In January of 2005, Florida Governor Jeb Bush proposed a Medicaid reform plan that he promised would empower patients, offer more than a "one size fits all" service and establish controllable, predictable spending for the state's $14 billion health system. The program had not been the subject of any noteworthy reform since its birth some 30 years earlier.



"To fulfill our commitment to Florida's Medicaid program, we must transform it completely so that the number one priority is patient wellbeing and the last consideration is government control," Governor Bush said at the time. After several years of planning and implementation, the new system is still not fully operational, although opinions differ - quite dramatically, in fact - as to whether the reform was a failure, a success or just the beginning of a long-term "work in progress."

Whatever the verdict, many residents of the Sunshine State are apparently unaware of the important changes that have taken place, which were phased in over a period time. In fact, the new Medicaid payment system did not go online until the middle of 2008, and as of January 2009, according to the Tampa Tribune, the problems that "erupted" then were "still happening." Clearly, it will take some ongoing work for anyone in Florida to get a grasp on the operation of this large and costly program.

A step at a time

The "new" program began two-year trial in 2006, but only in two counties at first, later expanded to five in 2007. Before going statewide, the idea was to have a "shakeout" of the system, which was to be overhauled to give patients more control and more discretion in their own health care. Proponents of the reform measures sought to place Medicaid participants in health-insurance schemes that are quite similar to those in the private sector.

Because competition is integral to the design of the new program, enrollees must contend with what the Tampa Tribune article called "a dizzying array of rules common in employer-based insurance plans." With a clientele drawn from the poorer and less-educated (and sicker) residents of the state - including the deaf and blind, the mentally ill and the elderly - confusion appears to be common.

Competition and choice

The reforms are based on consumer choice. Enrollees are able to select one of 15 insurers in the Ft. Lauderdale area, and six in Jacksonville. They can choose among plans that minimize co-payments, eliminate out-of-pocket expenses, offer more services, provide "regular" style managed care or mimic standard HMO offerings. Florida has worked with HMOs for a quarter century now, so overseeing managed care is nothing new, although the "competing company" model is.The two-year trial did not "end" so much as lose steam, as changing economic conditions resulted in the state implementing some parts of the proposal and not others, while delaying some features indefinitely. There have been some successes, as Floridians apparently like the concept of personal choice and control, and some failures, too. Notable among the latter has been the continuing problem ("glitches") with the computerized billing and payment system.

A quick review

- It is too soon to tell if the system will save money, the program's most advertised and quoted "goal," but officials told the Tribune that it is "no more expensive than the old way." Cost comparison is an ongoing task.

- There is vehement disagreement as to how the chronically have made out under the new program. Although the state has logged a modest number of official complaints, healthcare professionals serving the HIV-positive, mentally ill and disabled patient populations claim there is insufficient treatment being provided.

- Insurance companies and state officials claim there are few doctors leaving the new Medicaid program. Some patient advocates and a few doctors are on record as saying that fewer physicians were taking Medicaid patients.

- A "healthy rewards" program was made part of the new system. Patients who quit smoking, keep their appointments, lose weight, meet their fitness "targets," etc., can earn points redeemable for healthcare products. According to state figures, after the first year of the trial enrollees had amassed almost $4 million in rewards value, but claimed less than $100,000 worth.

Work yet to do

As for how to make appointments, fill out forms, get a specialist or work with your doctor, hospital and the Florida Agency for Health Care Administration (AHCA), no single article - no single book - could contain the incredible amount of material, charts, diagnostic and billing codes, forms and definitions that have been created to administer this huge undertaking. The navigation panel on the ACHA website has some 50 subject areas, from "About Florida Medicaid" and "Abuse