The authors propose a new Medicaid Advantage program that would integrate acute and long-term care benefits for dual-eligible beneficiaries into a single program.
Medicaid Advantage: A medical home for dual-eligibles
By Grace-Marie Turner and Robert B. Helms, Ph.D.
Submitted to the Medicaid Commission
Grace-Marie Turner of the Galen Institute and Bob Helms of the American Enterprise Institute have proposed a new Medicaid Advantage program that would integrate acute and long-term care benefits for dual-eligible beneficiaries into a single program. The program, submitted to the Medicaid Commission, would be managed by the states and would provide a medical home and better coordinated care for beneficiaries.
Background:
Our most vulnerable citizens – those dually eligible for Medicare and Medicaid – often fall into a fragmented care delivery system that perpetuates episodic rather than coordinated care. Patients may have difficulty accessing the medical care they need. And information about their care and their needs can be scattered among providers and facilities facing two different payment systems and sets of program rules.
Because physicians and others treating these patients don’t have the patient’s complete medical profile, patients can face gaps as well as duplication in treatments with no medical home responsible for optimizing their care.
To assure that Medicaid patients are receiving quality care, Medicaid must adopt new systems with better incentives to design more flexible and more effective care management programs for these recipients, especially those with disabilities and significant chronic illnesses. Having a medical home is central to this process. A comprehensive program that integrates Medicare and Medicaid coverage into a new integrated Medicaid Advantage plan would allow providers to focus on the best way to design and provide benefits to these beneficiaries with the right care in the right setting, rather than spending time on complying with rules for different payment systems. Significant efficiencies and better outcomes could be achieved through a comprehensive approach to providing health care for these Medicare and Medicaid-eligible beneficiaries.
Findings:
Cost-effectiveness studies of state Medicaid managed care programs have demonstrated that they generally save states money while providing better access to care for recipients. The commission also has heard numerous testimonies demonstrating the creativity of state and local governments in developing programs to target services to their vulnerable dually-eligible residents, often through contracts with private managed care organizations.
Vermont obtained a waiver to fine-tune delivery of long-term care services and demonstrated that better care can be provided more cost-effectively in appropriate settings when solutions are tailored to individual needs. We heard about similar examples in New York, Massachusetts, Arizona, and other states.
States are much more adept at tailoring these programs to their citizens than the Federal government because they are closer to the people being served and know better both their needs and the resources of the community to meet those needs. But states are not able to shoulder the full financial burden of providing these services. Continued Federal funding is essential.
Other options:
The Federal government has recognized the need to better integrate care for dually-eligible populations and has developed several programs as a result. The Program for All-Inclusive Care for the Elderly (PACE), targeted waivers, and Special Needs Plans (SNP) are the primary Medicare programs designed to achieve this goal.
• PACE is a capitated benefit program authorized by the Balanced Budget Act of 1997 and developed to provide better coordinated long-term care for Medicare and Medicaid recipients who have been certified as eligible for nursing facility care. PACE enables states to provide defined services to Medicaid recipients as a state option, and Medicare and Medicaid funds are integrated to allow a contracted plan to provide the care.
The state plan must include PACE as an optional Medicaid benefit before the state and HHS can enter into a program agreement with PACE providers.
While the program has had some success, it is a Medicare program with a Medicaid option and has not been widely adopted. And the BBA limits the number of PACE programs that may be implemented annually. As of January 2005, there were 73 PACE sites in the U.S. serving limited geographic areas.
• Several states (Massachusetts, Minnesota, and Wisconsin) obtained waivers to combine Medicaid and Medicare funds to purchase health care services for dually-eligible populations. But the waiver negotiations each took several years, limiting the appeal to other states interested in using this approach.
• The Medicare Modernization Act created a new coordinated care option called Special Needs Plans as part of the Medicare Advantage program. SNPs are distinct from regular Medicare Advantage plans in that they can enroll a group of individuals with “special needs,” such as 1) institutionalized beneficiaries; 2) dual eligibles; and 3) beneficiaries with severe or disabling chronic conditions.
SNPs are able to offer a full array of Medicare services, including supplemental benefits, through a single plan with a single benefit package and set of providers. Medicare Advantage payments to SNP plans are risk adjusted based upon beneficiary health conditions, dual eligible status, disability eligibility, and institutional status.
In 2006, 276 SNPs are available, with more than 500,000 enrolles, including 440,000 dually-eligible beneficiaries.
Absent other legislation, SNP authorization in the MMA will sunset on January 1, 2009.
But even with these programs, the Federal government -- through CMS -- still is in control of decisions for PACE, waivers, and SNPs, providing states much less flexibility than if they were running the plans themselves. For example, states must get authorization to put a dually-eligible patient into a managed care plan – an unnecessary administrative hurdle.
Recommendation for Medicaid Advantage
Some people have called for Medicare to take full responsibility for duals, but this centralization would move away from, rather than toward, more finely-tuned care for this vulnerable population. States need more flexibility than Medicare’s top-down system of rules can provide for patients requiring tailored care and services. States have demonstrated that they are up to the task.
On average, total spending for duals, including Medicare and Medicaid contributions, is more than twice as high as that for non-duals -- $20,840 compared to $10,050. It is essential to find a way to manage these costs and care delivery more efficiently.
We recommend creating a new Medicaid Advantage program modeled after the Medicare Advantage program, but with States, rather than the Federal government, in control.
Medicaid Advantage would offer dually-eligible recipients a medical home where they would receive a seamless continuum of medical care and care management under one program and not have care split between Medicare and Medicaid programs. But unlike Medicare Advantage, SNPs, and PACE, the states rather than the Federal government would be the primary managers of their Medicaid Advantage programs.
The Federal government would continue to provide financial support to the states for Medicare services, but through a risk-adjusted, capitated system of Medicare payments. States and the Federal government would continue to share the cost of the Medicaid portion of the benefit.
States or the plans they select could manage the full spectrum of services to provide an integrated care delivery program for dual eligible populations. These plans would be close to the patient, collecting and evaluating treatment data, and states would monitor the plans to make sure obligations are being met.
The Federal government would set and monitor goals, not micromanage processes, so that the states, in conjunction with health plans, can work to improve the quality of care, design plans to fit the needs of patients, and benefit from greater efficiency.
Mechanisms:
• The states would have the option of participating in the new Medicaid Advantage program which they would be primarily responsible for managing, with the goal of developing a better system of providing more efficient, coordinated care for their dually-eligible residents.
• Participating states would contract with competing health plans* to provide the full spectrum of care for dually-eligible populations and would enroll individuals into these integrated Medicaid Advantage care management plans.
o Patients could choose from among competing plans.
o Patients would have the ability to opt-out.
o Medicaid Advantage plans would be required to provide core Medicaid and Medicare services to duals, but states would have more authority and flexibility to design benefit packages that meet the specific needs of patients without having to request waivers.
o Plans would participate in a bidding process, submitting bids representing their cost of providing Medicare and Medicaid-covered services as well as other services determined by the states.
o States would build in incentives for plans to compete on the basis of quality and value and could reward health plans that provide higher quality care at a reduced price. States could also share in a portion of these savings.
o *States would have the option of managing the care and assuming the risks themselves, as Kentucky is doing with its new KY HealthChoices Medicaid reform plan.
• Financing: The states and the Federal government would each contribute, as they do today, to the costs of providing services to dually-eligible beneficiaries but through the new Medicaid Advantage program which would be managed by the states.
States and the Federal government already have some experience with the basic mechanisms that would be needed to calculate payments for this new program. The rate-setting and risk-adjustment systems that Medicare currently uses to pay Medicare Advantage plans and that states use to pay for standard Medicaid managed care programs would provide a foundation for their calculating payments that would fund this new integrated care management program for duals.
There would be three funding streams:
o Federal Medicare payments, which are generally provided through Medicare’s defined benefit structure, would be allocated to the states through a new funding mechanism. The Federal government would develop a system of capitated, risk-adjusted Medicare payments. These payments would be sent to the states to fund the Medicare portion of services for dual-eligible residents. This is not a block grant because funds would follow each recipient and would be adjusted for that patient’s risk profile. Medicare would use its actuarial data and payment history in determining the capitated rate it pays per dual eligible patient, and this funding stream would continue to be updated.
CMS is developing a system of risk adjustment that includes not only health status but also geographic payment variation, frailty, and other factors which could be employed in this new program.
o States would have two options in setting their payments for the Medicaid portion of services for their dual-eligible residents:
Those states that decide to contract with private managed care plans to provide coordinated care for their dual populations could calculate an actuarially-sound capitated rate for the state share of the Medicaid set of services. The plans, not the state, would be at risk.
• While many states have experience in setting payments for Medicaid managed care, their experience is in settings payments for acute care services, not long-term care support. As a result, they would need assistance in calculating these capitated payments for state-financed Medicaid services for duals.
Those states that decide to operate the program themselves and assume the risk (as well as potentially garnering more savings) could make contributions based upon their own Medicaid payment experience for services for duals, again with assistance in making the calculations.
In either case, a transition period would be required where the federal government and the states would share the risk until they have gathered enough information to refine this new system of payments.
Whether the state chooses to contract with Medicaid Advantage managed care plans or to operate the program itself, the states would still receive a federal match for their Medicaid contribution based upon existing formulas.
• Alternatively, CMS/Medicaid could determine a capitated amount of Medicaid funds that it would allocate per recipient based upon data about the cost of its share of Medicaid-covered services in that state for this population.
o Drug coverage, currently paid by Medicare, would be integrated into the Medicaid Advantage plans. Medicare would calculate a Part D allocation that would be returned to each state in the form of a capitated, risk-adjusted payment. This would be another part of the patient’s Medicaid Advantage funding stream.
Since implementation of Part D that assigned duals to drug plans, skilled nursing facilities have had many problems tracking many different drug plans and formularies for these residents. Medicaid Advantage would provide a mechanism to coordinate drug coverage, as well as medical care, through one plan.
States would have access to the pharmacy data that they lost after the transition to Part D in January, 2006.
• The joint Federal and state Medicaid contributions plus the Federal Medicare and part D contributions would be combined into one funding stream to finance care for duals through the new Medicaid Advantage plans. States could use this pool of money in designing benefits for duals and negotiating with health plans that would deliver required services. Duals would receive a full range of services currently financed separately through Medicare and Medicaid through this new integrated program, from hospitalization and skilled nursing care to physicians’ visits, personal care, home and community based services, prescription drugs, diagnostic and laboratory tests, etc.
o States would gain new flexibility in designing benefit packages in exchange for receiving a capitated, risk-adjusted payment from Medicare with fewer strings attached.
• Once the Medicaid Advantage plan has agreed on a contracted fee, the plans would be at risk for providing care to dual eligibles (except for those states that decide to carry the risk themselves). The plans or state contractors would be responsible for providing care, for collecting and providing performance data on treatments and outcomes for each patient, and for reporting this information to the states for their monitoring activities. The plans would be accountable for outcomes with strict oversight by the states, but they would have the flexibility to manage care creatively to meet the needs of patients.
• States also would be given greater flexibility to coordinate treatment for those with mental illness through Medicaid Advantage plans. Providing targeted case management, rehabilitation services, medication management, community mental health center services, and other less-costly services through a Medicare Advantage medical home could reduce the use of expensive hospital and emergency room services while providing improved care for these patients.
• The Federal government and the States would be responsible for carefully monitoring the plans and for bringing action against plans that do not meet their contractual obligations.
Benefits:
Medicaid Advantage (MD-Advantage) would minimize the current incentive to avoid caring for the most costly patients and would better align incentives for Medicare, Medicaid, plans, and recipients. Medicaid Advantage would allow states to:
• Integrate acute and long-term care benefits into a single program they would oversee in which competing private plans (or the states) would provide a coordinated care management program for dually-eligible beneficiaries
• Share in the savings achieved through innovative policies, such as disease management and care coordination
• Streamline cumbersome rules governing marketing, enrollment, performance monitoring, quality reporting, rate setting, bidding, and grievances and appeals
• Eliminate redundant and inefficient spending
• Provide both the Federal and state governments more predictability in budgeting for the significant part of their Medicare and Medicaid spending on dual eligibles.
All American Senior Care
The CareGiver
Tuesday, November 07, 2006
Thursday, November 02, 2006
The CareGiver: My mother the Dynamo
My mother at the age of 85 was a dynamo. She lived on her own, paid her own bills, and took care of herself.......
My mother at the age of 85 was a dynamo. She lived on her own, paid her own bills, and took care of herself. She had been doing this for more than ten years since the death of my father. She was on her own.
My mother was often spotted walking to the pool in her community. A tiny women the senior citizens all around her marveled. It seemed as if father time had forgotten about her. There was no limit to what she could do. Walk 20 blocks, no problem, you name it.
My mother was very funny, a real character. She made people laugh and smile. She was also a wonderful person: always welcoming people into her home. She was noted for all of my 50 years for her great Italian cooking. I remember as a kid that all of my friends really looked forward to staying over our house. Donuts, spaghetti and meatballs you name it. Ravioli anyone?
Me? I was thinking about her for years knowing that someday she had to live with one of us (I have a brother and sister). I was there when my fathered "passed away'; this was when I really started thinking about it. As the years flew by I started to think about it more and more.
Sometimes we had discussions about putting my mother into some kind of "facility". But to be honest, to be honest now, I knew I would never be able to do it. While I had only mentioned it to a few people, I had made a promise to my father not long before he died. I promised him no matter what I would take care of his wife of 55 years, my mother, our love. Dot. It was not a promise I made haphazardly. I had made up my mind about this while we were taking care of my dying father. It seemed as natural to me as breathing.
I knew the day would come. I just didn't know when. Or how.
All American Senior Care
My mother at the age of 85 was a dynamo. She lived on her own, paid her own bills, and took care of herself. She had been doing this for more than ten years since the death of my father. She was on her own.
My mother was often spotted walking to the pool in her community. A tiny women the senior citizens all around her marveled. It seemed as if father time had forgotten about her. There was no limit to what she could do. Walk 20 blocks, no problem, you name it.
My mother was very funny, a real character. She made people laugh and smile. She was also a wonderful person: always welcoming people into her home. She was noted for all of my 50 years for her great Italian cooking. I remember as a kid that all of my friends really looked forward to staying over our house. Donuts, spaghetti and meatballs you name it. Ravioli anyone?
Me? I was thinking about her for years knowing that someday she had to live with one of us (I have a brother and sister). I was there when my fathered "passed away'; this was when I really started thinking about it. As the years flew by I started to think about it more and more.
Sometimes we had discussions about putting my mother into some kind of "facility". But to be honest, to be honest now, I knew I would never be able to do it. While I had only mentioned it to a few people, I had made a promise to my father not long before he died. I promised him no matter what I would take care of his wife of 55 years, my mother, our love. Dot. It was not a promise I made haphazardly. I had made up my mind about this while we were taking care of my dying father. It seemed as natural to me as breathing.
I knew the day would come. I just didn't know when. Or how.
All American Senior Care
Vermont gives seniors more options for care
In this experimental program the State pays family, friends, or aides to assist seniors at home. This keeps them out of a nursing home. If successful this program could serve as a model for the entire nation.
Bob
Vermont gives seniors more options for care
BY JOHN CURRAN
ASSOCIATED PRESS
November 2, 2006
WINOOSKI, Vt. -- At 93, Florence (Tubby) Parsons has a lot going for her. She has her cat, Buddy, the plants in her one-bedroom apartment to tend to and a weekly 25-cent poker game with neighbors.
Best of all, she doesn't have to live in a nursing home. Instead, she gets daily visits from a longtime friend who makes $10 an hour from the state to care for her.
She is part of a unique experiment in Vermont. Under the Choices for Care program, older adults who are eligible for Medicaid and need someone to tend to their needs can be cared for at home by a relative, friend or neighbor paid by the state.
"A nursing home? They sit there and moan and holler and sit in a chair and sleep. I don't want that," said Parsons, who has heart and thyroid problems and uses a walker to get around her apartment building.
Experts say the closely watched project could spur dramatic changes in the way the United States handles long-term care for elderly people.
One year after enacting it, Vermont officials say it is reducing the number of people sent to nursing homes, cutting the cost of taxpayer-funded care and improving the quality of life for people such as Parsons.
The nursing-home industry and other critics say subsidized home care by family members and other nonprofessionals is far from a panacea. They say the care isn't as good.
Parsons' former tenant, Penny Walsh, 41, gets paid $10 an hour for 35 to 40 hours of work a week. She said she took the job of caring for Parsons because she was already doing some of her cleaning and other chores for free.
"It's like seeing my grandmother every day," she said, sitting by Parsons' side during a Monday morning visit.
Previously, Walsh was a clerk and a worker at a day-care center.
Elder-care experts say the Vermont program could help blunt one of the longstanding criticisms of Medicaid -- that it shunts people into institutions without regard to what they really want.
Medicaid, which spent $38 billion on institutional care last year, wants to shift more toward home care and community-based systems, where "the medical dollars follow the needs of the patient, rather than the other way around," said Mary Kahn, a spokeswoman for the Centers for Medicare & Medicaid Services, the federal agency that administers the programs.
It costs Vermont about $122 a day for Medicaid-covered senior citizens who live in nursing homes, compared with about $80 a day for those being cared for in their homes.
Mary Shriver, executive director of the Vermont Health Care Association, a nursing home trade group, said that in-home care works for some but that it cannot match nursing home care for quality.
"Good intentions can cause some damage sometimes," she said.
Sometimes, good intentions are not enough.
"Typically, a family says, 'Sure, we can do this' and brings their grandparent into the home and starts into the role of caregiving and the state is paying them," said J. Churchill Hindes, president of the Visiting Nurse Association of Chittenden and Grand Isle Counties, a nonprofit home health care agency.
"And after a few months or a year, they realize how exhausting the work is, how emotionally draining it might be and just how hard it is."
Parsons' caregiver said the arrangement is working out great so far. Parsons said she likes the company and the help.
"She's been as close as family for a long time," Parsons said of Walsh. "You know what they say: You have to put up with your family, but you choose your friends. I chose her."
Bob
Vermont gives seniors more options for care
BY JOHN CURRAN
ASSOCIATED PRESS
November 2, 2006
WINOOSKI, Vt. -- At 93, Florence (Tubby) Parsons has a lot going for her. She has her cat, Buddy, the plants in her one-bedroom apartment to tend to and a weekly 25-cent poker game with neighbors.
Best of all, she doesn't have to live in a nursing home. Instead, she gets daily visits from a longtime friend who makes $10 an hour from the state to care for her.
She is part of a unique experiment in Vermont. Under the Choices for Care program, older adults who are eligible for Medicaid and need someone to tend to their needs can be cared for at home by a relative, friend or neighbor paid by the state.
"A nursing home? They sit there and moan and holler and sit in a chair and sleep. I don't want that," said Parsons, who has heart and thyroid problems and uses a walker to get around her apartment building.
Experts say the closely watched project could spur dramatic changes in the way the United States handles long-term care for elderly people.
One year after enacting it, Vermont officials say it is reducing the number of people sent to nursing homes, cutting the cost of taxpayer-funded care and improving the quality of life for people such as Parsons.
The nursing-home industry and other critics say subsidized home care by family members and other nonprofessionals is far from a panacea. They say the care isn't as good.
Parsons' former tenant, Penny Walsh, 41, gets paid $10 an hour for 35 to 40 hours of work a week. She said she took the job of caring for Parsons because she was already doing some of her cleaning and other chores for free.
"It's like seeing my grandmother every day," she said, sitting by Parsons' side during a Monday morning visit.
Previously, Walsh was a clerk and a worker at a day-care center.
Elder-care experts say the Vermont program could help blunt one of the longstanding criticisms of Medicaid -- that it shunts people into institutions without regard to what they really want.
Medicaid, which spent $38 billion on institutional care last year, wants to shift more toward home care and community-based systems, where "the medical dollars follow the needs of the patient, rather than the other way around," said Mary Kahn, a spokeswoman for the Centers for Medicare & Medicaid Services, the federal agency that administers the programs.
It costs Vermont about $122 a day for Medicaid-covered senior citizens who live in nursing homes, compared with about $80 a day for those being cared for in their homes.
Mary Shriver, executive director of the Vermont Health Care Association, a nursing home trade group, said that in-home care works for some but that it cannot match nursing home care for quality.
"Good intentions can cause some damage sometimes," she said.
Sometimes, good intentions are not enough.
"Typically, a family says, 'Sure, we can do this' and brings their grandparent into the home and starts into the role of caregiving and the state is paying them," said J. Churchill Hindes, president of the Visiting Nurse Association of Chittenden and Grand Isle Counties, a nonprofit home health care agency.
"And after a few months or a year, they realize how exhausting the work is, how emotionally draining it might be and just how hard it is."
Parsons' caregiver said the arrangement is working out great so far. Parsons said she likes the company and the help.
"She's been as close as family for a long time," Parsons said of Walsh. "You know what they say: You have to put up with your family, but you choose your friends. I chose her."
Crist, Davis differ on Medicaid overhaul
Republican Charlie Crist would continue Gov. Jeb Bush's shift from government simply paying the health care bills of Medicaid recipients to placing them in managed-care insurance programs. Democrat Jim Davis, a Tampa congressman, is at least partly opposed, saying that shifting all Medicaid patients involuntarily into private plans tries to "balance the Medicaid budget on the backs of people who depend on the state's health insurance program to stay out of hospitals."
Crist, Davis differ on Medicaid overhaul
DAVID ROYSE
Associated Press
TALLAHASSEE, Fla. - Medicaid has been obscured by homeowners' insurance, taxes and prescription costs, but the future of the program that provides health care to the state's poor, disabled and many elderly may depend on who wins Tuesday's gubernatorial election.
Republican Charlie Crist would continue Gov. Jeb Bush's shift from government simply paying the health care bills of Medicaid recipients to placing them in managed-care insurance programs.
Democrat Jim Davis, a Tampa congressman, is at least partly opposed, saying that shifting all Medicaid patients involuntarily into private plans tries to "balance the Medicaid budget on the backs of people who depend on the state's health insurance program to stay out of hospitals."
Florida's Medicaid program will cost about $16 billion this year - about $1 out of every $5 the state spends. Only education costs more.
Traditionally, Medicaid recipients - mostly the disabled and women with children who are close to the poverty line - have gone to see a participating health care provider, who then seeks reimbursement from the government. The program's costs are split between the state and the federal government.
In 2004, Bush proposed that the state place recipients in private health plans. The plans would have the ability to limit some benefits, such as which medicines may be purchased, and add others, like care for patients with HIV/AIDS or extensive prenatal care.
The idea was to force Medicaid recipients and their doctors to take some responsibility for their own care, which should lead to better health and save the state money, too.
But some advocates have worried it could lead to the most vulnerable patients not being guaranteed the options they currently have.
The shift has already started through test programs in the Jacksonville and Fort Lauderdale areas.
Crist, the state's attorney general, hasn't been a huge cheerleader for the Medicaid overhaul, but supports it.
"I certainly think the pilot's worth a try," Crist said. "Any way that we can spread those dollars and therefore be able to offer health care to more of the poor in our state I think is worthy.
"I think we're all aware how much Medicaid takes up of our state budget currently, and if we don't do something to strive to get a handle on it we're not going to be able to continue to provide the kind of health care that the poor deserve," Crist said.
Those who are skeptical of the changes say they are concerned the issue has been relegated to the campaign's periphery.
Neither candidate talks much about it on the campaign trail, focusing their health care discussions instead on prescription drug costs, and the question of importing medicine from Canada.
Bob Wychulis, president of the Florida Association of Health Plans, said his sense is that while the two candidates may differ on the details, neither is against allowing a managed care approach for at least some Medicaid patients.
Almost 1 million Florida Medicaid patients - about half of the total - have already gone into voluntary managed care programs over the last decade, and few of those have returned to more traditional programs, Wychulis said.
"Member satisfaction rates have been high in all the managed-care plans," he said.
Advocates for the elderly are worried about the planned next phase of the Medicaid overhaul, which will shift more nursing home care into managed care plans as well.
Nearly 50,000 of the 75,000 Florida nursing home residents have that care paid for by Medicaid. Under the proposed "Florida Senior Care" plan, nursing home patients could be shifted into HMOs, which would manage their nursing home care.
One group that has concerns is the massive senior lobby, AARP, although like other nonprofits it can't endorse candidates.
AARP argues that managed care may be fine for some nursing home patients, but shouldn't be mandatory.
"Consumers want the opportunity to make their own decisions about long-term services and supports so they can maintain their dignity and maximize their independence," the group said in a recent issue paper.
AARP spokesman Dave Bruns said many managed-care plans wouldn't likely let seniors pick their own long-term care facility.
"Our biggest concern is freedom of choice," Bruns said.
Crist, Davis differ on Medicaid overhaul
DAVID ROYSE
Associated Press
TALLAHASSEE, Fla. - Medicaid has been obscured by homeowners' insurance, taxes and prescription costs, but the future of the program that provides health care to the state's poor, disabled and many elderly may depend on who wins Tuesday's gubernatorial election.
Republican Charlie Crist would continue Gov. Jeb Bush's shift from government simply paying the health care bills of Medicaid recipients to placing them in managed-care insurance programs.
Democrat Jim Davis, a Tampa congressman, is at least partly opposed, saying that shifting all Medicaid patients involuntarily into private plans tries to "balance the Medicaid budget on the backs of people who depend on the state's health insurance program to stay out of hospitals."
Florida's Medicaid program will cost about $16 billion this year - about $1 out of every $5 the state spends. Only education costs more.
Traditionally, Medicaid recipients - mostly the disabled and women with children who are close to the poverty line - have gone to see a participating health care provider, who then seeks reimbursement from the government. The program's costs are split between the state and the federal government.
In 2004, Bush proposed that the state place recipients in private health plans. The plans would have the ability to limit some benefits, such as which medicines may be purchased, and add others, like care for patients with HIV/AIDS or extensive prenatal care.
The idea was to force Medicaid recipients and their doctors to take some responsibility for their own care, which should lead to better health and save the state money, too.
But some advocates have worried it could lead to the most vulnerable patients not being guaranteed the options they currently have.
The shift has already started through test programs in the Jacksonville and Fort Lauderdale areas.
Crist, the state's attorney general, hasn't been a huge cheerleader for the Medicaid overhaul, but supports it.
"I certainly think the pilot's worth a try," Crist said. "Any way that we can spread those dollars and therefore be able to offer health care to more of the poor in our state I think is worthy.
"I think we're all aware how much Medicaid takes up of our state budget currently, and if we don't do something to strive to get a handle on it we're not going to be able to continue to provide the kind of health care that the poor deserve," Crist said.
Those who are skeptical of the changes say they are concerned the issue has been relegated to the campaign's periphery.
Neither candidate talks much about it on the campaign trail, focusing their health care discussions instead on prescription drug costs, and the question of importing medicine from Canada.
Bob Wychulis, president of the Florida Association of Health Plans, said his sense is that while the two candidates may differ on the details, neither is against allowing a managed care approach for at least some Medicaid patients.
Almost 1 million Florida Medicaid patients - about half of the total - have already gone into voluntary managed care programs over the last decade, and few of those have returned to more traditional programs, Wychulis said.
"Member satisfaction rates have been high in all the managed-care plans," he said.
Advocates for the elderly are worried about the planned next phase of the Medicaid overhaul, which will shift more nursing home care into managed care plans as well.
Nearly 50,000 of the 75,000 Florida nursing home residents have that care paid for by Medicaid. Under the proposed "Florida Senior Care" plan, nursing home patients could be shifted into HMOs, which would manage their nursing home care.
One group that has concerns is the massive senior lobby, AARP, although like other nonprofits it can't endorse candidates.
AARP argues that managed care may be fine for some nursing home patients, but shouldn't be mandatory.
"Consumers want the opportunity to make their own decisions about long-term services and supports so they can maintain their dignity and maximize their independence," the group said in a recent issue paper.
AARP spokesman Dave Bruns said many managed-care plans wouldn't likely let seniors pick their own long-term care facility.
"Our biggest concern is freedom of choice," Bruns said.
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