New York Times: Opposing the Health Law, Florida Refuses Millions

By KEVIN SACK
Published: July 31, 2011

TALLAHASSEE, Fla. — When it comes to pursuing federal largess, most of the states that oppose the 2010 health care law have refused to let either principle or politics block their paths to the trough. If Washington is doling out dollars, Republican governors and legislators typically figure they might as well get their share.

Then there is Florida. Despite having the country’s fourth-highest unemployment rate, its second-highest rate of people without insurance and a $3.7 billion budget gap this year, the state has turned away scores of millions of dollars in grants made available under the Affordable Care Act. And it is not pursuing grants worth many millions more.

In recent months, either Gov. Rick Scott’s administration or the state’s Republican-controlled Legislature has rejected grants aimed at moving long-term care patients into their homes, curbing child abuse through in-home counseling and strengthening state regulation of health premiums. They have shunned money to help sign up eligible recipients for Medicare, educate teenagers on preventing pregnancy and plan for the health insurance exchanges that the law requires by 2014.

While 36 states shared $27 million to counsel health insurance consumers, Florida did not apply for the grants. And in drafting this year’s budget, the Legislature failed to authorize an $8.3 million federal grant won by a county health department to expand community health centers.

In interviews, Mr. Scott, a Republican, and state legislative leaders were clear about their rationale. They said they detested everything about the federal health law, which was declared unconstitutional by a federal judge in a case filed by the state. Unless ordered to do otherwise by an appellate court, they said, they had no intention of putting it in place, even if that meant leaving money on the table.

“There are a lot of programs that the federal government would like to give you that don’t fit your state, don’t fit your needs and ultimately create obligations that our taxpayers can’t afford,” said Mr. Scott, a former hospital company executive who rose to political prominence by financing an advertising campaign against the health care legislation.

State Representative Matt Hudson, the chairman of the Health Care Appropriations Subcommittee, said his chamber’s leadership felt the same way.

“I do not believe that act is the right thing for the country or the right thing for Florida,” Mr. Hudson said, “and I am not going to start implementing things that I don’t believe in.” Asked whether states had the authority to stymie federal law, Mr. Hudson answered, “We’re not required to accept a grant.”

Florida is by no means the only state hostile to the health care law. A majority of those states have gone to federal court to challenge the law’s central requirement that most Americans obtain health insurance. Alaska, Oklahoma and Wisconsin, among others, have turned away grants, some of them substantial.

But many of the states challenging the law have taken a posture more like that of Idaho, where Gov. C. L. Otter, a Republican, made a show this spring of ordering his agencies not to pursue Affordable Care Act grants and then quickly issued 10 exceptions to that rule.

Florida has had few peers in subverting the law’s provisions since Mr. Scott took office in January. After a federal district judge in Pensacola invalidated the entire act later that month, Mr. Scott quickly put the brakes on planning for the insurance exchanges and started rejecting grants pursued by his predecessor, Charlie Crist, a more moderate Republican. The state maintained its stance even though the judge, Roger Vinson, suspended his ruling pending appellate review.

“I don’t want to waste either federal money or state money on something that’s unconstitutional,” Mr. Scott said in a 30-minute interview in his office on Friday.

The governor, sporting black cowboy boots embossed with the state seal, said his subordinates had made case-by-case decisions about whether particular grants advanced the state’s efforts to remake its Medicaid program. This year, Mr. Scott and the Legislature enacted Florida’s own law directing most recipients into managed care plans.

But Mr. Scott deflected requests to explain where the line was drawn, other than to say that competition, personal choice and quality incentives should drive the health care market.

“I’d have to go through each program to look at it,” Mr. Scott said. “We have a Medicaid plan, so if it fits with that plan, then we’re interested, and if it doesn’t, we’re not.”

In distancing itself from the law, Florida declined to participate in a Medicaid pilot program that would have authorized up to $2 million in reimbursement to providers using a new hospice model for severely ill children. The state insurance commissioner applied to the Obama administration for a waiver from this year’s requirement that health insurers spend at least 80 percent of premium revenue on medical care. Only at the last minute did the State Health Department agree to provide required letters of support for community groups applying for federal wellness and prevention grants.

Critics say the state’s Republican leadership has carried its opposition to the health care law too far. The grants being shunned by the state, they point out, have little connection to the provisions that Florida is challenging in court, namely the insurance mandate and the expansion of Medicaid eligibility.

“It’s simply unconscionable that they’re turning back federal tax dollars that our citizens and businesses pay and sending those tax dollars to other states,” said Representative Kathy Castor, a Democrat who represents the Tampa Bay area. “Florida’s economy has been hit very hard, and we need every dollar and every job in our state.”

Health care advocates scoff at the assertion by Mr. Scott and the Legislature that some of the rejected grants would duplicate existing state programs (a few of the grants require a state contribution).

“Residents will suffer if the grants are turned away,” said Elizabeth M. Rugg, the director of the Suncoast Health Council in St. Petersburg. “There’s a lot of need in Florida, as everywhere else.”

Although Florida is the fourth most populous state, it ranks 12th in the amount of money received from health care act grants, according to the government’s grant-tracking Web site. The law has directed $46.4 million to the state out of $1.98 billion awarded nationally. Much of the money has gone directly to local governments, community groups and medical providers.

Three of four grants to expand community health clinics in Florida went to medical centers that are beyond the reach of the governor and the Legislature. The fourth was to the Osceola County Health Department, which under Florida law is effectively a unit of state government. The Legislature used its power to not authorize a grant won by the county to expand two health centers and build a third.

“The speaker had a policy that we weren’t going to be implementing any part of health care reform, so those grants were not included in our budget,” said Katherine Betta, a spokeswoman for Dean Cannon, a Republican and speaker of the State House.

Some of the forsaken grants were for small amounts, but others, over time, would have infused state programs with substantial sums. As long as the state makes no moves toward setting up an insurance exchange, it will not compete for grants worth tens of millions of dollars to help establish them and invest in needed technology. If Florida does not demonstrate adequate progress by early 2013, the federal government can take over the state’s exchange.

Although many conservative governors consider that the worst scenario, Mr. Scott said his antipathy toward the exchanges was so strong that he would oppose running it. “I’d rather nobody run it,” Mr. Scott said. “I don’t think there’s any way the state can do it where it’s good for health care policy.”