Feb. 24--TALLAHASSEE -- Until she was laid off from her job at a cell phone company, Toni Rosenberg said she'd always prided herself on being self-sufficient.
"I come from a generation taught not to ask for much," said Rosenberg, 68, of Boca Raton. "Something like Medicaid, that was always for poor people. Not for me."
But losing her job in 2010, followed by kidney failure, which put her in the hospital last year and then onto a regimen of costly medications, soon taught her otherwise, she said.
Money got tight, and she looked for help.
"I found out I qualified for Medicaid. It gave me just enough to help pay for groceries," she said. "But I tell you, it changed my view. Medicaid wasn't just for the poor. It was for me."
Like Rosenberg, Florida lawmakers are coming to grips with a new reality shaped by the Affordable Care Act, the federal health care overhaul pushed through Congress by President Barack Obama and, until last week, opposed at virtually every stop by Florida Republican Gov. Rick Scott.
In Florida, where 3.5 million people have no health insurance, the law has divided industries and interest groups. The state's option of expanding Medicaid coverage to a portion of that population -- about 1 million lower-income Floridians has suddenly been embraced by Scott.
But it is dividing the Republican-led Legislature, which begins the annual session March 5.
Many business leaders warn against the law's potential cost, penalties that loom over employers and the paperwork complexities it will bring.
Nurses support it but acknowledge that the federal overhaul will add to an already 55,000-nurse shortage in the state. Hospitals, lobbying hard for Medicaid expansion, predict it will ease the taxpayer cost of charity care, which robbed them of $2.8 billion last year.
Florida hospitals also will lose $14.3 billion in Medicare payments over the next decade, as part of the Affordable Care Act, while reducing payments they receive for treating those without insurance.
That heightens the need for Medicaid expansion, hospitals argue.
Watch the deficit in D.C.
But deficit hawks warn the state shouldn't rely on Washington, saying the spike in federal spending could bankrupt the government. Advocates, though, say the additional health care spending will spark a recovering economy.
Families USA last week forecast 71,300 new jobs and $8.9 billion in additional economic activity in Florida by 2016 because of the law.
Already, after weeks of contentious committee debate in Florida, Sen. Tom Lee, R-Brandon, said he is struggling to comprehend the scope of a measure many say packs the societal shaping force that Social Security or Medicare carried in the last century.
"I can see how it's going to change human behavior and change market forces," Lee said. "It's stunning and that's what I'm trying to get my head around."
Scott, though, last week sought to simplify the issue. He urged lawmakers to embrace the expansion -- at least for the three-year trial when it is fully financed by the federal government.
Scott recalled his late mother's struggle to raise five children on a modest income under a cloud of worry about maintaining health coverage.
Scott backs expansion
Defying conservatives in his own party, Scott said he wants the Legislature to approve expanding Medicaid to 138 percent of the poverty level, a move which would make eligible almost 1 million Floridians.
Medicaid already serves 3.2 million people and absorbs almost one-third of the state's $70 billion budget. But saying no to expansion just means Florida tax dollars will be spent in other states.
"My mom was a proud, strong woman who wanted to make it on her own without help," Scott recalled. "But how would she have felt if she knew she was denied help that she was already paying for?"
Rosenberg of Boca Raton, who changed her own thinking about the state-federal program while facing a financial crisis, said she was glad Scott had his own epiphany. She acknowledged, however, nothing is certain until lawmakers act.
"Look, I don't think anybody wants to ask for help," she said. "But being able to get health care is going to save money in the long run."
The Medicaid expansion was a key part of the 2010 health care law, until the U.S. Supreme Court ruled Congress could not make it mandatory for states.
So far, behind Scott's earlier resistance, Florida has done little to implement any portion of the law. But a framework for upcoming legislative battles is taking shape.
After missing deadlines for setting up its own health exchange, Florida has defaulted into using a federal exchange -- the online marketplace where some 1 million consumers are expected to purchase health insurance, beginning in October.
State analysts say that as many as two-thirds of Floridians are currently covered by employer health insurance.
Some workers with employer-provided coverage may opt to find cheaper insurance through the exchange. But most now with insurance should expect little change, although conservatives warn costs could rise.
Businesses and part-timers
Under the law, businesses with at least 50 full-time workers -- or the equivalent, including part-timers -- also must begin offering health insurance to those who work at least 30 hours a week. Employers that don't provide coverage must pay a $2,000-per-worker penalty, except on their first 30 employees.
This employer mandate kicks in next January. Critics warn it could prompt layoffs, as companies try to get under the threshold.
"Businesses really have to be getting prepared for this," said Bill Herrle, Florida director for the National Federation of Independent Business. "You're hearing people saying, 'I'm going to just cut back.' But it's not going to be that easy. It depends on how your employees are counted by the government."
Since governments are employers, Florida taxpayers also will shoulder a share of the changes.
About $29 million in state funds will be needed next year to expand the state-employee health insurance program to cover temporary, part-time workers, a group currently uninsured. The federal fine the state faces for not providing coverage would be $318 million.
With all the talk of health coverage, state Medicaid rolls are also expected to rise next year with people currently eligible but not yet enrolled. That's going to cost taxpayers another $116.1 million, analysts said.
But the central focus of the Affordable Care Act in Florida -- at least in coming weeks -- will be on the Medicaid expansion.
House opposes expansion
Scott regularly battled with outnumbered Democrats his first two years as governor. But on expansion, the partisan lines have blurred.
Democrats overwhelmingly favor the move. But the Republican-controlled House is dug in against expansion, while GOP leaders in the Senate seem likely to side with the governor.
House Democratic Leader Perry Thurston of Plantation acknowledged Scott's action was a surprise but declined to speculate whether the governor was seeking to bolster his re-election prospects by endorsing expansion, which polls show is generally popular with Floridians. "We're just glad he's coming to see things the way we see them," Thurston said.
Under the expansion, the federal government would pay for 100 percent of the expansion until 2016, when states would start paying a 5 percent share that would gradually increase to a maximum of 10 percent of new costs by 2020.
Estimates vary, but analysts have said Medicaid expansion could bring Florida$26 billion in federal dollars over the next decade. Florida taxpayers are expected to pay $3 billion during that period, according to the state's Agency for Health Care Administration.
The program also would be opened for the first time to non-disabled adults without dependent children -- a population that Florida officials warn could prove costly. But that expansion is certain to include many service- and tourist-industry employees who comprise a large share of Florida's workforce.
In January, individuals earning roughly $15,000 would qualify for Medicaid coverage. A family of three earning $26,300 would be eligible.
'You don't get a do-over'
State Agriculture Commissioner Adam Putnam, a Republican, blasted the idea of expanding Medicaid -- and Scott's three-year time limit, which he said was deceptive.
"In three years, you don't get a do-over just because it sunsets, which is a classic Tallahassee or Washington bait-and-switch," Putnam told the Florida Retail Federation. Putnam said expanding now means Florida taxpayers will be carrying the program long after federal dollars diminish.
Health care leaders, however, say that if more uninsured Floridians were covered by Medicaid, fewer would use emergency rooms, saving money.
Mark Robitaille, president of Martin Health System in Stuart and a leader in the Florida Hospital Association, told legislative committees last week that a decision to expand should be simple, especially with the federal government covering the bulk of the cost.
"There's just too much money on the table... for Florida to pass up," Robitaille said.
Before the legislature
Approval of an expansion of Medicaid under the Affordable Care Act. The federal government last week allowed Florida to put Medicaid into managed care in exchange for the expansion.
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