When it comes to health care, the Florida governor's race offers voters a clear choice. Republican Rick Scott and Democrat Alex Sink disagree on hot-button issues from abortion to Medicaid.
Scott supports expanding a controversial Medicaid "reform" pilot statewide --- or possibly creating a voucher system that would allow beneficiaries to shop for insurance.
But Sink says state leaders need to slow down and listen before deciding whether to expand the pilot, which requires low-income Floridians to sign up with HMOs and other managed-care plans.
Scott, who headed and funded a group that fought President Obama's health-care overhaul last year, supports a lawsuit filed by Florida and other states to challenge the constitutionality of what Scott calls "Obamacare."
But Sink's campaign blasted the lawsuit,saying she "does not agree with using our tax dollars to advance a partisan, political agenda on an issue as important and personal as health care --- or trying to overturn these needed reforms before they're even given a chance to work."
The Sink and Scott campaigns in recent days have answered a series of questions posed by Health News Florida about their positions on health-care issues such as Medicaid and the federal lawsuit. Other positions are evident in public documents and campaign websites.
On some issues, the candidates' positions remain vague. But there is little question the next governor will face major health-care challenges, with Medicaid's annual budget topping $20 billion and the federal health law fully taking effect by 2014.
Sink and Scott, who are running in the Nov. 2 election to replace outgoing Gov. Charlie Crist, don't talk about the complicated Medicaid issue in splashy campaign ads. But House and Senate Republican leaders have already signaled that revamping the program will be one of their top priorities during the 2011 legislative session.
"Both sides (in the gubernatorial race) know that Medicaid is going to be a huge issue, something they're going to have to deal with," said Michael Garner, president of the Florida Association of Health Plans, an HMO industry group.
While details might vary, Scott is lined up with the legislative leaders' philosophy of moving Medicaid beneficiaries into HMOs and other managed-care plans. Supporters say such a move would help control costs and reduce fraud by eliminating what is known as a "fee for service system," which involves the state making payments to tens of thousands of doctors and other providers.
Scott's campaign said he would support a statewide expansion of a five-county "reform" program that former Gov. Jeb Bush championed. That program, which operates in Broward, Duval, Nassau, Clay and Baker counties, requires most beneficiaries to enroll in HMOs or provider-service networks, which are managed-care plans typically run by hospital systems.
Also, Scott indicated he could back a proposal offered by some Senate Republican leaders to begin providing vouchers that Medicaid recipients would then use to buy insurance. That would be a dramatic change in the Medicaid program, however, and critics have questioned whether the federal government would approve it.
In response to Health News Florida's questions, the Scott campaign said major changes are needed in Medicaid, particularly because the new federal health-reform law will expand enrollment in the coming years.
"(There) are a lot of inefficiencies in the government-run health care program, and Obamacare is going to make it unaffordable," the campaign said.
Sink agrees that Medicaid needs changes to rein in soaring costs, but her campaign said reforming the system is about more than the lowering the price tag. The campaign said Sink wants a "comprehensive reform package" that would ensure quality care to the various types of Medicaid beneficiaries and include services such as wellness programs and disease prevention.
The Democratic state chief financial officer also thinks Medicaid deliberations need to be in public and include groups and people who would be affected. Spokeswoman Kyra Jennings said in an e-mail that Sink wouldn't support expanding the Bush reform program without first dealing with the Medicaid issue in public and taking a comprehensive approach.
"Alex Sink feels strongly that Medicaid reform must be addressed in a public forum --- not pushed through the Legislature in the dark of night without public debate," the campaign said.
Laura Goodhue, executive director of Florida CHAIN, an advocacy group that is critical of the Bush reform plan, said listening to other ideas about changing Medicaid would be a good move. Florida CHAIN and other critics have long questioned whether HMOs restrict care to Medicaid beneficiaries to save money.
"It is a big deal, and I think the thinking right now from our current leaders in the Legislature (is) one-sided," Goodhue said.
The issue also is tricky politically, as changes in Medicaid could affect the spending of billions of dollars and powerful special interest groups such as doctors, hospitals and HMOs. The Florida Medical Association, for example, often supports Republican candidates, but it also opposes a wide-ranging expansion of Medicaid managed care.
The FMA supported Scott's Republican primary opponent, Attorney General Bill McCollum, but has not made an endorsement in the general election. FMA Executive Vice President Tim Stapleton said the group will make a decision based on issues such as managed care, Medicaid reimbursement for doctors and support for limiting medical-malpractice lawsuits.
"The high cost of medical liability insurance and extremely low Medicaid reimbursement rates have made Florida a challenging place to practice medicine compared to other states," Stapleton said in an e-mail. "We know that physicians are choosing to either retire early or leave the state, and it is becoming increasingly difficult to recruit physicians to Florida."
Scott became a multimillionaire in the health-care industry, serving as chief executive of the Columbia/HCA hospital chain in the 1990s and later helping found Solantic, a company that runs urgent-care centers. His tenure at Columbia/HCA has become a controversial issue in the campaign, because the company had to pay $1.7 billion in fines after he left because of Medicare fraud.
Before and during the campaign, Scott has been an outspoken critic of the federal health law. Sink, a former bank president who was elected chief financial officer in 2006, has been more circumspect on the issue.
But in response to questions, her campaign offered at least limited support for the law, pointing to moves such as helping Medicare recipients pay for prescription-drug costs --- an issue that addresses what is known as the "donut hole" in Medicare.
"Alex Sink believes Floridians needed health-care reform and that many of the reforms finally passed were in the best interest of Florida, such as closing the prescription-drug 'donut hole,' offering tax breaks to our small businesses and ensuring people won't get dropped from their insurance for pre-existing conditions," the Sink campaign said. "Also, if Florida was not able to take advantage of these reforms, which were better than nothing, our state would be at a severe disadvantage economically."
The candidates also clearly disagree about abortion. In June, for example, Sink issued a news release praising Crist for vetoing a bill that would have required women to undergo ultrasounds before they could receive abortions. She said the bill would have interfered with a personal decision women should make with their families and doctors.
"Tallahassee politicians have no place whatsoever in these types of important medical decisions," Sink said.
But Scott said in an August interview with the Florida Baptist Witness newspaper that he would have signed the bill.
"I'm absolutely opposed to abortion," Scott told the newspaper. "Yeah, it's a moral evil."