THE CAPITAL, TALLAHASSEE, June 29, 2012
David Royse, The News Service of Florida
While the U.S. Supreme Court ruled Thursday that Congress was within its taxing power when it required Americans to buy health insurance, the sharply divided court also said that if Florida and other states don't want to dramatically expand Medicaid, there's not much Washington can do about it.
The 5-4 ruling on the final day of the court's term is still seen as a rebuke to Florida, which led 25 other states in suing to overturn the Affordable Health Care Act. Former Attorney General Bill McCollum initially filed the lawsuit and Gov. Rick Scott has been one of the most vocal opponents of the law, which is the signature act of the Obama administration.
McCollum and current Attorney General Pam Bondi focused mainly on the individual mandate. But for Florida lawmakers, the more practical issue -- and perhaps the larger one -- is going to be how to deal with the part of the law that requires states to expand their Medicaid programs, which pay for health care for the poor.
The law requires states to extend Medicaid coverage to people under age 65 with incomes up to 133 percent of the poverty level, or just under $30,000 a year for a family of four. Such an expansion could eventually cost the state billions
The federal government will initially pick up all the additional costs, but eventually the states would be on the hook for about 10 percent of the tab – and Florida is already strapped for cash in part because of high Medicaid costs.
As written, the government could have withheld Medicaid money for states declining to expand their Medicaid coverage, but the court said Washington couldn't coerce states that way. That ruling became a rallying cry for critics of the federal plan.
"I'm pleased with that part of the decision," said Sen. Joe Negron, R-Stuart. "….In terms of the practical effect, really the main way the law gets an increased number of people insured is through expanding Medicaid."
Seven of the court's justices agreed that the federal government can't coerce the states to expand their Medicaid rolls by taking away part of what they already get to fund Medicaid. That means, essentially, that Florida could decide not to participate in the part of the law that would cover more people through the Medicaid system.
Whether or not to adopt that portion of the ACA is now likely to be among the most heavily debated in Florida in the coming year.
"We have a tough decision ahead of us: do we accept additional federal funds?" said Negron, the Senate health care budget chairman who has been vocal about the need to reduce health care spending in Florida, "It's probably too early to tell. I'm generally cautious in signing up for new federal government programs … eventually that's going to become a state obligation."
Incoming Senate President Don Gaetz said in a statement that "foremost" among difficult decisions arising out of Thursday's opinion would be "the choice the court appears to have given the states regarding participating in the mammoth Medicaid expansion authorized by federal law…
"Medicaid enrollment will double in the next few years; the state's discretion in program design will be further curtailed; and even with a temporary enhancement of federal funds, the state's financial burden for Medicaid will increase significantly," Gaetz said.
Florida's attorney general said the state's apparent ability to opt out of the expansion was a huge victory.
"Seven justices agreed with our position that Congress could not force the states to make the unacceptable choice between losing all our Medicaid benefits or accepting a massive, unaffordable expansion of the Medicaid program," Bondi said after the ruling. "That part is very good for us. ... That's what we've always wanted – each state will have the choice to decide … whether we decide to accept that."
Currently, Florida covers pregnant women and infants above the 133 percent of poverty income level, but the law would require Florida to cover many more people in families with older children and some childless adults – increasing the rolls by about a third, or more than a million people - during the first decade of the ACA.
Estimates for the increased cost to Florida have varied, but the state Medicaid agency put it at $5.7 billion over six years.
Some advocacy groups say the number is inflated, and backers of the law said Florida wouldn't be wise to pass up the cash – nine times what the state would be on the hook for.
"Although the governor and Legislature could try to avoid extending coverage to more than a million uninsured, low-income Floridians, the fact is that there is no possible justification for doing so," the group Florida CHAIN said in a statement. "Federal funds cover 100 percent of the cost of expansion through 2016 and no less than 90 percent of that cost ever.
"Over the next decade, expanding Medicaid would increase total state spending on Medicaid by just 2 percent while creating tens of billions of dollars in additional economic impact," the group said.
Medicaid currently covers about 3.2 million people in Florida, at a cost of about $20 billion a year in state dollars.
Most of the immediate reaction to Thursday's ruling, however, was not on the Medicaid portion of the law, but the decision to keep the federal mandate alive.
Gaetz said it was a "vast, melancholy expansion of federal power unprecedented in our lifetimes, and it is the largest tax increase in our nation's history."
Scott, who led an organization that opposed the health care law before he was governor, said it ultimately will devastate the economy.
"Probably more importantly it is going to be devastating to patients," Scott said shortly after the ruling. "If you look at every government program in the world, they overpromise, they run out of money, they underpay providers, and that rations care. On top of that, as bad as it is for patients it's going to be just as bad for taxpayers. We're not going to be able to afford this."
The Scott administration has so far declined federal money to put in place a state-run insurance exchange that would allow consumers to buy insurance. The state must now do so.
Many Republicans immediately made the court opinion a call to action for the coming election.
"Constitutional issues aside, the final judgment on the wisdom of this law rests with the American people," Bondi said. "The American people have a say in November and I'm confident they will join me in rejecting a law that is harmful to individual liberty, our economy, and to the welfare of our people."
But the decision was expected to solidify the president's legacy, regardless of the outcome in November.
"When we talk about Obama 20 or 30 years from now, this is likely to be the bill we talk about," Princeton presidential historian Julian Zelizer told Bloomberg this week.