Florida lawmakers have proposed measures to redirect patients from hospital emergency departments as part of a healthcare package for 2024. The state's relationship to Medicaid is one influence on the possibility of added regulations.
Within the legislative bundle called "Live Healthy" is a requirement for all hospitals with emergency departments — including hospital-based, off-campus EDs — to submit a plan to the state that details how they will help patients access the appropriate care setting if and when they present to the ED with a nonemergent condition or do not have regular access to primary care. The goal is to divert such patients from presenting at the ED for future nonemergent care.
Diversion plans must include a partnership agreement with one or more local federally qualified health centers or other primary care settings to establish new patient relationships, and/or the establishment, construction and operation of a hospital-owned urgent care center adjacent to the hospital ED or an agreement with an urgent care center in close proximity to the ED.
Emergency departments in Florida likely share many of the same challenges with those around the nation that are grappling with staff shortages, which worsen to the problem of boarding. ED visits for mental health and substance-use issues have been on the rise for years. The emergency department is a central place in U.S. healthcare delivery, where nearly half of the country's medical care is delivered, according to a 2017 study out of Baltimore-based University of Maryland School of Medicine.
But something sets Florida apart from the majority of states: its decision to refrain from Medicaid expansion. Of the 10 states that have not expanded the program, Florida is one of the largest holdouts.
At the December news conference where Live Healthy was rolled out, Florida Senate President Kathleen Passidomo signaled no opening for changes to Medicaid eligibility. "Medicaid expansion doesn't work, and we're going to take care of everybody," she said, without providing further explanation, the Orlando Sentinel reported.
As a 2024 presidential contender, Florida Gov. Ron DeSantis has gone one step further by saying he aims to "replace and supersede" the Affordable Care Act — the law containing Medicaid expansion provisions — if elected.
Florida is among the most chronically underinsured states in the nation, with more than 11% of residents going without insurance. At the same time, about 79% of Florida residents report having a personal physician or healthcare provider, according to 2022 CDC data, putting it among the 10 worst-performing states.
Florida House Democratic Leader Fentrice Driskell said "stubborn politics" drive the decision to turn down up to $5 billion in federal money to add 1.5 million people to the 4.5 million in Florida already receiving Medicaid. "That means people cannot see a doctor till they are sick and can only go to the ER, which means we all pay for it," the lawmaker said, according to the Sentinel.
Under federal law — the Emergency Medical Treatment and Labor Act — Medicare-participating hospitals with emergency departments are required to screen and treat emergency medical conditions of all patients, regardless of their ability to pay or insurance status.
There is an assumption that expanding insurance access can alleviate pressures on EDs, which serve as a safety net for all patients, although there is data that challenges this premise. A study of data from 2012 to 2017 from Chicago-based Northwestern Medicine found emergency department wait times increased 10% in states that expanded Medicaid coverage compared to states that did not, for example.
EMTALA is not mentioned in the drafted legislation proposing ED diversion plans in Florida. The diversion plans would likely be designed to comply with EMTALA, in which ED care teams would treat patients for emergent medical needs and then assist them with primary care appointments or urgent care center referrals for follow-ups or chronic care management, returning to the state's goal to divert use of EDs for future nonemergent care.
Ms. Passidomo said the state is focused on expanding its healthcare workforce, which is central to Live Healthy legislation introduced so far. One bill earmarks $797 million for a number of workforce efforts in the short, mid- and long term, including the creation of 700 residency positions and increased practice permissions for advanced practice providers.
"It's not about whether or not you have insurance," Ms. Passidomo has said. "If we don't have enough people to see you, it's not going to make a difference."
Some Live Healthy legislation is up for consideration at the committee level in the Florida Senate, while other bills are set to be filed in coming weeks. The legislation currently available is SPB 7016, pertaining to the healthcare workforce, and SPB 7018, pertaining to healthcare innovation. Those two pieces of legislation, summarized here, call for approximately $873 million in appropriations.
The proposed diversion plans for hospitals' emergency departments would require state approval for initial licensure or renewal. After approval, hospitals must annually submit data to the state demonstrating the effectiveness of their diversion plan and update the plan as required by the state before license renewal. Read more about the proposed regulations here.
The Florida Hospital Association applauded Live Healthy upon its proposal.