Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

The Florida Legislature – at odds over the expansion of Medicaid – abruptly ended its session three days early on Tuesday, leaving hundreds of bills unrelated to health care unfinished.

Shortly after the adjournment, Gov. Rick Scott, a Republican, filed a lawsuit against the federal government over the same issue.

Here’s a brief overview of the fight: The Republican-led state House is firmly against Medicaid expansion, while the Republican-led state Senate supports it. Scott once supported expansion but is now against it.

And the federal government raised the stakes of the battle by refusing to negotiate on the renewal of $2 billion in funds, mainly for the Low Income Pool program, which reimburses hospitals for unpaid bills. The federal funding will expire at the end of June.

“The pool money was about helping low-income people have access,” Health and Human Services Secretary Sylvia Burwell told WFSU in January. “I think we believe an important way to extend that coverage to low-income individuals is what passed in the Affordable Care Act, is this issue of Medicaid expansion.”

Scott’s suit says it’s a case of coercion – Florida must expand Medicaid or lose $2 billion – and that was expressly forbidden by the Supreme Court when it upheld the health law in 2012.

Close to 800,000 Floridians could gain coverage if the state expands Medicaid.

House Appropriations Chief Richard Corcoran recently delivered a 20-minute speech against Medicaid to fellow lawmakers.

“Here’s my message to the Senate: They want us to come dance? We’re not dancing,” Corcoran said. “We’re not dancing this session, we’re not dancing next session, we’re not dancing next summer. We’re not dancing. And if you want to blow up the process because you think you have some right that doesn’t exist? Have at it.”

Senate President Andy Gardiner says he’s disappointed with the House’s decision: “The House didn’t win, the Senate didn’t win and the taxpayers lost. There are a lot of issues that aren’t going to make it, and it’s unfortunate.”

But House Speaker Steve Crisafulli says it was the right thing to do: “We’ve made every effort we can to negotiate with the Senate on a budget and at this time they’re standing strong on Medicaid expansion.”

Crisafulli’s top legislative priority, water policy reform, is among the many bills left hanging this session.

Scott tried to pressure the Legislature to the bargaining table to craft a state budget. He threatened to veto Senate priorities, but the Senate remained unmoved.

Now, the one task the Legislature is mandated to do — pass a budget — remains incomplete. Scott has said he will call the Legislature back for a special session to complete the budget.

This story is part of a reporting partnership that includes WFSU, NPR and Kaiser Health News.  

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

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HARTSVILLE, Tenn. — Lynda Douglas thought she had a deal with Tennessee. She would adopt and love a tiny, unwanted, profoundly disabled girl named Charla. The private insurance companies that run Tennessee’s Medicaid program would cover Charla’s health care.

Douglas doesn’t think the state and its contractors have held up their end. In recent years she says she has fought battle after battle to secure essential care to control Charla’s seizures, protect her from choking and tube-feed and medicate her multiple times a day.

“If you have special-needs children you would not want to be taking care of these children and be harassed like this,” Lynda Douglas said. “This is not right. No way, shape or form is this right.”

State Medicaid programs across the country, which operate with large federal contributions, have outsourced most of their care management in recent years to insurance companies like the ones in Tennessee. The companies cover poor and disabled Medicaid members in return for a fixed payment from taxpayers.

That helps government budgets but sets up a fundamental conflict of interest: the less care these companies deliver, the more money they make. Nationwide, such firms made operating profits of $2.4 billion last year, according to regulatory data compiled by Mark Farrah Associates and analyzed by Kaiser Health News.

In an attempt to manage that tension, Washington regulators are about to initiate the biggest overhaul of Medicaid managed-care rules in a decade. Prompted by growth of Medicaid outsourcing, concerns about access to care and stories like Charla Douglas, the regulations are expected to limit profits and set stricter requirements for care quality and the size of doctor networks.

“We want the enrollees to have timely access to integrated, high-quality care,” James Golden, who oversees Medicaid managed care for the U.S. Department of Health and Human Services, told a group of insurance executives in February. “There’s been some question about some of these issues.”

Tennessee Medicaid plans — operated by BlueCross BlueShield of Tennessee, UnitedHealthcare and Anthem — are among the most profitable Medicaid insurers in the country, according to data from Milliman, a consulting firm. The state, which runs one of the most respected Medicaid managed-care programs in the country, adopted that design in the 1990s and named it TennCare.

State officials point to quality data and survey results as evidence that the companies are doing a good job while allowing the state to spend far less on Medicaid than predicted. More than 90 percent of TennCare customers surveyed last year said they were very satisfied or somewhat satisfied, officials note.

“Our patient satisfaction scores are at the highest over the last five years they’ve been in 20 years of the program,” said TennCare director Darin Gordon, who worries new HHS rules could hinder states from improving Medicaid quality while controlling costs. “Don’t hamstring us from doing other innovative activities that are going to be able to help try to improve the health and wellbeing of our population.”

But doctors and patient advocates say state savings and insurer profits come at the price of inadequate physician networks, long waits for care and denial of treatments like the ones for Charla Douglas. Answering another question in the survey, 30 percent of adults said the quality of their TennCare care last year was only fair or poor.

“BlueCross is more organized and more strategic in its denials, and the other plans might be more careless, but the way it plays out for folks on the ground level is the same,” said Michele Johnson, executive director of the Tennessee Justice Center, a nonprofit law firm that helps TennCare members navigate the system. “What we find is that all three plans will deny care.”

Medicaid’s expansion in most states under the Affordable Care Act has obscured another big but more gradual change: More than half of Medicaid beneficiaries now receive coverage from private insurers, known as managed care companies, with incentives to limit care. The surge helped prompt inquiries by HHS’s inspector general last year that found widely varying state standards for access to doctors and poor information for members on where to find them.

In one nationwide study, half the doctors listed in official directories weren’t taking Medicaid patients. Among doctors who were, a quarter couldn’t see patients for a month.

In Tennessee views diverge sharply on whether the proposed federal rules, expected soon, are necessary. Many say the system is far from adequate.

Dena Deweese, who runs a primary care practice in Knoxville, has problems finding specialists for her patients who are covered through Amerigroup, a TennCare contractor and Anthem affiliate that recently began operating in the area.

“I kept running into no, no, no,” she said. “I’ve still got lots of folks that are simply not taking it.”

Amerigroup says it only recently started covering TennCare members in the area and is still expanding its network. Since January “we have added more than 3,600 specialty physicians,” said company spokeswoman Cindy Wakefield.

TennCare’s member-per-doctor standard for primary care is among the worst in states that have such rules — one provider per 2,500 members. Even for urgent care, TennCare rules allow waiting times of up to two days for an appointment.

The state allows one neurologist per 35,000 TennCare members, although most states have no network standards at all for such specialists.

Even when children are having seizures, Crossville pediatrician Dr. Suzanne Berman often can’t get a TennCare neurology referral for weeks.

“I have a kid who urgently needs to see a specialist,” she said. “We call and we beg. ‘We can see you in three months,’ the neurologist’s nurse will say. ‘OK we can see you in two weeks.’ No, we can’t wait that long.”

Often she must send the child to a hospital emergency room to get the proper care — it’s “the only way I have found to jump the queue,” she said.

Dr. Douglas Springer, a gastroenterologist and, until recently, president of the Tennessee Medical Association, recognizes states’ need to control Medicaid expense.

“The cost in that population keeps going up and up and up,” he said.

But he favors new rules to ensure adequate doctor networks and limit insurer profits.

“If they can make it hard on [a patient], and make it so the networks are poorly funded or poorly populated, then nobody can go see anybody,” he said. “They don’t have to spend any money.”

Evelyn Manley said she had to fight to get TennCare’s insurers to cover even a portion of the behavioral therapy that doctors recommend for Christian, her five-year-old son with diagnoses of autism and Down’s syndrome.

“I’m grateful” for TennCare, she said. “But it could definitely improve.”

Lynda Douglas, 69, knew she wanted to adopt Charla a decade ago as soon as she took her for foster care from the state. Charla’s problems include cerebral palsy, a badly curved spine, frequent seizures and osteoporosis. She cannot speak and takes most food by tube. She is 16, weighs less than 80 pounds and loves Barney the dinosaur.

Douglas, who lives about an hour east of Nashville, says she has often struggled to get adequate treatment for Charla. But she was grateful that TennCare’s contractors sent daytime nurses to monitor her seizures, keep her from choking, activate an implanted device to control seizures, administer medicine and maintain a tube that delivers medicine or nourishment eight times a day.

Then more than a year ago UnitedHealthcare reduced the nursing to one hour a day even though Charla’s condition hadn’t improved. Douglas protested with the help of the Tennessee Justice Center and a pro-bono lawyer and won, but TennCare appealed. It took two more rounds of adjudication before a judge ruled in Douglas’ favor late last year.

The managed-care companies “are making a mint down here,” Douglas said. “They’re getting rich at the expense of the kids. This is not right.”

UnitedHealthcare made operating profit of $236 million last year on revenue of $2.8 billion in its Tennessee Medicaid business, according to state filings. Anthem’s operating profit for TennCare came to $53 million on revenue of $946 million. BlueCross’s operating profit for TennCare was $121 million on revenue of $1.8 billion. Those results do not include expenses for taxes, depreciation and other items not directly related to health coverage.

“Our care teams worked with the family and with [Charla Douglas’] physicians and other providers to assure that her services were appropriate for her special health care needs,” UnitedHealthcare said in a prepared statement. The managed-care plan followed TennCare’s contract and care guidelines, it said. 

This year Charla switched to the BlueCross TennCare plan to better coordinate her care with two other disabled children in the Douglas household, one foster and one adopted. In March the plan denied coverage of the seizure-control pump that Charla’s doctors prescribed, saying it was medically unnecessary.

BlueCross now says it will pay for the procedure. A spokeswoman blamed the initial denial on a “physician’s failure to provide the needed medical information.”

Like TennCare officials, the managed-care industry is urging HHS not to publish overly rigid regulations that bog plans down in paperwork and hinder them from making investments to keep members healthy.

“You’re dealing with a huge variation in population” covered by Medicaid from state to state, said Jeff Myers, CEO of Medicaid Health Plans of America, an industry lobby. “Each state has an insurance commissioner. Presumably they’re very good about making decisions about insurance regulation” to suit local conditions, he said.

Myers and other officials expect HHS to issue rules for “medical loss ratios” that limit profits and force plans to spend a minimum portion of revenue on medical care. Such restrictions already apply to other insurance under the health law.

Imposing blanket profit standards on diverse Medicaid programs “would be terrible policy,” he said.

TennCare director Gordon, who frequently advises other states on Medicaid, rejects suggestions that managed-care networks are inadequate or that contractors deny needed care. Third-party surveys show that 90 percent of Tennessee doctors take TennCare and most of them take new TennCare patients, he said, although consumer advocates dispute this.

TennCare members sometimes have trouble seeing specialist doctors, but so do patients in commercial plans, he said. Like many state Medicaid directors, he wonders how HHS can publish network rules for 50 states with widely varying geographies and health systems.

“We actually have a pretty solid network,” he said, with systems to closely track how contracted insurers are performing. The HHS investigation into Medicaid doctor networks “looked at it very narrowly” and “gives you a less complete picture of what’s going on in the states,” he said.

Written the wrong way, Gordon said, HHS limits on managed-care profits could discourage spending on coordinators who improve care quality at decreased cost.

“Yeah, we’re a little concerned,” about the proposed rules to be published by the Centers for Medicare & Medicaid Services, or CMS, he added. “There are some things that we think may have adverse effects.”

Other Tennesseans tend to oppose Washington decrees no matter what they say.

“We need to keep CMS out of our business. They have done nothing but screw everybody up,” said Dr. Iris Snider, an Athens pediatrician who praises the job Gordon and other officials have done with TennCare. “It really worries me … when we finally get a system that’s working reasonably well for my patients.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

This week I answered questions from people about health insurance cost and coverage rules, including how getting married or working here as a foreign national may affect them.

Q. Last year, I had single coverage through the marketplace from January through May. Then I got married and canceled my policy because I had coverage through my husband’s job for the rest of the year. When I filed my 2014 taxes, we had to repay half of the premium tax credits for the months when I had a marketplace plan. Why? Those first five months I was single and relying on my own income. Why should my husband’s income be counted?

A. The Internal Revenue Service has a special rule to handle situations like yours when people get married during the tax year. Though not a perfect solution, without it, chances are you would have had to repay even more of your tax credit.

First, some background: The premium tax credits that people can qualify for if their income is under 400 percent of the federal poverty level (about $46,000 for one person) make coverage purchased on the health insurance marketplace more affordable. Like you, many people opt to receive the credit in advance and have it sent directly to their insurer, which reduces their monthly bill.

The amount of the tax credit is based on your annual household income, which you estimated when you signed up for coverage. At tax time, your estimated income is reconciled against your actual income and, if the estimate was too low, you have you repay the excess, up to a cap.

That’s the situation you found yourself in. However, when people marry during the tax year, the IRS offers an alternative way of calculating household income that for many reduces the excess premium tax credit they have to repay.

Under the IRS rule, the tax credit for the months when you were single is computed as if your annual household income were half of what it actually was. So if your joint income was $70,000 for the year, your tax credit will be computed on a $35,000 income rather than the whole $70,000.

Using that alternative calculation will generally reduce how much people have to repay.

Though not a precise income adjustment, “this creates at least some rough justice, in giving people a chance to simulate what they made when they were single,” says Judith Solomon, vice president at the Center on Budget and Policy Priorities.

IRS publication 974 has step-by-step instructions on how to do the alternative calculation, and tax preparation software generally incorporates that option.

Q. I am on a H1B visa, legally working in the United States. My employer provided my husband and me with health insurance, but it is costing us a lot. My husband is here on an H4 visa as my spouse. My question: Is it mandatory to have health insurance for him? What are my options?

A. In general, people who are living in the United States legally are subject to the health law requirement that they have health insurance. There are some exceptions for foreign nationals who are here only briefly, but as someone who is living and working here and has employer-sponsored health insurance you likely pass the IRS test for having a “substantial presence” in the U.S., says Sonal Ambegaokar, a senior attorney at the National Health Law Program, an advocacy group for low-income and underserved people.

To avoid the penalty for not having health insurance, you and your husband must have coverage unless you qualify for an exemption. Since you say that coverage is expensive, one possibility might be an exemption based on affordability, says Matthew Lopas, a health policy fellow at the National Immigration Law Center.

If the cost of your plan is more than 8 percent of your income you’d be exempt from the requirement to have coverage.

Q. If a person does not pay the premium and is charged a penalty for not having health insurance, is that penalty considered to be a partial payment of the premium and does it provide any health benefits?

A. No on both counts. The penalty for not having health insurance, which you pay when you file your federal income taxes, is completely separate from the health insurance premium you would pay to an insurer to provide coverage. The penalty can’t be applied to insurance in any way and provides no health benefits.

For 2014, the penalty is $95 or 1 percent of your income, whichever is greater. If you’re uninsured and didn’t realize you would owe a penalty for last year, you may still be able to sign up for 2015 coverage, says Cheryl Fish-Parcham, private insurance program director at Families USA, an advocacy organization. You’d still owe the fine for 2014 but you could avoid it for this year, and you’d have insurance that could provide benefits that the penalty cannot.

If this scenario fits you, better get cracking. The special enrollment period ends April 30.

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.