  64. Health Choices Florida. “Florida Health Choices Names Xerox as Program Administrator” (May 2012), http://myfloridachoices.org/florida-health-choices-names-xerox-as-program-administrator/

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  65. See Florida Health Choices: https://www.floridahealthchoices.com/.

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  66. Lily Rockwell. “Florida’s Health Care Insurance exchange” (Florida Trend, September 3, 2013), http://www.floridatrend.com/article/16056/floridas-health-care-insurance-exchange.

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  67. Carla Anderson. “Florida’s Ongoing Battle Against the Affordable Care Act” (HealthInsurance.org, October 14, 2013), http://www.healthinsurance.org/florida-state-health-insurance-exchange/ (accessed October 20, 2013).

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  68. State Health Facts. “Total Health Insurance Exchange Grants” (Kaiser Family Foundation, 2013), http://www.kff.org/health-reform/state-indicator/total-exchange-grants/.

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  69. Annie Mach and C. Stephen Redhead. Status of Federal Funding for State Implementation of Health Insurance Exchanges (Congressional Research Service, June 19, 2013), http://www.fas.org/sgp/crs/misc/R43066.pdf.

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  70. Data pulled on September 9, 2012 from Tracking Accountability in Government Grants System (TAGGS), http://taggs.hhs.gov/.

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  71. Kaiser Family Foundation Analysis of ACA Funding, May 1, 2012.  Per Capita calculations were completed using US Residents per State, KCMU/Urban Institute estimates based on the Census Bureau's March 2010 and 2011 Current Population Survey (Annual Social and Economic Supplements).

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  72. For more information on consumer assistance programs, see: Kaiser Commission on Medicaid and the Uninsured. Helping Hands: A Look at State Consumer Assistance Programs under the Affordable Care Act (Kaiser Family Foundation, September 2013), http://www.kff.org/health-reform/issue-brief/helping-hands-a-look-at-state-consumer-assistance-programs-under-the-affordable-care-act/.

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  73. Florida Statute § 625.25

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  74. Patrick Morrisey, Attorney General, State of West Virginia, A communication from the States of West Virginia, Alabama, Florida, Georgia, Kansas, Louisiana, Michigan, Montana, Nebraska, North Dakota, Oklahoma, South Carolina, and Texas regarding data privacy risks posed by programs assisting consumers with enrollment in health insurance through the new exchanges, August 14, 2013,  https://www.oag.state.tx.us/newspubs/releases/2013/Letter_to_HHS_re_Data_Privacy__final_8_14_13_.pdf, last accessed on October 17, 2013.

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  75. “Florida bans insurance ‘navigators’ in counties,” Herald-Tribune, September 12, 2013, accessed October 17, 2013, http://www.heraldtribune.com/article/20130912/ARTICLE/130919851.

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