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TALLAHASSEE - Leading lawmakers are sold on Gov. Jeb Bush's plan to overhaul Medicaid.
So are federal officials, who have given Bush the green light to draft a plan for their approval.
But convincing the doctors who treat Medicaid patients - and the advocates who represent them - that Floridians should forfeit their guaranteed entitlement to the $14-billion health care program for the poor will take work.
The Florida Medical Association, a key Bush political ally, already has told the governor it won't support capping spending.
AARP Florida, which claims 2.7-million voting members, warned Bush it opposes the approach, which Bush says is required to keep Medicaid from overwhelming the state budget.
Similar thoughts have echoed from other groups, which say dramatic changes to Medicaid could harm patients and the state's financial health.
"Capping Medicaid funding will put the state into a fiscal straitjacket and lead to rationing of services, waiting lists and sick Floridians unable to get needed care," said William Phelan, director of the Florida Health Care Association, a nursing home trade group.
Nevertheless, Bush is forging ahead, largely because Medicaid costs have doubled in six years and now gobble one of every four dollars the state spends.
Other health care programs have been cut to pay for Medicaid, which must cover everyone who qualifies. Bush wants to change that, and any change he proposes is likely to involve some kind of cap on federal funding. That could help stabilize state costs, but would end guaranteed coverage. If patients and doctors don't see the need for change now, they will when the state continues to cut payments to Medicaid health care providers, state officials say. Nursing homes took a 5 percent hit in the budget legislators passed last month.
"Real reform is needed for Medicaid," Bush said last week.
It's not the first time Bush has charged ahead with dramatic changes to key state programs before the constituencies of those programs even recognized a problem. In 1999, Bush surprised African-Americans around the state when he announced plans to replace affirmative action in state university enrollment and state contracts with a set of guidelines encouraging the recruitment of minorities. His decision sparked outrage around the state from groups affected by the changes.
This time, Bush has asked groups including the FMA and AARP for their views before he sends his proposal to the federal Center for Medicare and Medicaid Services. But he shows no signs of slowing down to give the interest groups a chance to catch up or get on board: State health officials gave advocates three weeks during the frantic legislative session to offer suggestions. Bush administration officials say speed is the one sure way to get a serious discussion going.
Based on the early responses, though, some seem uncertain the situation is as dire as Bush claims.
"One of the stated appeals of a capped Medicaid program is the belief that it will be a mechanism to control escalating health care costs. United Spinal strongly believes this assumption to be erroneous and shortsighted," said Jeremy Chwat, director of legislation with the United Spinal Association, a disability advocacy organization.
"A capped program will inevitably lead to the diminution of health care services, pitting the poorest and most vulnerable populations against each other in search of quality health care," Chwat said. Chwat, Phelan and other Medicaid providers and advocates dispute some of the basic reasons for Medicaid changes state officials cited when they asked for input: Many Medicaid recipients "work and have incomes above poverty."
They point out that more than half of Medicaid recipients are children whose family income is at or below the poverty level. Most of the rest are elderly or disabled and unable to work. Two-thirds of nursing home patients are covered by Medicaid. The only Medicaid patients who work are underemployed single parents.
Phelan and groups including the Florida Pediatric Society and the Florida Academy of Family Physicians also dispute state claims that Medicaid uses an outdated insurance model that has not responded to changes in the health care market. Phelan said Medicaid has expanded managed care models in the past decade and has controlled costs better that private market plans. In fact, the growth of Medicaid has been slower than the growth in costs of many employer-based plans, Phelan said.
"We are interested in discussing ways to bring down costs in the health care system as a whole, but focusing on the Medicaid program in isolation will do little to solve the ultimate problem of unsustainable health care costs for all of Florida's residents," Phelan said.
Bush agrees Medicaid changes cannot be done in a vacuum. The changes he favors go hand in hand with changes he proposed for private health insurance, particularly in the use of medical savings accounts and high-deductable, "bare bones" health insurance policies.
Some early suggestions floated by Bush's staff include capping federal funds to make costs more predictable and establishing a maximum lifetime benefit for some recipients, similar to welfare.
Legislators also wrote plans into the budget to start moving some Medicaid patients into bare bones policies on a test basis.
Bush's proposal will be ready for federal review by late summer or early fall, and something should be ready for legislators to look at by about December. State legislators must approve the changes.