Health Care: Lingering Effects
The pandemic has created nursing, mental health and Medicaid challenges that the state must address.
Three years after it began sweeping the country, COVID-19 continues to cast a pall over the state’s health care policy arena.
Among the issues legislators will grapple with is the federal public health emergency declaration, which has been in place since March 2020. Under the order, states are required to keep continuous coverage for individuals enrolled in Medicaid and in return get a 6.2% enhanced federal match. The proviso has swelled Florida’s Medicaid enrollment from about 3.8 million Floridians in January 2020 to 5.5 million Floridians (including 2.8 million children and 2.6 million adults) as of November 2022.
“The folks who’ve been enrolled have not been able to be kicked off those rolls. Even if they’re no longer eligible for Medicaid (such as when they get a job), they stay on the rolls,” Rep. Sam Garrison (R-Fleming Island), chair of the health care appropriations subcommittee, remarked during a recent hearing.
The Biden administration announced it would end the emergency declaration on May 11. When that happens, states will have up to a year to return to normal eligibility and enrollment. Florida officials have provided few clues publicly about their “unwinding plans” — but Garrison said any changes to the federal public health emergency and the state’s response to it will “very likely impact our future Medicaid expenditures,” which currently consume about 77% ($37.6 billion) of the state’s $49-billion health and human services budget.
Access to mental health care is also on lawmakers’ radar. “Our state’s mental health treatment facilities have been experiencing treatment wait lists for both civil and forensic commitments (for criminal defendants),” Garrison noted at the same panel hearing.
It’s been an especially challenging issue for the Department of Children and Families, which handles adult forensic mental health and under state law has 15 days to get an inmate placed in a state psychiatric hospital when a judge deems him mentally incompetent.
In fiscal year 2021-22, some 1,921 individuals were on the forensic admission wait list for more than 15 days, according to DCF’s Long Range Program Plan. The agency attributes the backlogs to the impact of the COVID-19 pandemic, during which admissions to state mental health treatment facilities were suspended. While a phased admission plan was eventually implemented, limited bed capacity, COVID-19 testing requirements and staff shortages continue to add to a backlog.
All sectors of the health care industry have been rocked by staff shortages sparked by the pandemic, and industry leaders don’t see the crunch ending any time soon.
Mary Mayhew, president of the Florida Hospital Association, says labor costs for hospitals have increased more than 45% over the past two years and many hospitals are “hemorrhaging red ink.” She says the negative monthly margins impacting most hospitals are a direct result of the “ongoing, unprecedented dependency on temporary staffing” fueled by the pandemic. “It just hasn’t gone back down to pre-pandemic levels,” Mayhew says. In addition, hospitals have had to dramatically increase wages of permanent staff to retain them.
Amid those challenges, she says, the FHA “plans to focus a great deal talking about hospital finances in order to guard against legislation that would add unnecessary costs and administrative burden to the delivery of health care services.”
Meanwhile, as GOP lawmakers look for ways to trim the Medicaid rolls, the Florida Hospital Association would like to see a bump in Medicaid reimbursement rates.
Hospitals don’t get compensated for the actual cost of the care when they take care of Medicaid patients, Mayhew says. They get about 55 cents on every dollar, which results in significant cost shifting to patients with private insurance. “It’s really important to understand that the Medicaid program is a core part of this state budget, and it is supporting the purchase of care for the elderly, for the disabled, for low-income children and extremely low-income parents,” Mayhew says.
Florida nursing homes face many of the same challenges as Florida’s hospitals, says Emmett Reed, CEO of the Florida Health Care Association, which represents 86% of the state’s nearly 700 skilled nursing homes. Last session, the Legislature approved a 7.8% increase in Medicaid funding for nursing homes that amounted to about $419,000 per facility. Lawmakers also approved revised staffing standards that broadened the type of staff that can provide direct care to patients and helped facilities “get more hands on deck,” Reed says.
While certified nursing assistant staffing has largely stabilized, Reed says, a nursing shortage continues. “We’re alarmed at the rate that we’re losing nurses. We’re not able to retain and keep them. It’s probably two reasons they leave — one financial, and sometimes it can be the regulatory, a very tough environment,” Reed says. “We’re regulated, and rightly so, but it’s just tough.”
As with hospitals, nursing homes are seeking a bump in reimbursements. Right now, it costs nursing homes about $283.13 a day to take care of a Medicaid resident, and the average reimbursement is $252.99. Reed says the industry would like to see higher reimbursement rates, with the increased funding tied to quality measures.
“As generous as the Legislature was last year, we’re still reeling as a profession,” he says. Occupancy is at 84%, “which is great compared to the rest of the country, but that’s 4% lower than pre-pandemic levels, which is what our business models are based on,” he explains. “A lot of times, our nursing homes can’t take in residents because they can’t care for them. Maybe they could be at 88%, but they don’t have the staff, so they’re taking fewer residents. It’s a vicious cycle.”
The Florida Department of Veterans Affairs, which operates eight skilled nursing facilities and one assisted living facility, has also been financially strapped over the past couple years and required general revenue funding from the state during the past two years when its trust fund became insolvent. Rep. Garrison, the chair of the health care appropriations subcommittee, said the funds were depleted because of the opening of two new nursing homes, as well as adverse impacts of the COVID-19 pandemic, which drove down occupancy numbers and decreased revenue streams.