Florida wants to be the first state in the nation to charge most of its Medicaid recipients a monthly premium as well as $100 for using the ER for routine care.
But even supporters acknowledge that the new fees, passed recently by the state legislature as part of a sweeping Medicaid measure, face long odds getting federal approval.
Today, four states have Medicaid premiums. But those fees, in accordance with federal law, apply only to people making more than 150 percent of the federal poverty level -- $16,335 for an individual or $33,525 for a family of four.
Florida's Medicaid Managed Care
Read more about Florida's proposed shift to Medicaid managed care.
Florida wants to impose the $10 monthly premium on all Medicaid enrollees – regardless of income -- who aren’t in nursing homes. At least two-thirds of Medicaid recipients in Florida, and in the U.S. as a whole, have incomes less than 150 percent of the poverty level, according to the Kaiser Family Foundation. (KHN is a program of the foundation.)
About a dozen states charge Medicaid co-pays for non-emergency care, but none has fees higher than $20 for people making less than the poverty level. Eight of these states only charge the fee for recipients making above 150 percent the poverty level.
Consumer advocates want the Obama administration to reject both Florida measures because, they say, they will make it harder for people to get Medicaid benefits.
Florida lawmakers who supported the changes say they would make Medicaid, the state-federal health insurance program for the poor, more like private insurance and deter unnecessary use of hospital emergency rooms.
Rep. Matt Hudson, the Republican chairman of the Florida House Appropriations Health subcommittee, said the new fees would make “people personally responsible for their own health.” He added: “This is not a budgetary decision -- it’s a philosophic stand. Everyone else in society is paying a portion of their own health care, including the military and retirees, so why shouldn’t this segment of the population?”
Diane Leone, spokeswoman for the Tea Party Network of Florida, said she supports the changes because the state faces a major budget deficit. “A $100 is a lot of money but if we keep clogging our ERs with folks who are there for non-emergency reasons, then that is a problem that can cost lives,” she said.
Hudson said he expects the Obama administration to either block the measures or approve them with the caveat that neither can stop Medicaid enrollees from getting care or coverage — which would nullify their impact.
While federal health officials have said they want to give states flexibility in running their Medicaid programs, the new premium could violate the 2010 health law, which bars states from making it more difficult for people to enroll in Medicaid, according to guidance from the U.S. Health and Human Services Department. That guidance said states could raise premiums to keep up with inflation but could not enact new premiums for groups they already cover.
In addition, federal law bars states from charging a premium to Medicaid recipients who make less than 150 percent of the federal poverty level.
The federal government has not yet evaluated the measure, which is expected to be signed by Gov. Rick Scott.
Florida’s ER co-pay, which is estimated to generate about $9 million a year, was aimed at Medicaid recipients who use the ER for primary care even though it’s cheaper to use a doctor’s office or clinic. National studies have shown that Medicaid enrollees use the ER about three times as much as people with private insurance. They tend to be sicker than people with private insurance and they have more difficulty finding a doctor to accept their coverage.
There is no official estimate of how much the $10 premium would generate. But if 2 million of Florida’s 3 million Medicaid recipients pay the fee, it would bring in $240 million.
Physicians and advocates for the poor criticized the fees.
“The ER $100 fee could simply put lives at risk,” Laura Goodhue, executive director of Florida CHAIN, a patient advocacy group. “You can imagine a host of examples, such as chest pains, false labor, children having problems breathing where a very low income person would have to make the decision to go to the ER or risk being fined $100.”
Dr. Peter Viccellio, vice chair of emergency medicine at SUNY-Stony Brook Medical Center on Long Island and a spokesman for the American College of Emergency Physicians, said Medicaid recipients use the ER more than privately insured individuals because they are sicker and have fewer doctors willing to see them. “When you add a co-pay you obstruct access to care for both emergency and non-emergency care,” he said. “This is not a way to save money, it’s a way to punish people for being poor.”
Peter Cunningham, senior fellow at the Center for Studying Health System Change, said an ER fee would reduce ER usage for both true emergencies and routine health needs. He said a better answer to curtail unnecessary ER use would be to develop more alternative health services that are open nights and weekends for people on Medicaid.