Fort Myers Florida Weekly

FOR MANY FLORIDIANS HEALTHCARE IS UNAFFORDABLE MAKING IT ENTIRELY UNATTAINABLE LEAVING MILLIONS IN OUR STATE UNINSURED

2.8 million Florida residents are currently without health insurance during this pandemic. Here’s how that could change.



“I will say that California is in a much stronger position to deal with the pandemic and with the economic fallout because we took the ACA Medicaid expansion. If you think about it that expansion provided coverage to roughly 3.7 million Californians and that includes, I think the estimate is, about a million front line and essential workers — you know, the people who are so critical and are risking their own health during the pandemic. And that means we just start off in a better position.” — Amy Adams, a health policy consultant and analyst based in Oakland, Calif.

“I will say that California is in a much stronger position to deal with the pandemic and with the economic fallout because we took the ACA Medicaid expansion. If you think about it that expansion provided coverage to roughly 3.7 million Californians and that includes, I think the estimate is, about a million front line and essential workers — you know, the people who are so critical and are risking their own health during the pandemic. And that means we just start off in a better position.” — Amy Adams, a health policy consultant and analyst based in Oakland, Calif.

AS A YOUNGER MAN IN HIS NATIVE Czechoslovakia, Rudy Hodermarsky played professional basketball.

As fit as he was, he still couldn’t avoid some conditions that run in his family: high blood pressure, cholesterol and arthritis.

Now a 62-year-old Naples resident, he is a carpenter and handyman who volunteers for the St. Vincent De Paul Society several days each week. But there is no route for him to afford health insurance and also stay in his home.

The last time he tried to sign up for insurance, his pre-existing conditions did not exclude him but it did put the prices out of reach.

“When you’ve got a mortgage, car payment and other things — it just wouldn’t fit,” he said.

Mr. Hodermarsky is one of more than 2.8 million people who are uninsured in Florida. The state consistently has one of the highest rates of uninsured in the country. That has led to ballooning costs for public hospitals where people often show up at the emergency room if they have no insurance.

Currently there are 343,000 children who are not insured living in Florida, a part of the 4.4 million uninsured across the United States, even though they may be eligible for Medicaid. COURTESY PHOTO

Currently there are 343,000 children who are not insured living in Florida, a part of the 4.4 million uninsured across the United States, even though they may be eligible for Medicaid. COURTESY PHOTO

It also strains resources at safety-net clinics that provide basic primary care to the uninsured and “working poor.” Those include Lee Community Healthcare in Lee County, The Health Care District of Palm Beach County, and the Virginia B. Andes Clinic in Port Charlotte.

In Collier County, The Neighborhood Health Clinic provides that care even if it can’t insure patients against a major health care disaster.

“They keep me healthy,” Mr. Hodermarsky said, with regular exams and medication, as well as dental care. “Those things can cost a pretty penny and it’s all covered on a regular basis, so it’s unreal what they do. And the staff is just like talking to your family.”

The decision by the Florida legislature and then-governor and now Republican U.S. Sen. Rick Scott to reject federal dollars for Medicaid expansion was the key factor leading to the state’s high numbers of uninsured, an annual U.S. Census Bureau report shows. Sen. Scott’s office said he would not comment for this story, but didn’t specify why. The senator recently tested positive for Covid-19.

HODERMARSKY

HODERMARSKY

States including Florida that did not expand Medicaid had an average rate of 12% uninsured compared to 7.6% among states that expanded the program. That was in 2019, and the disparity likely grew because of the pandemic.

Compare Florida and California.

Florida had the fourth-highest rate of uninsured in the country at 13.2% or more than 2.8 million uninsured, behind Georgia, Oklahoma and Texas. While the national rate was 9.2%, 7.7% of Californians had no insurance.

The Affordable Care Act sharply lowered Florida’s uninsured rates and CoveringFlorida.org will continue to help enroll residents right now until the Dec. 15 deadline.

But health care advocates say Florida could have signed up some 800,000 more people — typically, working adults age 19 to 64 — if it had accepted federal dollars to expand the public Medicaid insurance program to the working poor. Officially that is an individual who in 2020 earns $17,609 per year or a family of four that earns $36,156 (at or below 138% of the federal poverty line.)

SCOTT

SCOTT

Now with many in Florida’s tourism, service and other industries losing their health insurance along with their jobs, the Kaiser Foundation updated that figure to an estimated 1.5 million who could be eligible.

In California, the expansion of Medicaid alone was enough to cover roughly 3.7 million people, many of them essential workers during the pandemic, said Amy Adams, a health policy consultant and analyst based in Oakland, Calif.

The different roads the two states took to implement the ACA, such as outreach programs to sign people up, continue to have effects in both. But most point to the expansion of Medicaid — or Medi-Cal, as it’s called in California — as the key factor in Florida’s high percent of uninsured people and its often unaffordable premiums.

SOURCE: U.S. CENSUS BUREAU, 2019 AMERICAN COMMUNITY SURVEY (ACS), 1-YEAR ESTIMATES.

SOURCE: U.S. CENSUS BUREAU, 2019 AMERICAN COMMUNITY SURVEY (ACS), 1-YEAR ESTIMATES.

“That’s really the big dividing line right there,” said Ms. Adams, who works as senior program officer for California Health Care Foundation, an independent philanthropy that aims to improve the health care delivery system for low-income workers.

“California unlike Florida said, ‘yes, thank you, we will accept that federal funding’ (for Medicaid expansion).

“The ripple effect of that is just so, what’s the word I’m looking for, dramatic. Not only are you leaving those folks out of the Medicaid system but they’re forced to go seek coverage on the exchange at prices which are unaffordable.”

While advocates continue to push for Medicaid expansion in Florida, others argue for a fiscally conservative approach that calls for reining it in.

“(E)xpanding Medicaid is an overly simplistic response to a bigger issue,” said Nina Owcharenko Schaefer, a senior research fellow in health policy at The Heritage Foundation, which promotes conservative policies. “The real solution for the uninsured is to fix the underlying problems that make coverage unaffordable and unattractive for people. Rather than expanding an already overstretched Medicaid program

“Expanding Medicaid is an overly simplistic response to a bigger issue. The real solution for the uninsured is to fix the underlying problems that make coverage unaffordable and unattractive for people. Rather than expanding an already overstretched Medicaid program — where the state would have to either cut spending elsewhere or raise taxes — the better solution is to build on existing efforts to pare back costly regulations that are driving up the cost of coverage so that people have access to more affordable coverage options rather than expanding reliance on a government welfare safety net.” — Nina Owcharenko Schaefer, a senior research fellow in health policy at The Heritage Foundation, which promotes conservative policies

“Expanding Medicaid is an overly simplistic response to a bigger issue. The real solution for the uninsured is to fix the underlying problems that make coverage unaffordable and unattractive for people. Rather than expanding an already overstretched Medicaid program — where the state would have to either cut spending elsewhere or raise taxes — the better solution is to build on existing efforts to pare back costly regulations that are driving up the cost of coverage so that people have access to more affordable coverage options rather than expanding reliance on a government welfare safety net.” — Nina Owcharenko Schaefer, a senior research fellow in health policy at The Heritage Foundation, which promotes conservative policies

— where the state would have to either cut spending elsewhere or raise taxes — the better solution is to build on existing efforts to pare back costly regulations that are driving up the cost of coverage so that people have access to more affordable coverage options rather than expanding reliance on a government welfare safety net.”

Right now, that safety-net often comes in the form of local clinics that rely in part on government funds. Another model called Direct Primary Care (DPC) offers family medicine that avoids government or private insurance all together, making payment entirely at a doctor’s discretion.

Fort Myers DPC physician Dr. Rebekah Bernard charges a monthly membership fee that covers most services. She can also offer payment on a sliding-scale, in installments or however she sees fit. Roughly 20 percent of her patients are working poor, she said, and 60 percent have no insurance or a low cost, high-deductible plan for disasters.

“Most of our patients find us because they can’t afford traditional care,” Dr. Bernard said. “But a lot of other people find us because they are looking for a higher level of care: more time with their doctor, a relationship and better access.”

Another option championed by liberal health policy advocates such as Vermont Senator Bernie Sanders extend public universal health care to all, with the government as the “single payer.” A similar system is used in most wealthy countries.

It’s too early to know how many people have lost insurance along with work during the pandemic. Some evidence shows that while a staggering number of job losses occurred, many of those people may have gone back to work, at least part time.

“We just don’t know yet,” Ms. Adams said. “But I will say that California is in a much stronger position to deal with the pandemic and with the economic fallout because we took the ACA Medicaid expansion. If you think about it that expansion provided coverage to roughly 3.7 million Californians and that includes, I think the estimate is, about a million front line and essential workers — you know, the people who are so critical and are risking their own health during the pandemic. And that means we just start off in a better position.”

The Neighborhood Health Clinic’s founder Nancy Lascheid said that many of its patients lost their jobs during the pandemic and relied on the clinic to continue to monitor and treat their chronic conditions.

“They were definitely laid off, no question,” she said. “The majority of our patients are in the service industry, everything from dishwashers to shampoo girls and saloons. They do it all and it just wasn’t happening. We made a professional decision that instead of asking for a contribution from our patients (for each visit) we started out asking for $20 a month whether they came once a month or every day. As we got further and further into the pandemic, we realized even that was an unattainable goal so we waved it completely.

“About maybe June, July they started to be brought back into their jobs but on a very limited basis. When I looked at the August numbers it looked about 45% of them were back at work part time. That had been a challenge for them, too. But as we are speaking today I can tell you that the majority of patients are back at work and I feel very good about that.”

Many people across Florida struggle without health insurance because they fall into the Medicaid coverage gap or can’t afford premiums that cost more than a luxury car payment.

A 63-year-old nurse living in Punta Gorda, Shirley W. agreed to talk on the record about her experience using a pseudonym. She is among many stories of the uninsured collected by Florida Voices for Health, a Palm Beach County-based nonprofit that advocates for Medicaid expansion.

Shirley works part-time for a home health care provider and has no insurance, instead paying out of pocket for what she can for multiple health problems. She said she is overdue for a mammogram, bone scan, colonoscopy, endoscopy and gynecological exam.

“Despite our Social Security income and the income from my job, we are still struggling to make ends meet,” she said. “My husband and I live paycheck to paycheck. We can hardly afford to cover our rent and basic household bills. We don’t eat elaborate meals — mainly lots of soup, eggs, and pasta. There’s no way that I can afford to pay for health insurance.”

Although the Affordable Care Act is supposed to cover people with preexisting conditions, the high rates she would have to pay effectively denies coverage to someone with such conditions, she said.

“It (would have) cost me about $500 a month and then they said to get really good insurance is $800 a month. And it’s supposed to be the ‘affordable’ care act? It’s because I have preexisting conditions and because I take medications, but it’s not supposed to be like that. It’s supposed to not exclude people with pre-existing conditions. So I don’t get the whole thing, it doesn’t make sense to me.”

The supporters of Medicaid expansion contend that with more people signed up for insurance, a “healthy mix” of people on the exchange would lower the cost for everyone. Then, greater subsidies would be available for people who still didn’t qualify for Medicaid, even after an expansion. That’s how the Affordable Care Act was designed to work, said Alison Yager, an attorney and deputy executive director for Florida Health Justice Project in Miami.

“As originally designed the ACA was sort of meant to close in on the uninsured from multiple directions, one being raising the income eligibility guidelines for Medicaid so more low-income people were covered, and at the same time providing subsidies to middle income people. And the gap was supposed to meet at precisely a middle point, so there would be no one who wouldn’t be covered.”

Florida, too, has not instituted aggressive outreach programs to get people signed up under the ACA and it’s not certain if the state did expand Medicaid how many of those eligible would actually sign up.

California residents pay some of the highest taxes in the country, including on sales and state taxes. But the state put in place outreach programs and has made strides in creating that mix of insured people that help tamp down premium costs. And it doesn’t just rely on taxes. In addition to accepting federal dollars, California generates its own funds for outreach and enrollment by levying fees on the insurance provider for each plan that is bought, Ms. Adams said.

California also created its own state-based individual mandate penalty if you’re not signed up for a health insurance plan, replacing the federal penalty that was originally part of the ACA until lawmakers reduced the penalty to zero. That adds to that “healthy risk mix” that could lower costs.

“Average growth of their benchmark planned premium is much lower, like if you compared it nationally,” Ms. Adams said. “It’s still too high and too expensive and still more needs to be done to bring down the cost, but compared to many places in the nation they’ve done a lot to keep the premium price low.”

Too, it created insurance new subsidies for people within 400% to 600% of federal poverty guidelines. And the state used money from its general fund to continue to expand Medicaid to cover more young adults and children, who tend to be healthier and cost less for the system.

At the same time, 55,000 children in Florida lost health insurance between 2016 and 2019, the second highest rise in uninsured children in the country behind Texas, shows a report released in October by Georgetown University Health Policy Institute Center for Children and Families. The number of uninsured children in California at the same time rose by about 34,000.

Florida has about 343,000 uninsured children in total, a part of the 4.4 million uninsured across the United States even though they may be eligible for Medicaid.

The report cited a “hostile” political climate, funding cuts to Medicaid outreach and enrollment assistance and the Trump administration’s efforts to derail the Affordable Care Act as the main factors behind the increases.

Ms. Adams cited the Trump administration’s 2018 public charge rule, which blocked immigrants from gaining visas and entering the country if an examination of their wealth showed they might need social services. That has caused some immigrant families with eligible children to not sign up for Medicaid for fear it could effect their status even though it was never part of the public charge rule. In November a federal judge struck down the rule. But it could still reach the Supreme Court, where its life and the future of people impacted by it is uncertain.

California’s outreach program extended to all families with low incomes regardless of their immigration status.

“It said, ‘we don’t care about the immigration status of the parent we’re going to sign up the child,’” Ms. Adams said. “I would say that has been a national trend and a disturbing one in the decline of Medicaid to children.”

In Florida, Ms. Yager described the “chilling effect” of the Trump administration’s public charge rule even though it did not extend to Medicaid coverage.

“The chilling effect is in essence people saying, ‘I’m not enrolling my children on a benefit for which I could end up being dinged in my immigration application,’ even though U.S. citizen children and their use of benefits is not taken into consideration with public charge,” she said. “But there’s so much fear and misinformation that people are opting out of coverage for family members who are eligible and who should be remaining on care. But out of this anxiety and lack of access to correct information people are choosing to stay away from coverage. And with the huge immigrant population we have in Florida I think that’s another important piece.” ¦

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