Florida's Republican lawmakers are reluctantly acknowledging that the Affordable Care Act is the law of the land and are taking steps to determine exactly what that will look like. The Sunshine State has one of the highest numbers of uninsured residents in the country, some of the most stringent eligibility requirements for health care safety nets, a large number of legal immigrants and a proposal to privatize its Medicaid program statewide.
So how will the federal health overhaul impact that? There are still a lot of unanswered questions, perhaps the biggest being whether Gov. Rick Scott will expand Florida's Medicaid rolls. The Republican governor was a vocal opponent of so-called "Obamacare" but softened his stance after the November election. He remains wary of the increased cost a Medicaid expansion could bring to Florida taxpayers and has been accused of playing politics with numbers after he referenced figures showing costs could be as high as $26 billion over a decade. The state health agency later revised that figure to $3 billion.
Florida lawmakers are also playing catch-up because the Legislative session is not convening until March, after or very close to federal deadlines.
Here are some questions and answers about how the Affordable Care Act could play out in Florida.
Q: How many Floridians are uninsured and how many of those are projected to get insurance under the exchange?
A: Florida had the nation's third-highest rate of residents without health insurance during the past three years, according to Census data. It also has some of the most stringent eligibility requirements in the country for Medicaid. A family of three with income of $11,000 a year makes too much to qualify and single residents are not covered.
Nearly 1 million people are estimated to take advantage of the state exchange, including residents who are employed and the unemployed. Many would be eligible for federal subsidies to help pay for it.
Q: How many people Floridians are currently served by Medicaid and how many more will be served if lawmakers choose Medicaid expansion?
A: Florida's Medicaid program currently costs more than $21 billion a year, with the federal government picking up roughly half the tab. It covers nearly 3 million people - about half are children - and consumes about 30 percent of the state budget. About 900,000 more residents could be covered if Florida decides to expand its Medicaid rolls.
Q: Is it true that U.S.-born residents below the poverty line will not be able to get coverage in the exchanges but legal immigrants below the poverty line will be able to get coverage through the exchanges?
A: Yes. The Affordable Care Act assumes that states would expand Medicaid coverage, so the only provision for a subsidy below 100 percent of the federal poverty level is for aliens who are in the country legally but are ineligible for Medicaid because of their alien status.
That means if Florida does not expand its Medicaid rolls, only legal immigrants, but not citizens, would be eligible for subsidies under the exchange.
A spokeswoman for Gov. Scott has said he is concerned over "how legal immigrants and U.S. citizens are treated differently under the president's healthcare law, which we continue to learn more about."
Q: How many small businesses are likely to take advantage of the health insurance offered on the state exchange?
A: Many small business owners are still in wait and see mode. Florida led the country in challenging the constitutionality of the Affordable Care Act, but the Supreme Court upheld it. That's left Florida scrambling at the 11th hour to make decisions about how the state wants to implement the law and many unanswered questions.
With little guidance from lawmakers, many small business owners don't want "to jump right into an exchange environment because they don't know what to expect," said Jon Urbanek, a senior vice president with Blue Cross and Blue Shield of Florida.
Urbanek said about 50 percent of the small businesses his company talked with initially indicated they would opt out and pay a penalty for not providing coverage. But as Blue Cross Blue Shield of Florida is working with employers, that number has fallen below 20 percent, he said.
He also anticipated between 15 to 18 percent of small businesses will stop offering health coverage and allow their employees to seek their own individual coverage under an exchange.
Q: How is the exchange going to be set up in Florida and which agency will be responsible for overseeing it?
A: Florida has three options. It can run the exchange itself, partner with federal health officials or allow federal officials to run the program entirely. At this point, Florida has defaulted into allowing the feds to run the program because leaders missed key deadlines, but the door is still open for lawmakers to consider a partnership or run the program themselves in the future.
The Department of Children and Families currently determines Medicaid eligibility and the Agency for Health Care Administration oversees the program.
Q: How much money has Florida received so far from the federal government to do the initial work in setting up an exchange?
A: Florida was awarded $1 million in a planning grant in 2010, but never drew down the funds so they expired in 2011, according to federal health officials.
Q: How will the changes under the Affordable Care Act effect Florida's plans to privatize Medicaid statewide?
A: In an effort to cut costs, Florida lawmakers passed sweeping legislation in 2011 to privatize Medicaid. Rather than having government insurance, patients would be assigned to for-profit insurance companies, which would receive a per-person fee from the state and decide what services and prescriptions to cover. But the state is still waiting on the federal government to sign off on the proposal. If Gov. Scott decides to expand Medicaid, the 900,000 new recipients would get their Medicaid coverage under the privatized system.
Q: How will Florida residents access the exchange and what kind of customer support will be offered?
A: Regardless of who runs the exchange, making sure that Floridians have ample guidance in selecting a plan is a key priority. Federal health officials are launching a website with chat capabilities and a 24 hour call center. Individual health companies will also offer their own customer support. Some health plans will have walk-in storefronts and mall kiosks for customers to talk to someone in person.
The new marketplaces are supposed to take the confusion and anxiety out of buying private health insurance for individuals and families who buy their coverage directly. Exchanges are meant to have the feel of an online travel site.
Under the new law, about 8 in 10 customers in the new marketplaces will be eligible for income-based federal aid to help pay their premiums.
Small businesses will have separate access to their own exchanges.
Q: How many plans will residents and small businesses have to choose from?
A: Florida lawmakers still have to decide whether they are going to allow every health care company that wants to offer a plan to be included or whether they will limit the number of plans. Some experts warn that shoppers make poor decisions when they have too many options.
"People make worse choices when they have too many unfettered choices and then it limits competition because people get confused and insurers can exploit that confusion to not compete fairly," said Jonathan Gruber, an economics professor at the Massachusetts Institute of Technology, who worked on Massachusetts' health law.
Q: How will health plans under the exchange differ from current health plans?
A: Plans participating in the marketplaces will have to cover a set of "essential" benefits, including hospitalization, doctor visits, prescriptions, prevention and care for pregnant women and young children. Cost to the consumer will be the main difference among plans, with four levels of coverage: bronze, silver, gold, and platinum. A consumer with a bronze plan will pay lower monthly premiums, but would face higher cost sharing for medical care.
That means some of the plans that Florida small businesses currently offer their employers may have to augment their plans to make sure they are covering those essential benefits. Deductibles, co-pays and premiums may also change.
For example, federal law says plans can't have a maximum deductible of more than $2,000, but experts say a lot of Florida plans have a $2,500 deductible.