Miami Herald - December 9, 2005
Marc Caputo, mcaputo@herald.com

TALLAHASSEE - From people with AIDS and diabetes to children and the seriously disabled, most of Broward County's poorest and most fragile residents will be subjects of a nationally watched experiment to reshape Medicaid, after the Florida Legislature voted Thursday to turn over some control of the program to private companies.

"What the Legislature has done today is the single biggest change and the boldest reform since the beginning of Medicaid," Gov. Jeb Bush, who proposed the plan, said of the 40-year-old program that serves 2.2 million Floridians.

The plan, starting in Broward and Duval counties in July, puts the state on a five-year course to enroll nearly all of its Medicaid recipients into HMO-like managed-care companies. The firms will have unprecedented say in defining benefits that the government now decides.

Bush says the free-market fix should help control spiraling costs for Medicaid, which tops $15 billion and is nearly a quarter of the state's budget. Socked by higher enrollment numbers and healthcare inflation -- especially from prescription drugs -- states across the nation have experienced similar trouble, and many are looking to Florida for a solution.

Bush promised reform will bring more budget "predictability" because some costs will be capped. He said managed-care plans save money -- and improve health care -- by providing recipients regular therapy and check-ups to spot and treat ailments early and more cheaply.

But to 34-year-old Anita King of Pompano Beach, the proposal means more uncertainty, fewer choices and the possibility of worse healthcare for her 14-year-old daughter, who suffers from Type 1 diabetes.

"I know how managed-care works, and all the doctors I've talked to complain about it. I don't know what it will cover. I don't know what I'm going to have to spend. It's very stressful," King said.

Though nearly no one likes Medicaid now, it's tough to find any recipients, social service advocates or Democrats who don't share King's fear of change. Even many Republicans are concerned -- especially those from the two test areas and Miami-Dade.

'There was never one entity that liked this bill. There was never one time that people came to us and said, `You and yours are visionaries,' " said former Senate President Jim King, a Jacksonville Republican, who noted the "genuine concerns about the fact that lives -- lives -- are in danger."

CONTROLLING CHANGE

Senators blocked the governor and House's effort to weaken legislative oversight in expanding the reform plan more quickly beyond Broward and Duval. To make sure the plan works, they said, it must first be tested for two years in the Jacksonville area and Broward, which has 191,000 people eligible for the plan.

The Senate, led by Miami's Republican Majority Leader Alex Villalobos, also blocked a proposal to move more Medicaid recipients into HMOs, even if they don't live in the test areas.

The House passed the plan 87-31 after the Senate approved it 26-14, largely along party lines.

"This bill is going to potentially affect 2.2 million people in the state of Florida who don't have the money to come up here and lobby us," said Sen. Skip Campbell, a Tamarac Democrat. "There's enough inconsistency in this bill, which will make it a bad bill, which will allow things to happen that we don't intend to happen."

Few understand the arcane fix to the complex program that has life-and-death consequences for one in eight Floridians. Medicaid pays the healthcare of nearly half the state's pregnant women, almost a quarter of its children and about two-thirds of its nursing home residents.

AVOIDING HMOS

Anita King, a Broward County health worker, spent the past five years mastering Medicaid, making tearful calls to doctors, bureaucrats and hospitals and waiting for hours in hospital rooms and doctors' offices.

She said she deliberately avoided the existing Medicaid HMOs in Broward because none has pediatric endocrinologists who will see her daughter.

Only three of the specialists in Broward, she said, have seen her daughter on what's known as a fee-for-service basis -- an arrangement that the Medicaid reform plan will abolish.

"It took me all this time to find a doctor for my daughter, and now I just don't know what to expect," King said.

Bush's healthcare chief, Alan Levine, said recipients can expect better care. In contrast to King's experience, Levine points to people in rural counties without HMOs, such as Gadsden, where children couldn't find specialists.

Levine cites a number of studies showing results are better and cheaper when recipients receive care that closely monitors them to keep them well. He said people in fee-for-service arrangements get far fewer checkups for themselves or their kids.

"The overall big picture we have is everyone's in a system that's coordinated," Levine said. 'In a coordinated system you have a case manager who says, `You know what? This child needs help. We're going to take him to . . . where he gets assessed and treated.' "

Managed-care doesn't always live up to its promises, though, and doctors grouse that HMOs now cut their fees by 25 percent. Many worry that companies mindful of the bottom line could skimp on services. Critics also point to a managed-care experiment for dental services in Miami-Dade in which fewer children received dental checkups than before.

Under Bush's proposal, an array of health networks serving specific Medicaid populations -- such as those with AIDS or diabetes -- would crop up.

The networks would have doctors, specialists and care centers that would manage the health of recipients.

By getting regular check-ups, recipients would stay healthy and would win the right to access a special account to buy health needs, such as eyeglasses.

FUNDING CAP

But there's a catch to the plan.

To get approval from the federal government, which oversees the program and pays 59 cents of every $1 in Florida Medicaid, the state agreed to cap annual spending increases per person at 8 percent for most -- about 1 percent higher than the historical rate, according to Florida's Agency for Health Care Administration and legislative budget writers.

House bill sponsor Holly Benson, a Pensacola Republican, said the reform could save $1.3 billion over five years while accommodating future growth for new enrollees.

Sen. Mike Haridopolos, a Melbourne Republican, said he believed it would all work out, just like welfare reform in 1996. He said he was certain that "by doing nothing, there will be cuts to education, there will be cuts to road spending, there will be cuts to healthcare."

Senate Minority Leader Les Miller, a Tampa Democrat, countered that Republicans have supported billions in tax breaks, and said the plan to turn over decision-making to private companies was a "backdoor" effort to limit services.

"Who will be the losers? It will be the sickest, the oldest and those children who did not ask to be born poor," Miller said.

Anita King echoed a similar theme, saying there seems to be a contradiction in the state promising better health care on one hand and lower spending on the other.

"They're only going to change it to make it more cost-efficient," King said. "How can I honestly believe this will be best for my daughter?"

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