Tackle the problem of Floridians under age 65 who do not have healthcare coverage. Provide more funding to train more nurses and other hard-to-recruit medical personnel and designate the workers as "essential services personnel" so that they will qualify for affordable housing initiatives. Allow for flexible and innovative benefits plans that would come with lower premiums and encourage a product designed for uninsured college students and young adults. Continue to make healthcare costs "transparent" to consumers and the business community. Re-enact no-fault auto insurance. The Florida Hospital Association argues that without a solution, hospitals will immediately experience an increase of more than $450 million in uncompensated claims related to uninsured motorists.

Critical Stage

As Gov. Jeb Bush leaves office this month, his initiative to reform Medicaid -- the state-federal program that provides health benefits to lower-income children, pregnant women, parents, people with disabilities, seniors and others -- is moving into high gear.

At Bush's request, the U.S. Department of Health and Human Services in 2005 granted Florida a five-year waiver -- the first in the nation -- that gives the state flexibility to structure Medicaid benefit packages that don't follow the federal government's defined-benefit model.

The Legislature authorized pilot programs in Broward and Duval counties for children, parents and people with physical disabilities who receive health benefits through Medicaid. Mandatory enrollment began in those counties in September.

The distinguishing feature of Florida's experiment is that the Medicaid recipients make choices about their coverage. Program designers say that allowing them to select a benefit package that's most appropriate for their health needs will allocate the Medicaid dollars more efficiently, providing better care while holding down costs.

The more than 125,000 participating Broward County residents can choose from among nine health maintenance organizations (HMOs) and four provider service networks (PSNs). In Duval, 80,000 Medicaid participants can choose from among three HMOs and two PSNs.

To help people decide on a plan, the state provides a call center with 45 counselors. Additional counselors -- 10 in Broward and six in Duval -- work in offices in those communities.

The state pays the HMOs and PSNs a risk-adjusted premium for each Medicaid enrollee based on the age, sex and health status of the enrollee. "We have a defined investment going in," says Christa Calamas, secretary of the Florida Agency for Health Care Administration (AHCA).

The participants in the pilot programs can qualify for "enhanced benefits" by taking steps to stay healthier -- entering smoking cessation programs or disease management plans if they have chronic illnesses, for example, and undergoing routine mammogram screenings.

The participants can earn voucher credits, up to $125 annually, which can be used to buy over-the-counter medications and medical products.

How much the program will reduce the growth of Florida's Medicaid budget in the long term is unclear, but in its application for the waiver, Florida agreed that the federal government wouldn't have to increase its share of Florida's annual Medicaid budget by more than 8% per person.

"I think that people assume that this is about costs," says Calamas. Indeed, one of the first points made in the state's Medicaid waiver application is the dramatic growth of Florida's Medicaid program as a percentage of the overall budget.

But the waiver application also focuses on letting individuals make more of their own healthcare decisions -- a point that Calamas is quick to emphasize. The primary goal, she says, is to add choice, flexibility and a network in which care is coordinated. "We are replacing the outdated system that we have today."

Advocates for children and low-income Floridians as well as healthcare providers, state lawmakers and AHCA officials are watching the pilot programs carefully. Joan Alker, a senior researcher with Georgetown University's Health Policy Institute, says one question to ask is whether all the benefit packages are generous or whether generous benefits in some benefit categories are offset by restrictive benefits in others. The University of Florida's Florida Center for Medicaid and the Uninsured, the Florida Legislature's Office of Program Policy Analysis and Government Accountability and the Georgetown institute (working under contract from the Jacksonville-based Jessie Ball duPont Fund) will each evaluate the pilot programs.

Additional pilot programs in Baker, Clay and Nassau counties will be added this summer, but the Legislature must authorize any further expansion of the program.

Person to Watch

Josh Adler, CEO
Suncoast Medical Clinic St. Petersburg

Adler took the reins in 2004 of Suncoast Medical Clinic, an alliance of 57 physicians who serve 60,000 patients. Since then, he's focused on modernizing the clinic's technology, allowing Suncoast to eliminate paper orders for diagnostic tests and receive results electronically.

The electronic lab system gives physicians a spreadsheet of results over a two-year period, making it easier to check trends and abnormalities. Many billing, accounting and human resource functions also are done electronically. For its technology operations, the clinic recently won $25,000 in equipment and $3,000 in consulting from Cisco Systems.

Adler says his investment will produce an estimated $1 million in savings, primarily by slashing the $700,000 it had been spending on transcription costs.

Healthcare Facts

Tech Titans
Three Florida hospitals, Baptist Health South Florida in Coral Gables, H. Lee Moffitt Cancer Center and Research Institute in Tampa and Health First in Rockledge, made the American Hospital Association's 2006 list of the 100 Most Wired Hospitals.

Medicare Part D in 2007
Four Medicare Part D drug plans in Florida have premiums of less than $20 a month this year; there are 35 plans with no deductibles.

Non-citizens lack Insurance
Almost 47% of Florida's non-citizens, 1.8 million people, are uninsured, according to a study by the Research Institute on Social and Economic Policy at Florida International University (risep-fiu.org).

ER Crunch
While the number of Florida hospital emergency departments fell from 220 in 1994 to 209 in 2004, the number of emergency department visits rose from 4.8 million in 1994 to 7.2 million in 2004, according to the Florida Hospital Association.