To:

Professor Jacob Stewart

From:

Michael Pozo

Date:

April 6, 2016

Subject: Florida Medicaid Expansion

Currently Florida has not expanded Medicaid to its citizens for various reasons and some may be
political and can be associated with the Affordable Care Act. I have located information of this
problem, which include Floridians that may be affected by not expanding Medicaid, past actions
taken to try to address this problem and propose a course of action that possibly can be taken to
further expand Medicaid for Floridians.
Overview
Florida is one of a few states that have not expanded Medicaid which would have under the
Provisions of the Patient Protection and Affordable Care Act expanded Medicaid to all
Americans under age 65 whose family income is at or below 133 percent of federal poverty
guidelines. After researching the current state of affairs, I believe that this is a very serious issue
that is worth tackling. Some of the issues associated with the Florida Medicaid expansion can be
attributed to the Affordable Care Act, which was created to insure Americans, but lawsuits has
caused numerous problems with expanding Medicaid, which has caused some Floridians to fall
into what is known as the coverage gap where they dont qualify for, either the Affordable Care
Act or Medicaid because of the existing laws. Some of these arguments are political as an
attempt to undermine the Affordable Care Act and, in doing so, the opposing sides argument
does not take into account the numerous lives that are affected or may be affected by not
expanding Medicaid. Because of this, some proposed actions, which include protests, petition
signing and voting can be taken to attempt to enact change. However, there are also limitations
associated with these actions, which has to do with the effectiveness of each proposed action.
Current laws
The Affordable Care Act was signed into law in 2010 and further created certain limits on what
insurers may or may not do with respect to eligibility and coverage which include:

Dependents may be placed on the parents insurance until they turn 26

Coverage cannot be denied by insurers because of pre-existing conditions and must offer
the same premiums within the same age and geographical group regardless of gender and
pre-existing conditions with the exception of tobacco use.
Expands Medicaid eligibility to include those earning 133 percent of the official poverty
level, including adults without dependents, in participating states.
Subsidies in the form of refundable tax credits available on the state health insurance
exchanges for individuals with a household income up to 400 percent of the official
poverty level.

The important provision for this discussion is the expansion of Medicaid provision, which
was supposed to expand Medicaid eligibility to those earning 133 percent of the official
poverty level, including adults without dependents. There were lawsuits filed to stop this
expansion and the Supreme Court ruled in National Federation of Independent Business v.
Sebelius that the Medicaid expansion provision of the Affordable Care Act violated the
Constitution by threatening states with the loss of their existing Medicaid funding if they
declined to comply with the expansion. Therefore, Medicaid expansion was left to the states
to decide if they wanted to expand Medicaid.
Since, states were given the ability to expand Medicaid, if they choose to do so, we have to look
at how the Florida Medicaid laws are structured, since they have not expanded Medicaid. I have
listed certain requirements that I believe will be useful in showing where the problem exists.
The Department of Children and Families or the Social Security Administration for recipients of
supplemental security income determines who is eligible for Medicaid in Florida and to qualify
the applicant must meet certain requirements which include:

Being a child, the parent or caretaker of a child, pregnant, elderly, blind, or disabled, and
must meet certain income requirements.

Since, the affordable Care Act made changes to Medicaid eligibility, it is now determined
by IRS rules for determining household and income.

Eligibility is determined in relation to the Federal Poverty Level, which changes every
year and in Florida, if the household income of a person eligible for Medicaid is less than
a certain percent of the Federal Poverty Level, that person meets the income
requirements.
Florida may also set the income eligibility limit based on number of family members and
is calculated using the Modified Adjusted Gross Income.

Problem
In 2015, there were as many as 5.2 million people nationwide without healthcare because they
did not qualify for the Affordable Care Act subsidies because they made too little and did not
qualify for Medicaid because they made too much. And as of 2016, there are 19 states that have
not expanded Medicaid, which has gradually improved from the 22 not long ago.
Florida is one of those 19 states and in Florida, the tax credits are available to people who earn
100 percent to 400 percent of the federal poverty level, and those who earn less than 100 percent
fall into what is known as the coverage gap where they are not eligible for Medicaid and don't
make enough to qualify for tax credits afforded through the Affordable Care Act. For nondisabled adults in Florida, Medicaid is restricted to parents of dependent children with incomes
below 35 percent of the federal poverty level.

With these issues at hand, at the current moment, it does not seem as Medicaid expansion is on
the legislative list for this year. Since, there is no real possibility that the state government will
consider this anytime in the future, this a good moment to discuss the issues of not expanding
Medicaid, since this is the exigence of this campaign.
The issues associated with this current problem include:

People are not able to see a doctor

People are not able to seek medical care when it is needed.

Deaths have occurred.

One case where a Floridian did not qualify for either the affordable Care Act or Medicaid and
two particular cases where the people died is also worth noting to better explain the issues
associated with not expanding Medicaid:

Francesca Corr is an immigration paralegal, mother of five, who attempted to sign up for
healthcare, but did not qualify for government help through the Affordable Care Act. The
reason being that she earned $24,000 a year, which was too much to qualify for Medicaid,
but was $4,000 short to qualify for government subsidies under the Affordable Care Act. She
had to go without healthcare.

In March 2014, a 32 year old mother of 3 named Charlene Dill collapsed and died while
working as a vacuum salesperson at someones house. She was working three part time jobs
and at the time stopped taking prescription medication for her condition after she no longer
qualified for Medicaid because her yearly income of $9,000 was above the maximum amount
to qualify for coverage.

Another more recent case involves a woman who unintentionally ingested herbicide and
because of various hurdles through the medical system died. One particular problem here is
that, even though, both her and her husband owned a cleaning company and their annual
income was less than $28,000, which is the minimum amount to qualify for the Affordable
Care Act, they still made too much too qualify for Medicaid.

Potential Targets
While, I could not specifically locate any particular groups or pressure groups that are opposed to
the Florida Medicaid expansion proposal, I found that the house legislatures and the governor of
Florida are the main culprits who are opposed to the expansion. That is why these individuals are
the main targets of this campaign.
In 2013, Governor Rick Scott was on board with the federal government covering 100 percent of
the Medicaid expansion, which by 2020 the federal government would have covered 90% of the

cost leaving the remaining 10% to be covered by the state of Florida. But as of 2015 Governor
Rick Scott backtracked his support and has refused again to expand Medicaid in Florida.
Moreover, the Florida senate was on board with the expansion, but the Florida house voted
against the proposed expansion making the Florida house equally responsible.
Possible Solutions and Audience
This problem affects many people directly and indirectly. Because of this, I would be engaged in
deliberative discourse to attempt to force policy change. In my description I only detailed cases
involving woman, but this also affects the husband, which includes males that are left without a
wife, the children that are left with no mother or woman (and men) that have to put their
healthcare on hold because they cannot afford to let their children go hungry.
Others affected is the millennial generation in Florida. One member named Isabel Betancourt of
the newly formed young invincibles has threatened to take revenge at the ballot box by voting
out the current governor and legislatures. She is one of an estimated 250,000 Floridians between
the ages of 18-34 (including myself) who fall into this coverage gap. I could use this platform,
since I identify with this generation to attempt to persuade the millennials to vote and alter the
keys of power in Florida. Here also we could also see that I have the rhetorical agency to try and
persuade Hispanic millennials that this is an issue that we should try and address. But more
importantly I am a millennial, so this gives me the rhetorical agency to identify with this
generation to enact change in this policy.
Other actions that possibly could be taken besides voting is signing a petition, which I have
located on moveon.org that could possibly be sent to attempt to force the Florida legislatures and
Florida Governor to reverse their decision. A final possible course of action I propose that could
be taken is to organize a student protest to force the Florida governor and legislature to take into
account the numerous people that have no health insurance.
This means that my rhetorical audience for this campaign is the women affected, the husbands,
family members, the millennial generation and, finally the poor people.
Constraints
However, some negative constraints associated with these plans of action have to also be
discussed. This includes that there have been protests before to no avail and petitions may not
necessarily force Rick Scott or the Florida House to listen to the people. A vote can be attempted,
but this would mean mobilizing a significant number of people and particularly millennials to
vote, which under current millennial participation numbers throughout the country is low.
While this would be somewhat difficult, it is still not impossible to achieve. I believe if the
millennial population is mobilized, since Florida is in a unique position because of the numerous
higher education institutions throughout the state and the Hispanic millennials having the ability
to sway an election they could very well change the landscape of the Florida state government
which would also help to expand Medicaid to Floridians.

Additional positive constraints should also be noted that have to do with the women that either
died or were left with no health insurance. Here the argument could be made that the need to
address this issue is needed since children are being left without mothers, husbands without
wives or may go hungry because of this issue. This would be targeted at conservatives who may
hold a strong view on the family. By appealing to this aspect of the argument, I could possibly
sway them to support Medicaid expansion. If not the targets, then republican voters who may not
agree with what is going on, since these women were working when they had to go without
healthcare or lost their lives..
Conclusion
Medicaid expansion in Florida is needed for many of its citizens because of the current laws that
leave many without health insurance. This issue affects many people that cannot be lumped into
one specific group. Therefore, we have to force policy change by persuading the state
government, particularly the state governor and house legislatures that are opposed to its
expansion by engaging in various actions. And, while these actions have its limitations, I feel that
they still can be helpful in enacting change.
I hope the detailed information I have gathered outlines how we got to this point with the Florida
Medicaid expansion Battle and what we can do to fix it. If you have any questions please do not
hesitate to let me know.

Useful Links

https://www.oyez.org/cases/2011/11-393
http://pubsys.miamiherald.com/static/media/projects/2015/gap-explainer/index.html
http://www.bbc.com/news/blogs-echochambers-27027361
http://www.miamiherald.com/news/health-care/article54985205.html
http://www.theatlantic.com/politics/archive/2015/05/florida-struggles-to-pay-the-tab-forrejecting-obamacare/392678/
http://www.miamiherald.com/news/health-care/article18721668.html
http://www.mynews13.com/content/news/cfnews13/news/article.html/content/news/articles/bn9/
2016/2/15/millennials_pressure.html?cid=rss
http://petitions.moveon.org/sign/florida-medicaid-expansion
http://statelaws.findlaw.com/florida-law/florida-medicaid-eligibility-requirements.html
http://healthcare.findlaw.com/patient-rights/obamacare-basics-understanding-the-affordablecare-act.html
http://www.ncsl.org/research/health/affordable-care-act-expansion.aspx

https://www.healthinsurance.org/blog/2016/02/10/the-inevitable-expansion-of-the-medicaidexpansion/
http://floridapolitics.com/archives/199115-pew-study-florida-most-likely-to-be-affected-bygrowth-in-hispanic-voter-numbers
http://articles.sun-sentinel.com/2013-04-21/health/fl-uninsured-health-care-workers20130421_1_health-insurance-medicaid-expansion-health-care
http://www.npr.org/2016/02/24/462948346/the-10-states-where-millennials-couldsway-the-election