Florida Gov. Ron DeSantis keeps making news with his self-described campaign to fight “woke” ideology. The latest headlines came about two weeks ago, when the Republican announced that he was prohibiting public high schools from offering a new Advanced Placement course in African American history. The course, his administration explained, “lacks significant educational value.”
The announcement thrilled his supporters on the political right while infuriating his critics on the left. It’s safe to assume these were precisely the reactions that DeSantis wanted because they elevate his national profile and improve his chances of winning the 2024 Republican presidential nomination, which, as you may have heard, he is likely to seek.
But DeSantis has some other governing responsibilities, too. One of them is looking out for the health and economic well-being of Florida residents, including those who can’t pay for medical care on their own because they don’t have insurance.
Florida has quite a lot of them ― nearly 2.6 million as of 2021, according to the most recent U.S. census figures. That’s about 12% of its population, which is well above the national average of 8.6%. It’s also more than all but four other states.
Floridians without insurance suffer because when they can’t pay for their medical care, they end up in debt or go without needed treatment or both. The state suffers, too, because it ends up with a sicker, less productive workforce as well as a higher charity care load for its hospitals, clinics and other pieces of the medical safety net.
DeSantis could do something about this. He has refused. In fact, as of this moment, his administration is embarking on a plan that some analysts worry could make the problem worse.
This story probably deserves some national attention as well.
DeSantis Has A Clear Record On Health Care
The simple, straightforward reason so many Floridians have no health insurance is that its elected officials won’t sign on to the Affordable Care Act’s Medicaid expansion, which offers states extra federal matching funds if they make the program available to everybody with incomes below or just above the poverty line.
Most states have now done just that. It’s the single biggest reason that the uninsured rate nationwide is at a record low. But eleven states have held out, leaving in place the much more limited eligibility standards they had established before the Affordable Care Act took effect.
Florida is one of them. Childless adults in the Sunshine State can’t get Medicaid unless they fall into a special eligibility category, like having a disability. And even adults with kids have a hard time getting onto the program because the standard income guidelines are so low ― about 30% of the poverty line, which last year worked out to less than $7,000 for a family of three. That’s not enough to cover rent, food and other essentials, let alone buy a health insurance policy.
The non-expansion states all have Republican governors or legislatures or both, and are nearly all in the Deep South. They represent the last line of resistance against Obamacare, which Republicans have spent more than a decade fighting and, famously, came very close to repealing in 2017.
DeSantis was no mere bystander to that effort. As a Republican serving in the U.S. House, he was part of a far-right caucus that voted against the first ACA repeal bill that leadership brought to the floor because, DeSantis and his allies said, it didn’t undo enough of the law’s protections for people with pre-existing conditions.
GOP leaders eventually put forward a more aggressive repeal. DeSantis and his colleagues voted yes on that one, but it failed in the Senate.
With repeal now off the political agenda, the main question about the Affordable Care Act is whether states like Florida will follow the lead of all the others and finally open up its Medicaid program to everybody living at or just above the poverty line.
If it did, several hundred thousand currently uninsured residents would become eligible for the program, according to independent estimates.
End of a Pandemic Relief Effort And Its Impact
Florida’s refusal to expand Medicaid is not a new story. But it is newly relevant because of an expiring federal pandemic measure and its likely effect on access to health care for low-income residents.
When COVID-19 hit, the federal government offered states extra money to fund Medicaid as long as states agreed not to disenroll anybody who joined or was already on the program ― on the theory that in the midst of a public health emergency, the overwhelming priority was maximizing the number of people with insurance.
That arrangement is about to end. States will have a year to go through their Medicaid enrollment files, removing anybody who cannot reestablish their eligibility. And in every state, significant numbers of people are likely to lose coverage ― in some cases simply because they aren’t aware their coverage is in jeopardy or because they can’t make their way through a complex, confusing process their state has put in place.
Officials in some states are going out of their way to minimize coverage losses. Oregon, for example, will be letting all children younger than 6 stay on Medicaid automatically. Illinois is making it easier for adults to stay on the program while taking more time to go through the process of reestablishing eligibility.
Florida just announced its plan and, according to Joan Alker, executive director of Georgetown University’s Center for Children and Families, the state seems intent on pushing ahead quickly even though its own projections suggest 1.75 million Floridians could lose insurance as a result.
“They’re very anxious to get almost 2 million people off of Medicaid, which is scary,” Alker told HuffPost. She added that she is especially worried about children, who represent a disproportionate number of Florida’s Medicaid population because the income guidelines for young people are looser than they are for adults.
Alker was careful to say that it was impossible to be sure how Florida will ultimately handle the process of reviewing Medicaid enrollment. She also said she was pleased that state officials made statements acknowledging the special predicament of children.
A spokesperson for the Florida Policy Institute, a nonprofit organization that has been tracking the state’s plans, offered a similarly mixed assessment ― crediting state officials with an “intentional” plan that stressed communicating with parents clearly about their options while stating that it’s “too soon to tell whether the efforts outlined in the plans will be enough to make sure that Medicaid-eligible Floridians keep their coverage.”
But however Florida officials decide to handle this process, and however it works out, one thing is clear: If Florida were part of the Medicaid expansion, the number of people losing health coverage would be a lot lower.
The Uninsured In Florida Have A Difficult Time
Frederick Anderson, a family medicine physician, knows better than most what a difference health insurance can make for people in Florida. He oversees medical operations at a Miami-area clinic focusing on underserved populations, where large numbers of people have no insurance. He thinks a lot about one woman in particular.
She’s the primary caregiver for a son with autism, Anderson told HuffPost, and she has no insurance because her below-poverty income is too high for the state’s Medicaid threshold. She’s been suffering from serious, debilitating headaches, but she can’t pay for the MRI she needs or find a neurologist with an open appointment.
It’s a problem he sees all the time, Anderson explained, because there just aren’t enough safety net providers to meet the demand. Patients end up waiting for the care they need or skipping it altogether. “We do the best we can,” Anderson said, “but many of our patients will need to see orthopedists, or neurologists or you name it, and these individuals have no easy access to those services. Or they would benefit from certain medications that I would like to prescribe for them, but … it’s just unaffordable.”
Anderson lives and works in Miami-Dade County, where the uninsured rate is among the highest in Florida. But rural areas of Florida face their own, special challenges.
The economics of health care make it more difficult for rural hospitals to survive without help from Medicaid, which is why in states like Florida that haven’t expanded eligibility, rural hospitals are struggling and in some cases closing, depriving communities of more than just acute care.
“We think of hospitals as places to go when you have something major that is wrong,” Scott Darius, executive director of the advocacy group Florida Voices for Health Care, told HuffPost. “But in those rural areas, we’ve learned, hospitals are the primary care location for large portions of the population.”
DeSantis Hasn’t Had Much To Say On Medicaid
These accounts are consistent stories reporters covering health care hear all the time. They also echo some of the anecdotes that an organization called the Florida Health Justice Project has collected on its website as part of an ongoing campaign, in conjunction with other advocacy groups, to bring expansion to Florida.
“Florida ranks [near the bottom] for the rate of uninsured residents,” Alison Yager, executive director at the Health Justice project, told HuffPost. “Expanding Medicaid, as all but 11 of our sister states have done, would surely boost our shameful showing.”
But the cause has been a tough sell in Tallahassee, where Republicans have had nearly uninterrupted control of the Florida’s lawmaking process since 1999. Two previous efforts to get expansion through the state legislature failed. DeSantis’ spokesperson confirmed in 2021 that he remained opposed to it.
That was two years ago, and since then he’s managed to avoid saying much about the issue, including to HuffPost, despite several inquiries to his office over the past three weeks. Medicaid expansion got only sporadic attention in the 2022 gubernatorial campaign, although Democrats tried initially to make it an issue, and it didn’t draw so much as a mention in the lone debate DeSantis had with Democratic nominee Charlie Crist.
A year before that, DeSantis signed a much narrower measure: a 2021 bipartisan bill increasing Medicaid’s postpartum coverage from 60 days to a year. It was a priority for the outgoing GOP House speaker, and it’s always possible political circumstances will align and lead to more legislation like that in the future.
But DeSantis’ hostility to government health care programs runs deep.
Long before he was attacking “critical race theory” lessons and supposed sexual brainwashing in the schools, he was railing against Obama-era programs generally (as New York magazine’s Jonathan Chait has explained) and the Affordable Care Act specifically (as The New York Times’ Jamelle Bouie has written) as fundamentally incompatible with American principles of freedom and private property.
DeSantis may also have more practical objections to expanding Medicaid. Maybe he thinks it’s too big a drain on state finances or too wasteful a program, as many conservatives and libertarians argue. Maybe he thinks Medicaid does more harm than good for beneficiaries or that people on the program could find insurance on their own if only they were more industrious and got paying jobs.
Those latter claims don’t hold up well under scrutiny. The majority of Floridians missing out on Medicaid expansion are in families with at least one worker, according to the Center on Budget and Policy Priorities. And when the uninsured get Medicaid, their access to care and financial security improves, according to a large and still-growing pile of research.
Their health outcomes also seem to improve, though the evidence on how the Medicaid expansion has affected mortality specifically remains the subject of some debate.
The Politics of Medicaid May Be Different Nationally
Advocates today have their eyes on trying to expand Medicaid through a ballot initiative, which is the way it’s happened in Idaho, Missouri and several other states where Republican lawmakers had blocked it.
But Florida Republicans are already working to make that process more difficult because it’s a way for voters to circumvent GOP opposition to popular causes. And it’s not like waging a ballot campaign is easy now. Organizers recently told the Tampa Bay Times that 2026 is the earliest they could realistically get a Medicaid measure on the ballot.
As for DeSantis, his record on health care could become a key point of contrast in a hypothetical 2024 White House campaign. President Joe Biden, after all, is the guy who called Obamacare a “big fucking deal” and just signed into law reforms that make the program’s financial assistance more generous. Any conceivable replacement on the Democratic ticket would have a similar record of votes in Congress or state actions to support coverage expansions.
There’s no way to be sure how an issue will play out in the next election ― or whether it will even matter at all. But it’s not hard to imagine the contrast on health care working to the Democrats’ advantage. The Affordable Care Act is relatively popular these days, and Medicaid expansion tends to poll well even among Republican voters.
That may help explain why DeSantis and his spokespeople have so little to say on the subject. But that silence doesn’t change the real-world impact of his posture ― or what it reveals about his priorities.