Christine Jordan Sexton
Welcome back to Diagnosis, a vertical that focuses on the crossroads of health care policy and politics.
There are 4.16 million fewer children enrolled in government-paid health care programs nationwide after COVID 19-related coverage protections were lifted. Nearly 600,000 of those children live in Florida.
Florida ranks second behind Texas in a listing of states with the largest enrollment declines in Medicaid and the Children’s Health Insurance Program (CHIP), better known as Florida Kidcare. More than 1 million children lost coverage in Texas as that state unwound pandemic-related requirements that kept people enrolled in Medicaid.
Researchers were unable to determine how many of the children who were disenrolled from the health care programs ultimately became uninsured.
But Joan Alker, executive director at the Center for Children and Families and a Research Professor at the Georgetown McCourt School of Public Policy, says there’s a concern that a “substantial” number of children living in states such as Florida with high procedural termination may have become uninsured.
“Because they run Medicaid and CHIP the nation’s Governors, and to some degree their legislatures, but primarily the Governors, are ultimately responsible for how millions of children are faring during this process. They have made choices and these choices are reflected in the data we are presenting today,” Alker said.
The analysis shows there were about 3.1 million children enrolled in Medicaid in April 2023, before the unwinding process began. Enrollment had fallen to 2.5 million — a 19% decrease — by December 2023.
South Dakota, Montana and Utah experienced percentage declines of 25% or more in the Medicaid and CHIP programs while Texas, Idaho, Arkansas, and New Hampshire had percentage declines of 20% or more.
Enrollment changes are measured by comparing the number of children enrolled in the month prior to when states started the unwinding process compared to the number of children enrolled in December 2023.
Some states, including Florida, started unwinding in April, while others started unwinding in June or September. States with earlier unwindings have more months of data analyzed and, the authors note, “may show larger enrollment declines than states that started unwinding later in the year.”
Alker said separate data indicate an increase in Kidcare enrollment of 58,742 children since unwinding began and April 1, or about 12% of the overall loss in enrollment since Florida’s unwinding began.
I welcome your feedback, questions, and especially your tips. You can email me at [email protected] or call me at 850-251-2317.
—Legal wranglings—
The Georgetown analysis comes as the Gov. Ron DeSantis administration is in federal court battling two legal challenges to its children’s health insurance policies.
Filed on behalf of Medicaid beneficiaries last year, one lawsuit alleges Florida violated federal Medicaid unwinding protections enacted by Congress to ensure smooth post-pandemic Medicaid operations. The unwinding protections were part of the Consolidated Appropriations Act of 2023.
U.S. District Judge Marcia Morales Howard cleared the litigation for a class-action suit earlier this month and the trial is set to start May 13.
The CAA also required that all state Medicaid and CHIP programs extend 12 months of continuous coverage to eligible children beginning Jan. 1, 2024, regardless of whether they have state-mandated premiums. The Biden administration announced it would enforce the mandate in an October 2023 Frequently Asked Questions document.
The Agency for Health Care Administration (AHCA) filed a lawsuit in January in federal court challenging the mandate and asking for a preliminary injunction against enforcement. A preliminary hearing for a temporary injunction was held earlier this month.
U.S. District Judge William Jung, who was appointed by President Donald Trump, held an hour-and-a-half hearing in Tampa where he directed both sides to prepare potential orders by the end of the month. He subsequently ordered both sides to file the orders with his office and not electronically.
There was no ruling at press time. Meanwhile, 22,000 children have been dropped from the program since January.
— A closer look —
Florida Kidcare officials say that figure, obtained by the Florida Health Justice Project, includes about 7,000 “full pay” children not covered by the new federal requirements because they live in families that earn too much to qualify for Medicaid or CHIP.
Kidcare is an optional Medicaid expansion created in 1998 for children living in families earning too much to qualify for traditional Medicaid, which is free, but no more than 200% of the federal poverty level (FPL). Families pay monthly premiums and copayments toward the costs of the coverage. The remainder of the costs are subsidized by state and federal Medicaid dollars.
Kidcare policies also are offered to children living in families earning more than 200% of the FPL, usually referred to as “full pay,” because their monthly costs aren’t offset by Medicaid. The monthly premiums for those plans in 2023 were $210 per child up to 4 years old and $259 per child aged 5 to 18.
Because the premiums aren’t offset or subsidized by Medicaid, continuous eligibility requirements don’t apply to those 7,162 full-pay children who had been dropped from the program.
The flare-up between the state and federal officials has resulted in a delay in expanding available coverage. The Legislature in 2023 agreed to expand income eligibility for subsidized Kidcare policies allowing families to earn up to 300% of the FPL and maintain subsidized coverage. The expansion request, recently submitted by AHCA, requires federal approval,
AHCA attributes the delay in implementation part to the 12-month eligibility requirement. But there were signs before that that the DeSantis administration may not have been on board with the expansion, championed by Republican House Speaker Paul Renner.
During Senate confirmation hearings in 2023, AHCA Secretary Jason Weida used the Florida Kidcare program as a cautionary tale as to why Florida should not expand Medicaid to low-income childless adults.
And DeSantis didn’t directly answer a question about whether he supported expanding Kidcare income eligibility to 300% of the FPL during a 2023 post-Session press conference.
Instead, the Governor deferred to Renner who defended his priority legislation saying it allowed families to “work their way off welfare. I think that’s a very strong conservative position, pro-family, pro-child position.”
But when Renner concluded, DeSantis, who was poised to launch a presidential bid weeks later, chimed in with, “That sounds good. I think he made a good case. I think he made a good case.”
— Medically fragile children —
Parents of medically fragile children are growing frustrated as they wait for the state to implement a program that allows them to get paid to care for their children at home.
At a rule hearing in Tallahassee this week, parents pressed AHCA staff on whether the proposed regulations needed to implement a 2023 law would be in place by July 1, the start of the state fiscal year.
Moreover, they pressed as to what has taken the state so long to implement the regulations.
But they got no concrete answers from AHCA which published a notice in March that it needed additional time to develop and solicit public comment on the rule.
The Home Health Aide for Medically Fragile Children Program was passed by the Legislature in 2023. It allows a family caregiver to be employed by a home health agency and reimbursed by Medicaid, for providing up to eight hours of care a day to a family member.
The law required AHCA to work with the Board of Nursing on developing the requisite training programs and directed the agency to develop a Medicaid reimbursement rate of $25 per hour for up to 8 hours per day.
According to AHCA, 53 people participated in the meeting telephonically. The questions were posed by women, most of whom identified themselves by their first name, the county they live in, and as parents of medically fragile children.
The meeting focused on the rules outlining the minimum training requirements. Many if not most of the questions that were being fielded over the phone were Medicaid-related and not able to be answered.
Several women asked about the $25 payments with some wondering whether the income would push them above the Medicaid income limits and jeopardize their children’s enrollment in the safety net program.
Other women asked about the $25 rate and whether that was the amount they would be paid or the amount the state would pay the home health agency that employed them.
“I am under the understanding that the parent program is $25 to pay the parents but some people are kind of still thinking that is the amount the home health agency is going to be paid and then they determine what the parent would be paid,” said Becky Bowen from Suwanee County. “Can anyone clarify that?”
Team Select Home Care Vice President of Government Relations, Bill Sezepanski, touched on a similar theme. Appearing before the AHCA panel, she said the rule should require Medicaid managed care organizations to pass the $25 fee onto home health agencies to “ensure as much rate as possible is available to the family caregiver.”
Sezepanski told Florida Politics that home health agencies would not act as pass-throughs to the parents because the agency is required to hire the parents as employees and pay the costs associated with hiring and maintaining staff.
Implementation also is a top priority for Rep. Chase Tramont.
A woman who identified herself as Jenna from Volusia County said she’s frustrated.
“This has been delayed for so long. There are so many of us single mothers who are hanging on by a thread. We are barely making it and our children are suffering from it,” she said.
— It’s official: Medicaid ITN challenged —
Aetna Better Health of Florida, AmeriHealth Caritas Florida, Florida Community Care, ImagineCare, Molina Healthcare of Florida, Sentara Care Alliance and UnitedHealthcare of Florida filed protests to challenge the Medicaid ITN award with AHCA this week.
AHCA will try to reach settlements with those plans in the coming days to keep the protests from heading to administrative court.
In all, 11 plans responded to the multiyear Medicaid managed care invitation to negotiate (ITN) including two vendors that aren’t currently in Florida’s Medicaid managed care program: Sentara Care Alliance (formerly Optima Health) and ImagineCare, a provider service network and joint venture between CareSource and Spark Pediatrics. Spark Pediatrics is the largest provider of prescribed pediatric extended care in the state, according to its homepage.
AHCA announced the names of the winning bids for the Medicaid managed care program on April 12.
Eight plans filed notices of intent to challenge, but the South Florida Community Care Network, which operates under the name Community Care Plan, ultimately did not file a protest ahead of this week’s deadline.
CCP, Humana Medical Plan, Simply Healthcare Plans and Sunshine State Health Plan are the only vendors not challenging the bids.
The six-year contracts are massive in scope since the managed care companies that are picked will administer a health care program that annually costs tens of billions of dollars.
— Mental Health Month —
May marks Mental Health Awareness Month and the Florida Association of Managing Entities encourages all residents to prioritize their mental health and well-being in May and every day.
And here’s why.
In the ten years between 2011 and 2021 the suicide rate among people aged 10-24 increased by 60%, according to the Centers for Disease Control and Prevention. Moreover, the Substance Abuse and Mental Health Services Administration reports that in 2022, nearly 33% of U.S. adults experienced both a mental health condition and substance abuse.
“The first step someone takes to get mental health support can be the step that saves their life,” said Natalie Kelly, CEO Florida Association of Managing Entities, the organization representing the state’s seven managing entities.
The managing entities work with a network of 300 behavioral health care providers that have delivered services to more than 2 million Floridians. The networks provide wraparound services that not only address mental health and substance abuse issues, but also assist with care coordination, housing, transportation and employment. Community boards administer, manage, and help to ensure accountability of state and federal funds for behavioral health services, keeping oversight, transparency and accountability closest to the people they serve, Kelly said.
“In Florida, we have a robust behavioral health safety net system, consisting of seven managing entities, that not only oversees behavioral health care for our underinsured and uninsured population but also supports Floridians through various programs and community partnerships,” Kelly said.
People needing behavioral health support for themselves or loved ones — including those who are underinsured or uninsured — can be connected with community resources by calling 2-1-1. Those experiencing suicidal ideation, or thoughts of engaging in suicidal behavior, should immediately seek help by calling or texting 9-8-8.
— RULES —
—AHCA published Emergency Rule 59AER24-1 regarding medical records procedures for the treatment of premature rupture of membranes and other life-threatening conditions. More here.
—AHCA published Emergency Rule 59AER24-2 regarding required monthly abortion reports and the treatment of premature rupture of membranes, ectopic pregnancies, and trophoblastic tumors are not abortions and don’t need to be included on the required reports. More here.
— LOBBYISTS —
—David Allen, GrayRobinson: Memorial Healthcare System.
—Andrew Ketchel, Capital City Consulting: University of South Florida Foundation
— ETC —
—While DeSantis is promising budget vetoes, he announced this week he planned to keep intact more than $2.2 billion in funding for the state Agency for Persons with Disabilities for services through the iBudget waiver. The waiver program allows the state to provide services not traditionally covered by Medicaid, such as assistance with activities of daily living, that keep people living in the community and outside of institutions. The Governor held a press conference at the Els Center of Excellence. Lawmakers appropriated $100,000 for the Els for Autism Foundation to create a specialized autism recreation complex and hurricane shelter at the Els Center of Excellence. (We’re guessing the project won’t appear on DeSantis’s veto list. The $2.2 billion appropriated to the iBudget program is record-high funding, according to the Governor’s Office.) More than 20,000 people with developmental and intellectual disabilities are on a waitlist for iBudget services.
—State health regulators are pushing ahead with emergency rules they contend are needed to respond to “disinformation” that has come in the wake of Florida’s new ban on abortions after six weeks. The Agency for Health Care Administration (AHCA) released a pair of emergency rules making it clear that certain medical procedures — including the treatment of an ectopic pregnancy — are not considered abortions and do not need to be recorded as such. The rules apply to hospitals as well as abortion clinics and medical facilities.
—Florida ranked near the bottom (which is good) in WalletHub’s list of States with the Biggest Drug Problems. The study compares the 50 states and the District of Columbia in terms of 20 key metrics. For instance, Florida ranked 39th in the share of teenagers and and 36th in the share of adults who used illicit drugs in the last month; 19th in drug overdose deaths per capita; and 28th in drug arrests per capita. More here.
— ROSTER —
— Former U.S. Representative and Ambassador Francis Rooney has joined the Naples Comprehensive Health board of directors. Rooney represented Florida’s 19th congressional district from 2017 to 2021 and served as the U.S. Ambassador to the Holy See from 2005 until 2008. Rooney is also Chair of the Naple-based investment and holding company Rooney Holdings.
—Ronald Barton Tolchin, D.O., Chair of Nonsurgical Spine Care and Rehabilitation at Baptist Health Miami Neuroscience Institute, was installed as the Kalman Bass Endowed Chair in Pain & Rehabilitative Medicine at a ceremony earlier this month.
—Ivo Alexander Pestana, M.D., FACS, FAAPS, and a Board-certified plastic and reconstructive surgeon, has joined the Eugene M. and Christine E. Lynn Cancer Institute, part of Baptist Health at Boca Raton Regional Hospital.
—Michael Ruddy, M.D., an orthopedic surgeon, was elected Chief of Staff for Broward Health Medical Center and Mohammed Abdallah, D.O., a vascular surgeon, was selected to be chief of staff for Broward Health North. Ruddy succeeds Sunil Kumar and Abdalla replaces Evan Boyar, M.D., They assume their posts May 1. The facilities are part of the North Broward Hospital system that operates as Broward Health.
— ICYMI —
In case you missed them, here is a recap of other critical health care policy stories covered in Florida Politics this past week.
“Board of Medicine dishes on changes for international and domestically trained doctors” via Christine Jordan Sexton of Florida Politics — Some members of a state regulatory board are clapping back at lawmakers for passing legislation that they say makes it easier for internationally trained physicians to get licensed and practice in Florida, but makes it more difficult for out-of-state trained doctors to do the same. The Board of Medicine members briefly discussed earlier this month whether it would be appropriate for the Board to flag its concerns with SB 1600. The legislation was filed by Sen. Jay Collins and would create new statutes spelling out the requirements that health care practitioners, including medical doctors, must meet to qualify for licensure by endorsement.
“Gov. DeSantis signs bill to restrict single-use vapes with carve-out for e-liquids” via Jesse Scheckner of Florida Politics — Gov. Ron DeSantis has signed legislation to crack down on the sale of unauthorized vapes with marketing and flavors attractive to children. The new law (HB 1007), which targets only single-use products, goes into effect Oct. 1. It includes a carve-out for refillable devices and e-liquids that are part of so-called “open system” vape products that are often pricier and less colorful than their disposable counterparts.
“Gov. DeSantis signs legislation excusing new mothers from jury duty” via Jesse Scheckner of Florida Politics — New mothers in Florida will no longer have to choose between taking care of their infants and performing their civic duty as jurists. Gov. Ron DeSantis signed legislation (HB 461) excusing women from jury service if they’ve given birth within six months and requested an exemption. The new law is effective July 1.
“New law puts pharmacists on front lines of controlling the spread of HIV” via Christine Jordan Sexton of Florida Politics — Florida’s 36,000-plus licensed pharmacists can begin screening adults for HIV exposure starting July 1, and some pharmacists can begin to order and dispense drugs designed to reduce the risk of HIV infection under a new law. Sponsored by Democratic Rep. Gallop Franklin, HB 159 puts Florida pharmacists on the front line in the state’s efforts to prevent the spread of HIV by allowing them to screen adults for HIV exposure and to provide the results of the screening. Moreover, the law will enable pharmacists who enter into collaborative agreements with physicians to dispense post-exposure prophylaxis (PEP) for people who do not have HIV but are at a high risk of exposure.
“Gov. DeSantis signs first-in-nation ban on sale of lab-grown meat” via Jacob Ogles of Florida Politics — Florida will soon be the only state in America where cultivated meat cannot be sold. But only two restaurants in America sell the lab-grown product now, and neither operates in the state. At a press conference in Wauchula, DeSantis signed a legislative package (SB 1084) that includes a number of Florida Department of Agriculture and Consumer Services priorities. Most controversially, that includes the meat ban and a preemption on local regulation of electric vehicle charging stations.
— FOR YOUR RADAR —
Aside from coverage by Florida Politics, these stories are worth your time.
“Bacteria infections linked to Florida ‘Brazilian butt lift’ surgeries” via Sam Ogozalek of the Tampa Bay Times — The risks of undergoing a “Brazilian butt lift” in Florida are well documented, with dozens of deaths due to surgeries where fat is injected into patients’ buttocks and it enters the bloodstream, causing fatal blockages. But a recent report from a Centers for Disease Control and Prevention expert highlights the potential for another complication: infection. The report, published in January, described a state investigation into a South Florida cosmetic surgery clinic.
“Can a 911 drone stop your bleeding? It’ll fly to Florida emergencies for DIY rescues” via Victoria Villaneuva-Marquez of the Bradenton Herald — A Florida county will be one of the first in the nation to dispatch a drone that responds to 911 calls. On Wednesday, Manatee County was set to launch a new pilot program that uses a drone to deliver a defibrillator, a tourniquet, or naloxone — an opioid-overdose antidote — to emergency scenes. The program is meant to reduce response times for life-threatening situations. The government program, which has been cleared by the Federal Aviation Administration, is a partnership with Tampa General Hospital and Archer First Response Systems.
“Walmart is closing its 51 health centers. Here are the 23 Florida locations” via The Associated Press — Walmart is closing its health centers and virtual care service after struggling to find success with the offerings, the U.S. retailer said Tuesday. Walmart had 51 health centers in five states, including 23 in Florida, with the goal of helping people save money on their health care needs. The company said that after managing the clinics it launched in 2019 and expanding its telehealth program, it concluded “there is not a sustainable business model for us to continue.”
“Norovirus stomach bug spreads in Central Florida” via Caroline Catherman of the Orlando Sentinel — Norovirus, a highly contagious stomach bug known for spreading on cruise ships, appears to be spiking on dry land in Central Florida. The virus usually increases during winter and dies down around this time along with a host of other infectious diseases, but this year it looks to be sticking around, said Dr. Timothy Hendrix, medical director of AdventHealth Centra Care, the region’s largest network of urgent care centers. “Usually, we’ll see some decline in the numbers of people coming in with these intestinal infections as we get into the spring,” Hendrix said. “But it’s sustaining this year.”
“Will Florida’s strict six-week ban be bypassed by abortion by mail?” via Sam Ogozalek and Christopher O’Donnell of the Tampa Bay Times — Florida will this week begin enforcement of a six-week abortion ban, the state’s strictest limits on the procedure in more than 50 years. The law penalizes doctors who perform abortions with sanctions that could include revocation of their medical license. The ban covers abortions through medication, but abortion-by-mail providers say they will continue sending pills to women in Florida — even those beyond six weeks pregnant.
— PENCIL IT IN —
Saturday
Happy birthday to Sen. Tina Polsky!
Monday
Happy birthday to Rep. Toby Overdorf and Sen. Tracie Davis!
Wednesday
1 p.m. — The Health Information Exchange Coordinating Committee (HIECC) will hold a public meeting. Register for the meeting here. Dial-in instructions are provided at registration.
2 p.m. — AHCA will hold a hearing on proposed rule 59A-35.125 to establish facial covering requirements for health care practitioners and health care providers for infection control. 2727 Mahan Drive, Bldg. No. 3, Conference Room A, Tallahassee, 32308. Or, call 1 (888) 585-9008, then enter the conference room number followed by the pound sign, 998518088#.
Diagnosis is written by Christine Jordan Sexton and edited by Drew Wilson.
