Florida lawmakers chose to 'make dust' rather than 'eat dust' by reforming health care in their state before the Congress acts.
Florida lawmakers hope they have found a public-private solution to the health care crisis.
Pushed by Governor Lawton Chiles, the Florida Legislature in April enacted a sweeping model for heath care reform based on the idea that businesses pooling their buying power can obtain quality health insurance at affordable prices.
The managed competition approach places Florida in the forefront of states trying to solve the problem that threatens to consummate state budgets and sink small businesses.
'This is a great model for managed competition,' Chiles said the day after the Legislature passed the 186-page bill. 'We have everything in this we thought we needed.'
The bill also:
* Sets up practice parameters, or guidelines to show doctors the most cost-effective proven treatments to get the best results for hundreds of medical conditions.
* Encourages hospitals in rural areas to cooperate in networks through which some would specialize in emergency care, others critical care and others convalescent care.
* Encourages public hospitals receiving state money for providing indigent care to expand primary care clinics.
While most states face growing budget pressures from the health care quandary, the problem is even greater in Florida. Of the state's 13.5 million residents, 2.5 million--18.5 percent--are uninsured. When medical problems become acute, the uninsured get attention in hospital emergency rooms where costs are the highest.
Floridians spent $31.4 billion on health care in 1990, and the number is expected to rise to $90 billion by the end of the decade if nothing is done. Doctor bills for Medicare patients in Florida are the highest in the country, according to a recent study in the New England Journal of Medicine.
Florida's health care reform was launched last year when the Legislature began plans to develop health care for everyone by 1995. In his State of the State address on the Legislature's opening day, Chiles challenged lawmakers to act swiftly on his health care reform plan.
'We can't wait for a national plan that will delay our ability to provide access to people who need it,' he said. 'We can show the way. We can make dust or eat dust.'
Lawmakers chewed plenty on Chiles' plan before they finally swallowed it.
The most fiercely fought piece involved the community health purchasing alliances (CHPA), state-chartered buying pools of small businesses.
Republican legislator wanted the CHPAs to include only small businesses and to provide information about price and effectiveness of doctors, hospitals and other health care providers. Chiles wanted strong CHPAs that would have the power to negotiate directly with health care providers and insurance companies. He also wanted to jumpstart the alliances by including Florida's 312,000 state employees and dependents and its 1.5 million Medicaid patients.
The fight over strong or weak CHPAs, known as 'chippas,' became distilled into shorthand as 'Chippa-munk' vs. 'Chippa-Kong.'
In the final compromise, Chiles won most of his demands.
The purchasing alliances (11 of them across the state) will include businesses of up to 50 employees, plus state workers and Medicaid recipients. But, under pressure from Blue Cross and Blue Shield of Florida, the third-party administrator of the $450 million state employee health plan, the Legislature inserted language ensuring state employees' health benefits will be the same or better under a CHPA arrangement.
Businesses that join a CHPA will choose from a menu of plans assembled by health care providers linked with insurance companies.
In a concession to the Florida Medical Association, Chiles and the Legislature agreed that the menu must include both traditional indemnity type insurance and network arrangements such as health maintenance organizations.
Each CHPA will have a board representing government, business and consumer interests. The board will provide members with information on the plans, rating them by quality and price.
Insurance reforms represent another major breakthrough.
The bill requires insurance companies in the small group market to take all comers and bars insurers from writing coverage for only the healthy.
Under modified community ratings, insurers may vary rates based only on age, gender, family composition, location and tobacco use. No more cherry-picking--and insurance company practice of covering a small business with healthy employees and then drastically raising premiums or refusing to renew the policy when one or more workers incur expensive medical costs.
Chiles, a Democrat, had both Republican and Democratic support for his goal or reducing health care costs immediately and making sure all Floridians had health care coverage by Jan. 1, 1995.
Health Care Reform Not Limited to Sunshine State
Florida isn't alone in seeking health care reform. Maryland and Washington also enacted health care plans this session, and Vermont reformed its system in 1992. Oregon and Massachusetts adopted health care reform in the late '80s. Hawaii and Minnesota have plans that date back to the '70s.
Here's what these states have done:
* Maryland approved cost control on doctors' fees and changed state insurance laws to make coverage cheaper for small businesses.
* Washington adopted a comprehensive program that provides basic coverage for 500,000 uninsured residents, establishes guidelines for managed competition among doctors and hospitals and sets ceilings on health insurance premiums.
* Vermont expanded access for all children, instituted community ratings for individual insurance policies, established incentives to contain costs and created a health care authority.
* oregon received federal waivers this spring to institute its 1989 plan to deny Medicaid coverage for some medical services in order to make benefits for basic procedures available to 120,000 more poor people.
* Massachusetts postponed implementation of its Health Security Act adopted several years ago. The new target date is 1995. The act requires companies with six or more workers to offer health insurance or pay a tax that will be held in pool for uninsured workers.
* Hawaii, with one of the oldest state programs, requires that small businesses provide insurance coverage for employees. it also insures citizens not covered by Medicaid or by prepaid health care through a state health insurance program.
* Minnesota endorsed managed care in 1972 when it required that employers of 50 or more offer health maintenance organizations as an option to individual insurance. More recent legislation provides a source of insurance coverage for low-income families, requires insurers to offer plans with minimum benefits and cost-sharing to small employers and creates a commission to help reduce health care inflation.
Eighteen other states are considering health care reform programs this session.
Oregon Gets its Waiver, But Now the Money Isn't There
Innumerable days and nights of drafting, redrafting and fine-tuning an innovative health care plan ... four years of controversy ... one failure on the federal level ... and, finally, success of a sort.
It's been a long, bumpy road for the oregon health care plan devised in 1989. Waivers from a federal Medicaid law that requires provision of 'all medically necessary services for recipients under age 21' were finally granted this spring. But now there is serious concern that the state may not be able to afford the program that would add an estimated 120,000 more poor people to its rolls. Oregon is suffering an estimated $1.7 billion budget shortfall this year.
Restrictions applied by the Clinton administration and increased cost have raised serious questions as to whether or not the state can executive its plan to deny Medicaid coverage for some medical services in order to make benefits for basic procedures available to all poor people.
Senate President Bill Bradbury and House Speaker Larry Campbell say the plan cannot be funded with existing state revenues.
Oregon's effort to devise a better state Medicaid program was first stymied when it was denied exception from federal law last year by the Bush administration on the basis that the plan conflicted with the new Americans with Disabilities Act (ADA).
The original proposal used 'contribution to a patient's quality of life' as one of the criteria to rank medical services. That provision, said the feds, discriminated against people with disabilities who were viewed as not having a high quality of life.
The quality of life guideline was deleted from the current plan, but advocates for the disabled are still not happy. State officials say critics will probably file a lawsuit to block implementation of the program. Opposing Oregon's model are the AIDS Action Council, American Civil Liberties Union, the American Foundation for the Blind and other organizations.
Oregon's controversial plan ranks 688 medical procedures and services according to cost and benefit to patients. Services ranked 1 through 568 will be paid for under the program. (In general, the state will not pay to treat conditions that will clear up on their own nor for ineffective practices.)
Rankings include treatment of severe head injuries, No. 1; treatment of insulin-dependent diabetes, no. 2; and obstetrical care, no. 27. Services below the no. 568 funding cutoff include treatments for the common cold or chronic back pain.
Similar to what is being considered by the Clinton administration for a national health program, the Oregon project encourages Medicaid recipients to use health maintenance organizations or other managed care. It also requires employers to provide health insurance for workers, a provision that will take effect in July 1995. The plan emphasizes preventive treatment and early intervention for women and children.
In granting the waivers from federal Medicaid law, Donna Shalala, secretary of the U.S. Department of Health and Human Services, said the Oregon plan was consistent with the president's philosophy of giving states 'flexibility to design new approaches to local problems.'
Bill Moss covers the state capital for the St. Petersburg Times.
