December 2019 (Updated February 2020)
Florida's Medicaid Expansion Opportunity
Medicaid Expansion Would Grant 805,000 Low-Income Floridians Access to Health Insurance and Thirty Percent Live in Greater Miami
Signed into law in 2010, the Patient Protection and Affordable Care Act (ACA) allowed states to expand Medicaid to all adults younger than 65 who have incomes within 138% of the federal poverty level (FPL). As of this writing, 36 states and the District of Columbia have expanded the program. Florida is one of only fourteen states that have foregone expansion, preventing 805,000 uninsured low-income residents from having access to affordable health insurance. If the state reversed course, over 234,000 adults in the Miami metropolitan area would gain access to Medicaid. In the following sections, I will offer a brief primer on Medicaid expansion under the ACA, touch upon its health and fiscal benefits, and conclude by discussing the number of potential beneficiaries of Medicaid expansion in South Florida.
Medicaid Expansion Under the ACA
The ACA expanded access to health insurance in two ways: federal subsidies to purchase private insurance through new health insurance marketplaces for individuals without employer-sponsored insurance plans and by expanding Medicaid to people with low incomes. The law set up a federal marketplace for health insurance coverage featuring the available plans in each state and it also allowed states to set up their own exchange in lieu of the federal one. The U.S. government provides subsidies for insurance premiums for people with incomes between 100% and 400% of FPL, with the size of the subsidy inversely related to the level of income.
The ACA intended to cover low-income adults by expanding Medicaid to every adult under 65 with incomes within 138% of FPL beginning in 2014. This translates to $29,435 for a family of three and $35,535 for a family of four in 2020 in the 48 contiguous states (for more information, see Table 1). The national government would fund 100% of the costs for all newly eligible beneficiaries through 2017 and then its share would gradually fall to 90% by 2020. In 2012, however, the Supreme Court ruled that the Medicaid expansion requirement was unconstitutional and that each state could choose whether or not to expand its Medicaid program.
Table 1: 2020 Federal Poverty Guidelines for the 48 Contiguous States
Note: For households with more than 8, add $4,320 for each additional person.
Benefits of Medicaid Expansion
States that have expanded Medicaid have significantly improved health outcomes and experienced fiscal benefits since expanding the program. Expansion has improved low-income individuals’ access to health care, raised the quality of care, and improved hospitals’ financial performance (including reductions in how much they spend on services for people who cannot afford to pay for their care). Research also shows that in comparison between expansion and non-expansion states, declines in expansion states’ uninsured rates are directly related to expanding Medicaid. Expansion has also led to health coverage gains for a number of vulnerable population groups, including young adults, prescription drug users, veterans, newly diagnosed cancer patients, and low-educated adults, among many others. For a more comprehensive analysis of Medicaid expansion’s positive impacts on health outcomes, please see Alison Yager’s “Connecting the Dots.”
History of Medicaid Expansion Efforts in Florida
As previously noted, Florida is one of fourteen states that has yet to expand their Medicaid program to all low-income nonelderly adults. In 2015, the FL Senate developed a bipartisan bill expanding the program, but it included significant restrictions: work requirements, premiums and lockout periods. It passed the Senate almost unanimously (31-3), while the House went through the regular session without considering it or an alternative. Despite the House’s inaction, Florida’s expansion effort gained significant state and federal attention and the legislature held a rare Special Session, in part to allow the House to consider the Senate bill. Prior to the Special Session, the Miami Herald ran a week-long series on Medicaid expansion, providing front page coverage each day to feature county residents in the coverage gap. Throughout the week WLRN also ran a daily series interviewing people in the coverage gap and their providers. Unfortunately, in spite of the fact that a majority of Floridians supported Medicaid expansion at the time, the Florida House voted against it 72 to 41.
Between 2015 and 2018, there were no viable expansion efforts in the state. In 2018 and early 2019, however, a coalition of health care advocates pursued a constitutional amendment to expand Medicaid through a ballot initiative. The coalition made significant progress, including formation of a political committee and collecting the required number of signatures to trigger a Florida Supreme Court review of the language and a fiscal impact estimating conference. After the legislature passed a law making it more difficult to collect registered voters’ signatures on ballot petitions , the coalition suspended efforts to include a proposal for the 2020 election. The group, however, is planning to mobilize again for the 2022 election.
Florida's Beneficiary Population
If lawmakers decided to expand the program or if voters were to approve of expansion via ballot initiative, without restrictions, the Kaiser Family Foundation (KFF) estimates that 805,000 uninsured Floridians would gain access to health insurance. There are 391,000 currently in the coverage gap, meaning that while they are uninsured, their incomes are too high to make them eligible for Medicaid under the state’s Medicaid program, but they also do not make enough money to qualify for federal subsidies on the health insurance exchanges (as noted above, subsidies are for those between 100% and 400% of the federal poverty level). Additionally, 414,000 uninsured Floridians have incomes between 100% and 138% of FPL.
Video: Florida's Health Care Coverage Gap
South Florida would disproportionately benefit from Medicaid expansion. Working from KFF’s Florida estimates, we estimate the number of low-income nonelderly adults who would benefit from expansion residing in the Miami metropolitan area (Miami-Dade, Broward, and Palm Beach Counties). Our estimates take KFF’s state-wide figures and calculate the size of each area’s prospective beneficiary population based on its share of adults within 138% of FPL.
As Table 2 shows, 243,145 currently uninsured low-income residents in greater Miami would gain access to Medicaid under expansion. Roughly half of them are in the coverage gap (113,727) and the remaining half are between 100-138% of FPL. Miami-Dade is home to 118,337 prospective beneficiaries, including 26,485 in the city of Miami. Broward County has 68,675 low-income residents who would benefit from expansion and Palm Beach County has 47,133.
Table 2: Number of Uninsured Nonelderly Florida Adults Who Would Gain Access to Health Insurance Under Medicaid Expansion
Note: Nonelderly adults: adults aged 19-64 years old. Miami Metropolitan Area includes Miami-Dade, Broward, and Palm Beach Counties
 Garfield, Rachel, Kendal Orgera, and Anthony Damico. “The Coverage Gap: Uninsured Poor Adults in States That Do Not Expand Medicaid.” Washington, D.C.: Kaiser Family Foundation, January, 14 2020. https://www.kff.org/medicaid/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/.
 By “Miami metropolitan area,” I am referring to the tri-county Miami-Fort Lauderdale-West Palm Beach Metropolitan Statistical Area, as defined by the federal government for data collection and other purposes. More commonly referred to as the “Miami metropolitan area,” or “Greater Miami,” this area includes Miami-Dade, Broward, and Palm Beach Counties. For more information, please see Donovan, Shaun. 2015. “OMB Bulletin No. 15-01: Revised Delineations of Metropolitan Statistical Areas, Micropolitan Statistical Areas, and Combined Statistical Areas, and Guidance on Uses of the Delineations of These Areas.” Executive Office of the President, Office of Management and Budget. https://www.bls.gov/bls/omb-bulletin-15-01-revised-delineations-of-metropolitan-statistical-areas.pdf.
 Center for Budget and Policy Priorities. “Yearly Guidelines and Thresholds: Coverage Year 2020.” Center for Budget and Policy Priorities, September 2019. http://www.healthreformbeyondthebasics.org/wp-content/uploads/2019/10/REFERENCE-GUIDE_Yearly-Guideline-and-Thresholds_CoverageYear2020.pdf.
 Mazurenko, Olena, Casey P. Balio, Rajender Agarwal, Aaron E. Carroll, and Nir Menachemi. 2018. “The Effects Of Medicaid Expansion Under The ACA: A Systematic Review.” Health Affairs 37 (6): 944–50. https://doi.org/10.1377/hlthaff.2017.1491.
 Antonisse, Larisa, Rachel Garfield, Robin Rudowitz, and Samantha Artiga. 2018. “The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review.” Report. Washington, D.C.: Kaiser Family Foundation. https://www.kff.org/medicaid/issue-brief/the-effects-of-medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review-march-2018/.
 Yager, Alison. “Connecting the Dots: How Medicaid Expansion Will Improve Public Health, Increase Financial Stability, and Lessen Disparities in South Florida.” Issue brief. Miami, FL: Florida Health Justice Project, December 2019. https://www.floridahealthjustice.org/connecting-the-dots.html
 Bean, Aaron. 2015. Health Insurance Affordability Exchange. http://www.flsenate.gov/Session/Bill/2015A/2A/?Tab=BillText.
 Miami Herald. n.d. “Life in Florida without Medicaid Expansion | Miami Herald.” Miami Herald, sec. Health Care. Accessed September 21, 2019. https://www.miamiherald.com/news/health-care/article18726207.html.
 Sayre, Wilson. 2015. “Floridians Affected By The Health Coverage Gap.” Series. Falling Into the Gap. Miami, FL: WLRN. https://www.wlrn.org/post/floridians-affected-health-coverage-gap.
 Cancer Action Network. 2013. “Polling: Public Wants States to Use Federal Funds to Cover Uninsured Through Medicaid | American Cancer Society Cancer Action Network.” News release. Washington, D.C.: The American Cancer Society Cancer Action Network. https://www.acscan.org/releases/polling-public-wants-states-use-federal-funds-cover-uninsured-through-medicaid; University of North Florida Public Opinion Research Laboratory. 2013. “University of North Florida Poll Reveals Crist Leads Scott.” News release. fhttps://www.unf.edu/uploadedFiles/aa/coas/porl/FL%20Statewide%20Poll%20Oct%202013%20Press%20Release%20I(1).pdf.
 Political committees must collect 10% of the total required signatures in order to trigger the Supreme Court review and the fiscal impact estimating conference (collected statewide in ¼ of the state’s congressional districts). For 2020, the total number of required signatures to get any ballot question to secure placement on the ballot is 766,200, collected in 14 of Florida’s 27 congressional districts. For more information, see Florida Department of State, Division of Elections. 2017. “2018 Initiative Petition Handbook.” Florida Department of State. https://dos.myflorida.com/media/697659/initiative-petition-handbook-2018-election-cycle-eng.pdf; News Service of Florida. 2019. “Medicaid Expansion Amendment Reaches Review by Florida Supreme Court - South Florida Sun-Sentinel.” South Florida Sun-Sentinel, June 4, 2019. https://www.sun-sentinel.com/news/politics/fl-ne-nsf-medicaid-expansion-florida-supreme-court-20190603-5v7pys52jfbqnijfpw5bjej4um-story.html.
 Dunkelberger, Lloyd. 2019. “Medicaid Expansion Won’t Go before Voters next Year.” Florida Phoenix, August 9, 2019. https://www.floridaphoenix.com/blog/medicaid-expansion-wont-go-before-voters-next-year/.
 News Service of Florida. 2019. “Florida’s Medicaid Ballot Proposal Pushed Back to 2022 - Jacksonville Business Journal.” Jacksonville Business Journal, August 12, 2019, sec. Health Care. https://www.bizjournals.com/jacksonville/news/2019/08/12/floridas-medicaid-ballot-proposal-pushed-back-to.html.
 Garfield, Rachel, Kendal Orgera, and Anthony Damico. “The Coverage Gap: Uninsured Poor Adults in States That Do Not Expand Medicaid.” Washington, D.C.: Kaiser Family Foundation, January 14, 2020. https://www.kff.org/medicaid/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/.
 Miami Metropolitan Area, County, and the City of Miami figures were compiled by the author using data from the 2017 American Community Survey: Ruggles, Steven, Sarah Flood, Ronald Goeken, Josiah Grover, Erin Meyer, Jose Pacas, and Matthew Sobek. 2019. “IPUMS USA: Version 9.0 [Dataset.” Minneapolis, MN: University of Minnesota. https://doi.org/10.18128/D010.V7.0.