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Even before the Florida House adjourned early, Speaker Steve Crisafulli laid blame for the session’s budget impasse clearly on Medicaid expansion.
In an essay printed by the Tampa Bay Times, Crisafulli wrote the Senate had "partnered with the Obama administration" to demand the expansion. But the House believed the move would drag people into a costly system that didn’t work.
"Under federal law, other low-income Floridians have access to health care subsidies to buy private insurance for less than the average cost of a wireless phone bill," said Crisafulli, R-Merritt Island. "In fact, if we choose Obamacare expansion, 600,000 will lose eligibility for their subsidies, of which 257,000 would be forced into Medicaid. "
Estimates say the expansion would cover more than 800,000 people, many of whom are currently uninsured. We wondered where Crisafulli was getting his numbers.
This subject can make heads spin pretty easily, so before we begin, let’s review a few basics about the Affordable Care Act.
The law’s intent was to expand coverage to the uninsured through two different ways. The first was to give subsidies to people who needed help to buy insurance through HealthCare.gov or a new state marketplace. The second way was to expand Medicaid, a state-federal insurance program for the very poor.
Medicaid expansion ended up being optional for the states, thanks to a 2012 Supreme Court ruling. This is what the Florida House and Senate are arguing about. The Senate wants to expand Medicaid so that recipients end up buying heavily subsidized insurance. The House doesn’t want to expand Medicaid at all.
Crisafulli’s numbers are based on how many Floridians would qualify for the expansion, which would be extended to all adults up to 138 percent of the federal poverty level (100 percent is currently $11,770 for an individual and $24,250 for a family of four). Technically the calculation is actually 133 percent under the law, but a 5 percent deduction is added on top of that.
If a state doesn’t expand Medicaid, people who make 100 to 400 percent of the poverty level can get subsidies to buy insurance in a marketplace. These are the subsidies Crisafulli is talking about.
But if you qualify for Medicaid, you’re not eligible for help paying premiums. His argument is that if the state extends the program, the people between 100 and 133 percent of the federal poverty level (he’s not citing the full 138, you’ll note) will lose their subsidies to buy policies, and the House simply won’t let that happen.
Crisafulli is using 2015-16 fiscal year estimates by the Florida Office of Economic and Demographic Research, which we examined ourselves. That projection says there are about 609,000 people in the 100 to 133 percent of poverty level range, and a little more than 351,000 of them have insurance of some kind. They get it through employers, Medicare or some other form of government assistance program, or buy insurance on their own (subsidized or not). Those people could enroll in Medicaid if they wanted to.
More than 257,000 have no insurance at all, and these are the ones Crisafulli is saying will be "forced into Medicaid." His office confirmed he meant they will be left without subsidies and will not make enough money to buy policies, so Medicaid will be their only option.
What it means
The Centers for Medicare and Medicaid Services and health policy experts largely agreed the numbers were plausible, but there are some points they said Crisafulli is sidestepping.
Foremost is the idea that 257,000 people would be "forced" to join the program. There is no law that says you have to use Medicaid if you qualify, and not everyone who is currently eligible enrolls. Ben Sommers, a health policy and economics professor at Harvard, said it’s pretty tough for Crisafulli to imply those quarter-million people would be upset by suddenly qualifying for Medicaid.
"Giving uninsured people Medicaid is pretty popular among uninsured people," Sommers said. "There aren’t any public opinion surveys I’ve seen in which low-income adults don’t generally support the Medicaid expansion."
Crisafulli neglects to mention there are many Floridians who right now don’t qualify for either Medicaid or federal subsidies, an estimated 669,000 people whose income is below 100 percent of federal poverty level. Those uninsured Floridians account for 18 percent of all Americans in the so-called coverage gap -- second only to Texas. They would all benefit from Medicaid expansion by gaining coverage.
Finally, Crisafulli is arguing that expanding Medicaid under Obamacare would unfairly take away subsidies that Floridians need to buy their own insurance. Those subsidies are a feature of the very same Affordable Care Act he criticizes.
Crisafulli said, "If we choose Obamacare expansion, 600,000 will lose eligibility for their subsidies, of which 257,000 would be forced into Medicaid."
Crisafulli is using incendiary language to describe state projections about Medicaid expansion. The state estimates that about 609,000 Floridians would lose access to subsidies to buy insurance under an expansion. About 257,000 of those people would be uninsured, likely because they’re too poor to buy their own. The rest could enroll in Medicaid if they wanted to. So his numbers can be considered accurate.
But experts tell us saying those people would be forced into the program isn’t accurate. Many of the very poor would likely see becoming eligible for Medicaid as a benefit.
We rate the statement Mostly True.
Tampa Bay Times, "Crisafulli: Why the Florida House opposes Medicaid expansion," April 28, 2015
HealthAffairs.org, "Reasons For The Wide Variation In Medicaid Participation Rates Among States Hold Lessons For Coverage Expansion In 2014," May 2012
Urban Institute, "Medicaid/CHIP Participation Among Children and Parents," December 2012
HealthAffairs.org, "Low-Income Residents In Three States View Medicaid As Equal To Or Better Than Private Coverage, Support Expansion," October 2014
Kaiser Family Foundation, "Are Premium Subsidies Available in States with a Federally-run Marketplace? A Guide to the Supreme Court Argument in King v. Burwell," Feb. 25, 2015
Kaiser Family Foundation, "The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid – An Update," April 17, 2015
PolitiFact Florida, "What polls say about Medicaid expansion in Florida," April 20, 2015
Florida Times-Union, "Despite differences with Senate, House leaders willing to protect hospitals from cuts," April 21, 2015
Florida Office of Economic and Demographic Research, "Impact Analysis LIP, IGTs and SB 2512," April 21, 2015
South Florida Sun Sentinel, "Scott on wrong side on health care," April 24, 2015
Center on Budget and Policy Priorities, "Understanding the Issues Surrounding Florida’s Low-Income Pool," April 27, 2015
Tampa Bay Buzz blog, "Senate continues session after House's abrupt sine die," April 28, 2015
Florida Office of Economic and Demographic Research, Medicaid eligibility projections, accessed April 28, 2015
U.S. Department of Health and Human Services, "2015 Poverty Guidelines," accessed April 29, 2015
Interview with Craig Palosky, Kaiser Family Foundation communications director, April 28, 2015
Interview with Amy Baker, Florida Office of Economic and Demographic Research coordinator, April 28-29, 2015
Interview with Ben Sommers, Harvard University health policy and economics professor, April 28-29, 2015
Interview with Leighton Ku, director of the Center for Health Policy Research for the Milken Institute School of Public Health at George Washington University, April 28-29, 2015
Interview with Aaron Albright, Centers for Medicare and Medicaid Services spokesman, April 28-29, 2015
Interview with Michael Williams, Crisafulli spokesman, April 29, 2015
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