February 9, 2017

What does Governor Scott's "Repeal and Replace" Proposal Mean for Florida Children and Families?

In a recent letter to Congress [1], Governor Scott describes a “Swiss cheese-like” vision for Florida health care reform. Key questions about coverage for lower income children and families remain unanswered.

The opening salvo – that Obamacare (the Affordable Care Act, or ACA) has been “devastating” for Floridians belies the facts. For 2017, nearly 1.8 million Floridians have already signed up for coverage on the federal marketplace, more than any other state. [2] The newly covered include thousands of children and families who otherwise would be uninsured and unable to access quality affordable health care.

Essential to continuation of children’s health care coverage is survival of the Children’s Health Insurance Program, or CHIP, known in Florida as “KidCare.”  Federal CHIP funds are due to expire on September 30, 2017, [3] leaving over 400,000 Florida children from lower income families at risk of becoming uninsured. [4] The loss of CHIP funding would trigger a devastating reversal in the progress that Florida has made in reducing the number of its uninsured children.

Therefore, this crucial question remains unanswered: Where does Governor Scott stand on the reauthorization of CHIP funding?

The governor also proposes troubling changes in the funding of Medicaid, the other mainstay program for children and their parents. He proposes capping Florida’s access to federal funding through “managed care rate cells”- another way of describing “per capita caps.” Rather than the current open-ended federal funding, per capita caps set a hard limit on how much the federal government will reimburse states per Medicaid enrollee.

The pitfalls of per capita caps are already well documented. [5] As noted in a recent report by the Center on Budget and Policy Priorities, recent per capita cap proposals provide for fixed amounts of federal funds per enrollee that are well below the amounts states are projected to need. This saves money for the federal government by shifting costs to the states with the size of the cost shift growing larger each year.

This new funding scheme would have particularly draconian consequences in Florida. The state already has one of the lowest per person Medicaid expenditure rates in the country. [6] Per capita caps will lock in unsustainable funding levels, diminishing year after year, leading to inevitable reductions in coverage and services for families and children. Children with disabilities will be at particular risk.

Under the current funding structure, Florida has flexibility to respond to unanticipated costs and public health emergencies arising from disasters, epidemics (e.g., Zika, opioid addiction), or new advances in medical care. [7] Case in point: the state expanded Medicaid coverage to include new life-saving Hepatitis C treatments through additional “kick payments” – supplemental payments to the health plans above and beyond the annual negotiated rate. [8]. Similar scenarios have arisen to expand therapy coverage for children with autism and organ transplants for children and adults.

This flexibility would not be possible under a per capita cap.

Ironically, the governor is simultaneously seeking an increase in federal funding through an enhanced match (90 percent federal funding) for “vulnerable populations.”  It’s unknown whether low income parents fall under this proposed new coverage category.

Florida Medicaid has one of the stingiest parent income eligibility thresholds in the country – 34 percent of the poverty level ($8,262 annually for a family of four.)  As a result, thousands of parents in poverty fall into Florida’s Medicaid coverage gap. Inexplicably, for the past three years Florida has passed on the unprecedented opportunity to receive enhanced federal funding (greater than a 90 percent match) to cover parents and other low income adults.

Multiple studies show the importance of parents being covered as it relates to their children’s health. For example, as reported by the Georgetown Center for Children and Families, untreated maternal depression is a major public health problem. [9] In large part, this is due to the parents being uninsured and not able to access treatment. Florida children’s healthy development is highly dependent on addressing these and other health challenges facing their parents.

The governor’s health reform plan is full of holes and fails to protect the health and economic security of Florida’s families and the future of its children.


[1] Rick Scott’s letter of January 6, 2017. http://www.flgov.com/wp-content/uploads/2017/01/smcl.pdf

[2]   ASPE, Office of the Assistant Secretary for Planning and Evaluation, Compilation of State Data on the Affordable Care Act, December 13, 2016.  https://aspe.hhs.gov/compilation-state-data-affordable-care-act; Covering Florida The ACA Is Still Available and Open Enrollment Ends Soon  http://www.coveringflorida.org/news; http://www.politico.com/states/florida/story/2016/12/hhs-florida-leads-the-nation-in-obamacare-selections-for-2017-108280

[3] Alker, Joan. 2017. Georgetown University Health Policy Institute, Center of Children and Families How Should We Be Thinking About CHIP in the New World Order?,  http://ccf.georgetown.edu/2017/01/16/how-should-we-be-thinking-about-chip-in-the-new-world-order /

[4] Kaiser Family Foundation, Total Number of Children Ever Enrolled in CHIP and Medicaid Annually, FY 2014  http://kff.org/other/state-indicator/annual-chip-enrollment/?currentTimeframe=0

[5] Solomon, Judith Caps on Federal Medicaid Funding Would Give States Flexibility to Cut, Stymie Innovation, January 18, 2017, p. 3 http://www.cbpp.org/research/health/caps-on-federal-medicaid-funding-would-give-states-flexibility-to-cut-stymie

[6] Young, Katherine, Rudowitz, Robin and Garfield, Rachel, The Henry J. Kaiser Family Foundation Medicaid Per Enrollee Spending Variation Across States, January 28, 2015 http://kff.org/medicaid/state-indicator/medicaid-spending-per-enrollee/?currentTimeframe=0

[7] Supra note at v.

[8] Issue Brief 2011-226, The Florida Senate, Committee on Health Regulation, Medicaid Managed Care Rate-Setting, November 2010, p. 4, f.n. 11; Gentry, Carol, Medicaid Plan to Get Extra Drug $, Health New Florida, June 10, 2014

[9] Chester, Alisa and Alker, Joan. July 26, 2016. Georgetown University Health Policy Institute, Medicaid Expansion Promotes Children’s Development and Family Success By Treating Material Depression,  http://ccf.georgetown.edu/2016/07/21/medicaid-expansion-promotes-childrens-development-and-family-success-by-treating-maternal-depression/

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