The changing global climate is already creating far-reaching impacts on population health in Florida that, paired with barriers to affordable healthcare access, will impact Florida’s most vulnerable populations. One particular concern is the increased threat of vector-borne diseases. Thanks to South Florida’s unique environment and status as an international gateway, Florida is particularly vulnerable to vector-borne diseases. The public health impacts of this threat are compounded by the fact that many cannot access affordable health coverage, including over 20% of adult Floridians. This brief explains the increasing threat of vector-borne disease in Florida as a result of the changing climate and the available public-sector responses, including expanding Florida’s Medicaid program under the Affordable Care Act (ACA).
Vector-borne diseases are transmitted through a vector species, such as a mosquito, usually through a bite. Several biological and environmental factors control the transmission and spread of vector-borne diseases. While some factors are capable of human control, Florida also faces major environmental factors, including temperature and rainfall, which impact pathogen infectivity and survival as well vector species breeding. Hurricanes also provide an opportunity for vector-borne diseases to spread—heavy rains, storm surge, and damage create breeding opportunities for disease-carrying mosquitoes.
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
The Florida Health Justice Project, a new nonprofit advocacy organization, seeks to improve access to affordable healthcare for Floridians, with a focus on vulnerable low-income populations.
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