Gov. Rick Scott doubled down that he could outlast Obamacare. He lost.
Tuesday's re-election of President Barack Obama, along with the return of a Democratic-led Senate, guarantees the Affordable Care Act will keep moving forward, including here in Florida, where Scott has been among its staunchest opponents.
Scott placed his bet just days after the U.S. Supreme Court upheld the law in June, saying Florida wouldn't implement two key provisions: the expansion of Medicaid for poor adults and the creation of a state-run marketplace where residents shop for and buy commercial health insurance policies.
He was confident Republican presidential nominee Mitt Romney would win the election and promptly repeal the contentious law. But experts from both sides say Obama's win -- and wide voter sentiment that there should be an end to partisan bickering -- will force Scott, Florida's Legislature and the U.S. Congress to seriously address health care reform.
The situation reminds some of what it was like 40 years ago, when reluctant states eventually introduced Medicaid programs to avoid losing millions in federal reimbursements.
"People believe that over time all states will have to participate ... even if they do it kicking and screaming," said Dave Rogoff, director of the University of South Florida's Center for Leadership in Public Health Practice.
Soon, leaders in Tallahassee and Washington, D.C., will have to decide which parts of the 2,000-page law they will phase in, and how and if they can install those parts by the Feb. 1, 2014, deadline.
The most immediate issue for the federal government: making realistic cuts to health care spending as part of an end-of-year deficit reduction debate.
"You don't have the money or administrative ability to pull it (all the law's proposals) off as is," said Tom Miller, a health care fellow with the American Enterprise Institute and an Affordable Care Act critic.
In Florida, leaders must quickly determine and explain what the health insurance choices will be for the state's 19 million residents, including 3.7 million who today don't have any coverage at all, said Greg Mellowe, policy director for Florida CHAIN, a health advocacy group for the poor. It's a mistake to wait until March's legislative session to get moving.
"This is going to be a busy session," he said.
Since passing in 2010, the Affordable Care Act has unfolded in installments, even as legal challenges from Florida and other states were making their way toward the Supreme Court.
So far, mostly noncontroversial concepts have been introduced, such as offering free preventative checkups and allowing children to remain on their parents' health plans until the age of 26.
Miller doesn't expect the Republican Congress to test those politically popular ideas, especially since most major private insurance carriers also embraced them.
More likely, there will be challenges to the state-based health insurance marketplace called exchanges, Miller said. The Affordable Care Act asks states to create a place where an estimated 15 million Americans without insurance could buy some type of coverage, with monthly premiums tied to income.
A legal challenge, however, won't be easy, since the law already has been upheld, he said. "It's not impossible to dislodge (regulations), but it is a lot harder," Miller said.
Scott is one of more than a dozen governors to say they won't set up a state market, leaving the creation of those exchanges up to the federal government. Scott, a former hospital executive, reiterated his position Wednesday, saying it would hurt small business and force the state to raise taxes.
Mellowe, from Florida CHAIN, said Obama's win nationwide and among Florida voters could imply that voters want the governor to compromise.
"Gov. Scott may have to reconsider his stance," he said.
And pressure could come from a major health care business coalition. Florida's hospitals have a lot at stake with Scott's decision to not create an insurance exchange as well as his decision to not expand Medicaid to an estimated 1.5 million low-income adults.
Both programs would guarantee some form of financial reimbursement for hospitals, which every year report millions in unpaid medical costs, said Bruce Rueben, president of the Florida Hospital Association.
Without expansion or the exchanges, hospitals would get "a double whammy" because the Affordable Care Act also has reduced how and how much it will be reimbursing health care practitioners in the future for Medicaid and Medicare, government health insurance for seniors.
"The costs have to be paid somehow," said Rueben, who estimates the reimbursement cuts will amount to billions in lost revenue.
Politics may have dominated the health care debate until now, but the election's end puts the focus entirely on one issue: money.
That's the sole reason why Florida is one of six states opting to not expand the number of residents covered under Medicaid, the government-backed health insurance paid for by a mix of state and federal tax dollars.
In 2010, Medicaid cost Florida nearly $17.4 billion and the state covered 32.6 percent of that total while federal funds picked up the rest, according to the Kaiser Family Foundation's StateHealthFacts.org.
Right now, 83 percent of Florida's 3.1 million Medicaid participants are children, disabled or elderly needing long-term care. An expansion would add poor working adults and parents to that list, most of whom have no insurance at all now.
An estimated 1.52 million adults statewide would be added to Medicaid if eligibility increased to 138 percent of the federal poverty level, according to a Florida Center for Fiscal and Economic Policy analysis. That would include single adults paid up to $1,284 a month, or a family of three earning up to $2,195 a month.
Scott's decision would not affect existing Medicaid money coming from Washington, D.C. But the state would be turning away hundreds of millions of dollars set aside within the Affordable Care Act for expansion and the consumer insurance exchange.
If Florida were to change its stance, the federal government would pay 100 percent of Medicaid expansion costs the first three years, and roughly 90 percent after that.
More significantly, Rueben said, the poor who previously had no insurance could get services that would help them prevent an illness before it becomes too serious and avoid trips to the hospital emergency room.
"They get more effective care, they get better care and the outcome is better," the hospital association leader said.
Miller doesn't dispute the value of improved health. But it is important that government leaders make fiscally responsible decisions about what now is the health care law of the land, he said. Obama may have won, but don't expect opponents in the debate to roll over, he said.
"It's not like a new dawn has arisen," he said. "There are still significant differences of opinion over how health care should operate." ___[Image from flickr user Gage Skidmore]
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