With the rejection of Gov. Rick Scott's Medicaid expansion by both chambers of the Florida Legislature, the measure has hit a stumbling block but is far from dead. The expansion could be revived with substantial revision, such as adoption of the Arkansas Medicaid model, where Medicaid beneficiaries will be given vouchers to buy plans on the health insurance exchange. But closer examination of the demands put forward by Senate leaders may show that the two sides are not that far apart. The rejections by the state GOP may mostly be bluster in order to score political points with their base, while signaling a narrow path for the expansion.

Senate Budget Chairman Joe Negron put forward five demands for Medicaid expansion in the state. First, the expansion should use an exchange as a vehicle. Second, beneficiaries should have skin in the game, in the form of copays and premiums on a sliding scale. Third, the attachment of health reimbursement accounts. Fourth is making family plans available alongside individual plans, and fifth is a declaration that that the ?Florida Plan? eventually replace Medicaid (Health News Florida).

The main emphasis that the Republicans in the legislature are demanding is that Medicaid beneficiaries enroll in private plans, which is baffling because Scott's acceptance of Medicaid expansion came with a waiver that requires enrollment in private insurance. So essentially, the Negron Plan wants an insurance exchange for Medicaid, copays and HRAs, most of which could be added to the Scott plan with relative ease.

Since beneficiaries will already have to choose a private healthcare plan, an exchange-like system will have to be in place anyway. The exchange that Negron suggested was Florida Health Kids, which pairs children whose parents make too much for traditional Medicaid with private insurance on a sliding scale. An exchange waiting in the wings is Florida Healthy Choices, which was launched in 2008 by GOP Golden Boy Sen. Marco Rubio. The marketplace has never completely gotten off the ground, but it has been touted as a possible platform for the federally mandated health insurance exchange. Simply add this to Scott's plan.

Adding copays may be something that CMS could be receptive to in order to get Florida to come along with expansion. In early 2012, CMS knocked down Florida Medicaid's request to add a $10 monthly premium and $100 copay for nonemergency ER use, but the rejection was more about the size of the deterrent, not the principle. Negron floated the idea of a $3.80 copay for an ER visit, which may be more palatable to CMS than $100.

The health reimbursement account may be a stickier issue, and could serve as a sort of poison pill for Medicaid expansion. If Florida legislators still feel that expansion is politically troublesome even after getting the superficial concessions of a Medicaid exchange and minor copays, they can always say that the administration wouldn?t budge on HRAs; if they can frame the exchange and copays as victories, they may be willing to give up HRAs, or replace it with a wellness incentive, such as reward cards for use at drugstores.

What both the House and Senate leaders really want is to appear that they didn?t roll over for the Obama administration, the same way Gov. Scott was able to wrangle illusory concessions, including the mandatory managed Medicaid waiver and the ability to pull out of the program (which were discussed in a March 12, 2012 blog post). At the end of the session, Florida Medicaid still has a viable window to expansion, if the add-ons of the exchange and copays can provide legislators enough cover.

Follow Mark Cherry on Twitter @MarkCherryHLI


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