The cliffhangers are dangling into 2023.
Framed by the ongoing fallout of the COVID-19 pandemic to the seismic shift in abortion rights, the past year in Florida contained significant moments in the intersection of health care policy and politics, much of it driven by Gov. Ron DeSantis, who is seen as a likely Republican presidential contender.
Many of these stories, however, are only half-written with more to come in 2023, including a probe into vaccine manufacturers and another round of legislation dealing with abortion as well as likely legal battles over transgender care. Here’s how the year shaped up, and what serves as a prelude for the next 12 months.
Battles continue over reproductive rights
Anticipating a U.S. Supreme Court turnabout on Roe v Wade, Florida Republicans in 2022 passed legislation to restrict abortions after 15 weeks of pregnancy with no exceptions for rape and incest. The ban was challenged on the grounds of a 1989 precedent that interprets the state constitution’s privacy provision as applying to abortion rights. But that precedent appears to be on shaky grounds given the current roster of Florida Supreme Court judges, several of whom were appointed by DeSantis.
The legal battle is still unresolved and the ban on 15-week abortions still is in place.
But anti-abortion protestors want more. They gathered at the Capitol in November during an organizational session, pressing lawmakers to support an all-out ban on abortions. House and Senate leadership gave them no heed, but there are discussions underway on how to further tighten Florida law even in 2023 and to tighten regulations over access to chemically induced abortions.
In the meantime, the state Agency for Health Care Administration (AHCA) which licenses abortion clinics, hit three abortion clinics with a combined $237,000 in fines for allegedly violating a state law that requires women to wait 24 hours prior to having an abortion. The Center of Orlando for Women was fined $193,000 for the alleged violations, a move that, according to court documents, will likely bankrupt the abortion provider.
The state moved to dismiss the case in November saying it would reach a settlement with the center which had acknowledged it didn’t adhere to the 24-hour ban, which had been the subject of legal wrangling for years. But the provider opposed AHCA’s move to dismiss the case noting that there were disputed allegations including whether the 24-hour ban went into effect April 26 as the state alleged in its complaint and whether the clinic obtained informed consent from the patients prior to the procedure.
The judge agreed and refused to dismiss the case. AHCA did dismiss its case against A GYN Diagnostic Center, Inc. which it hit with $41,000 in penalties for allegedly violating the law. The judge allowed that case to be dismissed.
Changes pushed for transgender care
Transgender children in Florida and poor transgender adults have had their access to health care limited. The DeSantis administration moved to ban Medicaid from picking up the costs of trangender care for children and adults. To ensure that children with commercial health insurance coverage weren’t receiving the benefits, Florida State surgeon General Joseph Ladapo also petitioned the state’s medical boards to alter their rules to limit the care. Ladapo had already taken a lead on the issue of transgender care, releasing recommendations against providing gender-affirming care, including social transitioning, to children. Ladapo’s recommendations don’t have the weight of law, though, and didn’t apply to Medicaid, which is housed in AHCA.
Florida Medicaid subsequently released a report summarizing what it called a “robust review” of available medical evidence and the assessment of five medical experts and determined gender-affirming care doesn’t meet the generally accepted professional medical standards. To that end Medicaid Director Tom Wallace (who serves at the pleasure of the Secretary, who in turn serves as the pleasure of the Governor) deemed the health care experimental and investigational. The label is equivalent to a death knell because the Florida Medicaid program does not cover experimental care.
Rule changes to ban Medicaid from providing the care were swiftly approved but have been challenged in court.
Meanwhile, the same day Wallace released his report Ladapo sent a letter to members of the Florida Board of Medicine and Florida Board of Osteopathic Medicine reiterating his opposition to gender-affirming care and asking that they alter their standard of care rules to prevent physicians from providing minors care and to make adults wait before receiving care.
Neither board agreed to rule changes that would make adults wait before receiving care. The Board of Medicine did agree to propose changes that would ban minors from receiving gender-affirming care. The Board of Osteopathic Medicine has proposed a rule that would ban minors from receiving gender-affirming care unless they participate in a study at a Florida based university.
Vaccine skepticism growing
In late December 2020, DeSantis ignored the vaccine rollout recommended by the Centers for Disease Control and Prevention and issued an executive order that put people over the age of 65 in the front of the COVID-19 vaccination line in Florida. It marked the beginning of DeSantis’ oft-repeated line that he was “putting seniors first.” Two years later, the state supreme court on Dec. 23 agreed to impanel a statewide grand jury to look at “wrongdoing” associated with the development, promotion and distribution of vaccines.
DeSantis had petitioned the court days earlier noting that “the pharmaceutical industry has a notorious history of misleading the public for financial gain. Questions have been raised regarding the veracity of the representation made by the pharmaceutical manufacturers of COVID-19 vaccines, particularly with respect to transmission, prevention, efficacy and safety.” The petition also said, “an investigation is warranted to determine whether the pharmaceutical industry has engaged in fraudulent practices.”
Much of the vaccine skepticism from the DeSantis administration comes from Ladapo who in October talked about an increased risk of cardiac-related deaths among males 18-39 after receiving a COVID-19 mRNA vaccine. That analysis has drawn sharp criticism from medical experts as flawed. Meanwhile, the state is collaborating with the University of Florida, where Ladapo is on contract, to compare Florida research into the sudden deaths of individuals who received the COVID-19 vaccine with studies done in other countries.
More MMJ licenses, higher fees
2022 was the year it became more expensive to operate in Florida’s medical marijuana market. The state doubled to $146,000 the costs of a medical marijuana application and announced it will initiate a competitive review for new licenses expected to be awarded in 2023. It also upped the costs of licenses for existing players to $1.3 million, up from $60,000.
The initial application fee is more than double what licensees initially paid but reflects the amount the state charged so-called Pigford applicants.
The state can issue another 22 medical marijuana licenses to accommodate Florida’s growing market. The state is projecting 1,044,072 patients will qualify for medical marijuana treatment and register with the state by June 2024.
But according to the Department of Health’s legislative budget request its Office of Medical Marijuana Use (OMMU) only plans on awarding eight additional eight medical marijuana treatment center licenses between July 1, 2023, and June 30, 2024.
The LBR also shows the OMMU plans on opening regional headquarters and hiring an additional 31 staff for its Tallahassee office.
Canadian Rx drugs stalled
We are sticking with the pharmaceutical industry and putting the failure of this program to launch on the top stories list. It’s been more than two years since the state filed Section 804 Importation Program (“SIP”) with the U.S. Department of Health and Human Services (HHS) for approval.
The plan had Florida importing a few drug classes which according to a press release will include maintenance medications to help individuals and consumers who have chronic health conditions such as asthma, COPD, diabetes, and HIV/AIDS. Lawmakers have directed $30 million to the program in the last two year’s spending plans.
Frustrated with the lack of progress, the DeSantis administration announced this summer that it had submitted a (FOIA) regarding the state’s SIP.
The FOIA was filed July 6, just days after California Gov. Gavin Newsom declared his state is preparing to produce its own supply of insulin. The California budget allocates $100 million to develop and manufacture biosimilar insulin products for Californians. Half the $100 million will support the development of low-cost insulin products for residents. The remaining funds will be appropriated to a California-based insulin manufacturing facility to create high-paying jobs and a new insulin supply chain for residents.
Embracing behavioral health
First Lady Casey DeSantis has been steadfast in her commitment to increasing access to behavioral health services for those in need and in 2022 the Legislature and the Department of Education delivered changes that should help make improvements in how the state funds mental health services as well as how it approaches teaching public school students about mental health and substance abuse.
Florida lawmakers agreed to put an additional $126 million in recurring general revenue and more than $50 million in one-time spending for community mental health and substance use disorder services, investments that were praised by the Florida Behavioral Health Association CEO Melanie Brown-Woofter and Natalie Kelly, the CEO of the Florida Association of Managing Entities.
The State Board of Education in October agreed to update its rules regarding required instruction in public schools, shifting the focus from teaching about mental health disorders to instructing resiliency, instead.
While the former rules require public schools to annually provide five hours of instruction on “mental and emotional health education” to students in grades 6-12 the new rules require schools to teach about resiliency, which includes civic character education as well as life skills education.
At a minimum, the new rules require schools to teach students in grades 6-12 about resilience through adversity, including the benefits of volunteerism; healthy characteristics that reinforce positive core values such as honesty, empathy, perseverance, grit, gratitude and responsibility; critical thinking, problem solving and responsible decision-making; and mentorship and citizenship.
Armed with information that showed the state needs about 60,000 additional nurses over the next 15 years, Florida lawmakers this Session agreed to pump $125 million into educational programs and efforts to increase the number of licensed nurses in the state.
The commitment came after the Florida Hospital Association released the Florida Nurse Workforce Projections: 2019 to 2035. The analysis projected a 12% shortfall in the number of registered nurses and a 30% shortfall in the number of licensed practical nurses working in 2035 if the state doesn’t move to produce more nurses.
The shortage is being fueled by several different factors including high turnover rates. Overall, there is a 25% turnover rate for Florida nurses with higher (35%) turnover rates for licensed practical nurses and certified nursing assistants (CNAs).
Additionally, Florida colleges and universities are struggling to find enough well-trained faculty members to educate and train the next generation of nurses. As a result, the schools are limited in the number of students they can admit into their programs.
The $125 million is spread across three different education areas of the budget: $20 million for workforce training; $59 million for state colleges; and $46 million for the state university system, which includes Florida’s public universities.
It didn’t take long for higher learning institutions to take advantage of the additional funds and work to increase the number of nurses in the state.
The Florida State University (FSU) College of Nursing announced it would expand admissions from once per year to three times per year in an effort to increase the number of registered nurses in the state. It made the announcement July 1, the day the budget took effect.
UF announced it will recruit about 20 new faculty members and that enrollment in its nursing program at UF Health Jacksonville will increase by 50% in 2023 and will double by 2025. Enrollment in the nursing program in Gainesville is expected to jump by 15% in 2023.
Biggest Medicaid fine
Florida health care regulators in March levied the largest fine in the history of the state’s Medicaid managed care program after it ordered Sunshine Health Plan to pay $9.1 million for failing to pay, or to timely pay, 121,227 claims from health care providers.
Sunshine officials said at the time the errors were a result of a software issue following the company’s merger last year with WellCare which, at the time of the merger, had been the state’s second largest Medicaid managed care plan behind Sunshine.
Previous news accounts detailed how, for months, Sunshine failed to pay providers for some of the state’s severely sick children that receive coverage as part of Medicaid’s children’s medical services portion. At least one provider shut down.
The state levied a $75 fine for each delinquent payment. The 121,227 unpaid claims were identified either through complaints made to the state from providers or by the health plan itself.
In addition to levying a fine the state also placed sanctions on Sunshine State Health Plan and required it to take a series of “corrective” actions before the state agreed to auto-assign to Sunshine people who did not voluntarily choose a Medicaid managed care plan.
AHCA does not routinely issue “sanctions” against Medicaid managed care plans, nor are corrective action plans often required.
Assistant Deputy Secretary for Medicaid Brian Meyer sent Sunshine President and CEO Nathan Landsbaum a letter announcing the record setting fine.
“(AHCA) takes (its) obligations seriously to ensure high quality health care is delivered to all enrollees in the Florida Medicaid program,” Meyer wrote.
Medicaid managed care changes
AHCA started 2022 with a goal of getting lawmakers to sign off on changes to the state’s mandatory Medicaid managed care program. The agency finished the year trying to finalize the details of an invitation to negotiate to bid on the state’s health care program for the poor elderly and disabled.
After a previous failed attempt, AHCA’s legislative team this year convinced lawmakers to crack open the state’s Medicaid statutes and make (mostly administrative) changes to how it must be competitively bid and how it operates.
In passing SB 1950 lawmakers agreed to reduce the number of Medicaid managed care districts from 11 to nine. The proposal also deleted a requirement that the state issue separate bids for each Medicaid region.
Florida’s existing managed care contracts expire on Dec. 31, 2024. The multiyear contracts are worth tens of billions to the Medicaid managed care companies that submit winning bids. Plans that aren’t chosen to participate in the program are locked out for six years unless they buy or merge with another health plan.
The state this summer issued a five-page request for information (RFI) asking those with experience in the Medicaid managed health care and Medicaid managed long-term care industries to provide the state ideas and best practices to improve Medicaid for patients who receive care and providers who render services. The answers to the RFI could be used to help inform AHCA as it worked on the ITN.
While AHCA didn’t get the ITN published prior to the end of the year the state did publish the Medicaid data book on Nov. 22. The data book provides relevant background information that managed care plans will want to have as they decide whether to compete to participate in the Medicaid managed care regions. The state is required by law to publish the information at least 90 days prior to issuing the ITN.
PHE expiration and Medicaid
The number of Floridians on Medicaid swelled during the COVID-19 pandemic as more than 5 million people wound up in state and federal funded health care safety net health care program.
The state cannot actively disenroll people in the program as long as the federal COVID-19 public health emergency remains in place, a move that also brings in substantial added federal funding to the state.
The big question is when the public health emergency declaration will be lifted. The current declaration is due to expire on Jan. 11, but it is anticipated it will be extended since the Biden administration did not give an anticipated 60-day notice that it would expire. There have been growing calls to end the public health emergency.
DeSantis joined 24 other Republican governors who sent a letter to the Biden administration in late December asking that the public health emergency be lifted in April 2023. That letter said while increased funding does “blunt the increasing costs” of keeping people enrolled on Medicaid it is “negatively affecting states.”
Some health advocates remain concerned about what will happen when states including Florida begin to disenroll people from Medicaid, contending that children may be most at risk. A group of 40 Florida organizations in early December asked the DeSantis administration to come up with a detailed plan. That letter stated that more than 525,000 children had enrolled in Medicaid since the pandemic began in March 2020.
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