The LGBT population encompasses a highly diverse group of individuals that present unique healthcare challenges and barriers. Florida’s distinct demographics add further complexity to these challenges. This brief summarizes LGBT healthcare issues, highlights those challenges unique to Florida, and finally, suggests how expansion of Medicaid in Florida will benefit LGBT individuals in the state.

LGBT Health Concerns
The LGBT population as a whole experiences poorer health than its heterosexual counterpart. LGBT individuals exhibit higher prevalence, as well as earlier onset, of general disability. Studies show that the population experiences elevated rates of asthma, allergies, osteoarthritis, and gastrointestinal problems. The LGBT population also experiences higher risks of cardiovascular disease and some cancers.1 Additionally, gay and bisexual men continue to account for the highest rates of HIV and new HIV infection in the U.S. as well as other sexually transmitted infections.2, 3 Transgender women also face a higher prevalence of HIV.4 Lastly, LGBT persons experience higher rates of mental health conditions and substance abuse.1, 5 These statistics warrant particular attention to LGBT healthcare access.

Florida’s LGBT Population
LGBT individuals in Florida experience higher rates of unemployment, food insecurity, and low-income status than both their national LGBT counterparts and non-LGBT persons in the state. Similarly, lack of health insurance affects Florida LGBT persons at a higher rate. Furthermore, data show that Florida’s LGBT population includes a higher percentage of individuals over the age of 50 compared to national numbers (32% v. 23%). Florida’s LGBT population also consists of a higher percentage of Latino persons (30% v. 21%).6 These factors create a complex array of challenges affecting Florida’s LGBT population.

Impact of Florida Medicaid Expansion
Nationally, Medicaid expansion resulted in an estimated 511,000 additional LGB* individuals being covered thus far in those states opting to expand coverage.7 The Kaiser Family Foundation estimates that 837,000 total Florida residents may benefit from Medicaid expansion in the state. That total ranks second only to Texas of the fourteen states that have not expanded.8 The exact number of LGBT individuals included in Florida’s total remains unknown. However, with an estimated LGBT proportion of 4.6% in Florida, extrapolation yields that approximately 38,500 LGBT individuals might benefit from expansion. This significant number highlights the importance of Medicaid expansion to healthcare for Florida’s LGBT population.
*Transgender individuals not included.

BACKGROUND ON MEDICAID EXPANSION

The Affordable Care Act (ACA or Obamacare) provided two “paths to coverage” for people with low to moderate incomes.  First, people with moderate incomes (100 to 400% of the federal poverty level) could receive subsidies to help pay for insurance in the new Healthcare Marketplace.  Second, the law provided that very low-income, uninsured adults between the ages of 19 and 65 would get health care coverage through an expanded Medicaid program, to be largely paid for by the federal government. The expansion extended coverage to adults below 138% of the federal poverty level (FPL) and eliminated Medicaid’s “categorical requirement,” which limited adult coverage to pregnant women, parents and people who were aged, blind or disabled.  Although Medicaid expansion was meant to be national in scale, the Supreme Court ruled in 2012 that the federal government could not force states to expand their Medicaid program, but rather expansion must be a state “option.” 

STATUS AND IMPACT 

Florida is one of only 14 states that have not expanded Medicaid.  As a result, approximately 445,000(1)  Floridians fall into the “Coverage Gap,” meaning they have no path to affordable coverage. For example, a working parent with one child who earns just $500/month (35% of the Federal Poverty Level) is above the income threshold, and therefore ineligible, for Florida’s very limited Medicaid coverage, and at the same time is below the income cut-off for, and therefore unable to purchase, Marketplace coverage.  Additionally, approximately 392,000(2) low-income Floridians who do qualify for Marketplace insurance (those between 100 and 138% FPL) are severely burdened by out-of-pocket costs and challenges in accessing care, many of which would be resolved with Medicaid expansion.

A large body of data and evidence show that those states which have chosen to expand Medicaid under the ACA have witnessed improved healthcare access and individual financial stability, as well as economic benefits for states, local communities and providers.

NEXT STEPS

Until Florida expands Medicaid, policy makers and the public must hear from uninsured residents about the suffering and loss that comes with lacking health coverage.  The Florida Health Justice Project is working with impacted individuals, advocates and health care providers to help bring these stories to light through our Florida Health Justice STORIES initiative. 

​First, a “thank you”to those responsible for the recent Global Health Equity Symposium at Carrolton School of the Sacred Heart in Miami.  They gave everyone present the precious gift of inspiration. Part of the gift was no doubt due to the setting-- an iconic old school on Biscayne Bay where nature and buildings blend to make the other even more beautiful.  And “credit where credit’s due:” the Symposium coincided with 3 days of perfect 70 degree weather and brilliant blue sky.
 
The event began with a documentary about the work of Partners in Health (PIH), Bending the Arc.  If you’ve not heard of PIH or the co-founder, Dr. Paul Farmer, and you care about social justice and access to health care, you should read one of Farmer’s books or speeches or, better yet, see the movie. Famer has touched and saved countless lives, helped transform the health care systems of some the world’s poorest nations; co-founded one of the most profoundly positive and impactful non-profits in the history of nonprofits; spoken truth to power.  Perhaps most inspiring…. he’s humble and collaborative. 
 
A quick background on how the Symposium happened:  Laurie Weiss Nuell, a Miami native whose family has long supported health care equity in Miami and around the world, suggested to Dr. Farmer that he collaborate with Patti Wiesen.  Patti is a Carrolton teacher who shares their passion for social justice and imparts it to her students through her art classes, (scroll to bottom of homepage for a short video that tells symposium’s history.  http://globalhealthequity.net.)
 
After the movie, in response to a question about Miami’s health disparities, Dr. Farmer said global health equity is not just about “far away problems;” that working on health justice in the states means focusing on legislation,  and that this effort requires some understanding of the economics and financing of health care in America.  
 
So, thank you Dr. Farmer for the perfect segue to a breakout session I led the next day on the moral and economic issues in Florida’s Medicaid expansion debate.  Florida is one of 19 states that has still not extended health care coverage to low-income uninsured adults under the Affordable Care Act.  As a result, over half a million Floridians have no path to affordable health care and Florida is leaving over $ 5 billion of federal funds per year on the table.  We talked about how people (and our local economies) are suffering unnecessarily and how students, faculty and others can work with advocates, including the new Florida Health Justice Project, www.floridahealthjustice.org., on expanding Medicaid. 
 
We talked about how Florida’s Medicaid expansion fight is similar to PIH’s struggle—both are about health care access for poor people who don’t have it.  But compared to the monumental efforts of PIH in Haiti, South American and Africa-- where MOUNTAINS have been moved-- the struggle here is like moving a molehill.  There are many of us in Florida to move that molehill; we don’t have to get on a plane, we can bend the arc at home. 

By Miriam Harmatz, Co-Executive Director

In past years, the Florida Legislature debated Medicaid expansion, the Senate passed expansion bills twice, and the state’s press corps-- given that they had something to “cover”—did a tremendous public service in helping Floridians better understand the costs and benefits of decreasing the state’s rate of uninsured. But for the last few years, health care policy debates have ignored Medicaid expansion and, instead, focused on different issues, including this year’s debate over whether hospital rates for safety net providers should be “enhanced.”  Because respected Senate leaders, even within the same party, have opposing positions, it’s hard for stakeholders to understand which side to champion.  Consumer advocates support critical safety net providers.  But can they be supported through enhanced rates? What does that even mean?? 

​Understanding hospital funding, is not for the feint of heart—particularly in Florida.  Years of state cuts to the Medicaid program, including cuts to safety net hospitals, led to a confusing and arcane system of hospital funding.  Adding to the confusion is that separate funding formulas for different hospitals exist within the state’s managed care system (referred to as “LIP” payments) as opposed to the specific rates that each hospital is assigned for the relatively few patients who are still in “fee-for-service” rather than managed care (referred to as “rate enhancements”). 
 
In a nutshell, the Low Income Pool Program (LIP) provides a mechanism by which supplemental payments—separate and apart from regular managed care reimbursement rates—can be made to providers who treat a large percentage of uninsured patients.   The state match for the LIP program comes through local funding sources, known as intergovernmental transfers, or IGTs, rather than general revenue; most LIP funding goes to safety nets and it is a defined amount.  By contrast, a hospital’s “rate enhancements” represent a projection based on the rates paid by the State for patients in the fee-for-service system. Thus, under a managed care system, a hospital’s rate enhancement distribution can only be projected since it depends on 2 variables:1) the extent to which managed care company contracts with that individual hospital mirror the hospital’s “enhanced rate” agreed to by the State;  and 2) the extent to which a given number of the managed care organization’s enrollees actually receive “enhanced rate” services at that hospital.
 
As a health care consumer advocate, I’ve spent significant time unpacking and explaining hospital funding so that stakeholders could better understand how the debates over hospital funding fit within the larger health care debate. Notwithstanding these by these efforts, I’m not sure I understand these issues well enough to “take a side” in the current Senate debate.  But I do understand enough to note that the current debate isn’t raising the rights questions.
 
If we can agree that the goal of health care policy should be lowering costs and improving outcomes, two questions should be answered: 1) how can we get more people covered; 2) how can we ensure that coverage dollars are used to improve outcomes?   The first question is easy. Unless/until most people are covered, the health care system as a whole (it is ultimately one system), will never be able to effectively control costs and improve outcomes. Because over half a million low income Floridians don’t have access to employer based coverage or coverage in the marketplace, the answer to the first question is simple:  accept federal funding to pay for their care under the state’s Medicaid managed care program. 
 
Answering the second question is much harder. But because Florida requires that virtually all Medicaid recipients receive their health care services through a managed care organization (MCO), we can begin. First, MCOs must receive a sufficient amount of funding in order to ensure that medically necessary services are adequately available to their enrollees.  Because the federal government will reimburse Florida for roughly 60% of the MCO’s costs (for Medicaid expansion enrollees the federal government would pay 90%), Florida has to come up with a sufficient 40% “state match.”  If we do that, theoretically at least, the MCO rates paid to providers will be high enough to ensure adequate provider networks for enrollees —from hospitals to doctors to therapists to midwives. Second, the state Medicaid agency must have sufficient funding to adequately monitor timely access to all medically necessary services. 
 
But back to the safety net hospitals that treat a “disproportionate” number of patients on Medicaid. These patients are, by definition, low–income.  It is undisputed that poverty and poor health go hand in hand and that it costs more for providers to treat patients who present in poor health. Additionally, Florida’s safety nets treat a large number of immigrants who are living and working here but who are not eligible for health coverage, even under Medicaid and the ACA.  In short, Florida’s safety nets are critical and need to be supported.  What is less clear is whether we do that through enhanced hospital rates.
 
Moreover, improving the health outcomes of low income Floridians means doing a lot more than increasing safety net reimbursement rates. As Maggie Kuhn observed, “the war on poverty has never been more than a skirmish,” and immigration debate in America may be even more contentious than the health care debate. But if Florida can at least address the first question and finally accept federal dollars to cover half a million uninsured Floridians -- we will free up some of the local IGT dollars now used to help safety nets cover the cost of treating the uninsured. Imagine the potential for improved health outcomes if, for example, some of those local tax dollars were freed up for more affordable housing and healthy food gardens?  

​By Miriam Harmatz, Co-Executive Director of the Florida Health Justice Project

A new Florida Policy Institute (FPI) report projects net state budget savings of a half billion dollars if Florida expands its Medicaid program. Under the Affordable Care Act, the state can tap into billions of new federal Medicaid dollars if it opts to cover more than 500,000 low-income uninsured Floridians.

Based on the experiences of other states and FPI’s analysis of FY 2016-17 data, the potential savings and increased revenues far exceed the additional costs that would accompany Medicaid expansion.

Savings and increased revenue would be generated through:

• Enhanced federal matching dollars to continue coverage for the medically needy, adults with disabilities, pregnant women and women with breast and cervical cancer. Currently, the federal government pays 61 percent of every state dollar spent on care for these groups. With Medicaid expansion, the federal match would increase to 90 percent.
  

• Replacing millions in state General Revenue funds with federal Medicaid dollars to support mental health and substance abuse treatment programs, hospital inpatient costs for prisoners and uncompensated care programs.

• Revenue gains from provider assessments.
  

Medicaid expansion provides Florida policymakers an unprecedented opportunity to free up state resources that can be used to meet the pressing needs of our families, communities and economy. These include education, workforce training, affordable housing, roads and building sustainability into our coastal communities.

Much has been written—from blogs to briefs—documenting the tremendous positive impacts of Medicaid expansion. Less well-documented are the negative impacts that flow from rejecting expansion. Obviously, non-expansion states fail to reap the profound benefits of expansion. But they are not just failing to move forward with the expansion’s huge financial boom to health care providers and improved individual and population health. Instead, they are moving backward. The “health “ of both providers and the uninsured in non-expansion states is going from bad to worse as scheduled cuts to local safety net hospitals have begun to take effect.

Living in a non-expansion state like Florida is like watching a slow motion train wreck in your own neighborhood. As with any major local disaster, responsible county leaders should understand the causes and consequences, and this particular disaster requires a basic grasp of Medicaid hospital financing. Unfortunately, this topic is mind-bogglingly complex. It involves an alphabet soup of programs—LIP, DSH, RE, RA, IGT—and is currently understood by only a tiny handful of officials, industry insiders and policy wonks. In an effort to educate more key stakeholders, my office recently released the first of three county specific briefs explaining the implications of local safety net funding reductions and structural changes. We hope this resource will enable local leaders to both understand and address county specific funding issues and re-engage their community leaders and policy makers in dealing with the cost of treating uninsured residents.

But rather than use this guest blog opportunity to dive into arcane Medicaid financing stream issues related safety net hospitals in non-expansion states with a managed care system and an uncompensated care pool program within an 1115 waiver, I’d like to put a human face on one casualty of this train wreck. In mid January, I received a call from Senator Nelson’s office requesting assistance on behalf of a low-income constituent in Miami. The family of Maria Huaman, a mother with 3 young children, was desperately trying to get her transferred to Miami’s public safety-net hospital. Maria needed a lung transplant in order to survive. According to the family, the county hospital, which is the only local transplant center, allegedly refused to admit her for an evaluation because she did not have insurance and could not pay the requested large deposit. Maria had recently been enrolled in a market place plan, but the coverage was not effective until February.

As a long time Miami legal services lawyer, I knew that the county’s public hospital had a charity care program and that under the program’s eligibility requirements, Maria was entitled to free or reduced cost care without a preadmission deposit. I immediately emailed the hospital officials citing the relevant standards and “demanding” her admission for evaluation. But by that time it was too late. Maria died the next morning. The Miami Herald covered her family’s struggle with the hospital in a front-page story.

While the story focused on the hospital’s alleged refusal to accept Maria’s transfer without a $350,000 deposit, the reporter also included factual context and background relevant to the safety net’s failure, i.e. the Florida legislature turning down federal money to provide coverage for single, childless adults as well as low-income parents like Maria. The head of the hospital’s transplant unit, Dr. Ernesto Pretto, Jr., wrote an op-ed calling out for the need to “highlight the impact that the failure to expand Medicaid under Obamacare is having on thousands of sick and uninsured in Florida.” According to Dr.Pretto, “this is but one of many tragic stories that could have been prevented had the governor and the Florida Legislature agreed to accept federal funds to expand its Medicaid program to include low wage earners, such as the [Maria[Huaman] Marquezes.”

When Florida leaders ultimately reengage with this issue, they should not be allowed to shift blame to the federal government as they did in 2015 when Gov. Scott sued CMS over continuation of the state’s Low income Pool (LIP) waiver. Leaders should not forget the numerous problems with LIP, including the fact that there was never remotely enough funding to cover the cost of treating the uninsured (even at the height of LIP), and that it was often difficult or impossible for low-income residents to access a hospital’s charity care program.

In sum, CMS has articulated reasoned and responsible principles for reviewing any state waiver requests, including the indisputable principle that coverage is a much better use of public funds than uncompensated care pools such as the LIP. But regrettably, tragedies like Maria’s will likely continue and increase in non-expansion states because the funding for safety nets is being legitimately reduced and not replaced with expansion funding.