(Bloomberg) — Millions of people in the US are expected to lose their health coverage in coming years because of shrinking funding for federal programs. Few states would suffer a bigger blow than Florida.<\/p>\n
Enhanced Affordable Care Act subsidies expired in December. More than $900 billion in cuts to Medicaid safety-net programs are on the horizon. Across the US, in excess of 14 million people are expected to lose health insurance through 2034, according to health-policy research nonprofit KFF.<\/p>\n
Florida, the third-largest state by population, is exposed to cutbacks by President Donald Trump\u2019s administration on several levels. The state\u2019s hospitals, including facilities that serve its neediest residents, are bracing for a large decline in revenue and reimbursements. And some Floridians who had counted on federal help to buy coverage through the Obamacare exchanges say they\u2019re having to cash out investments in order to cover their health-care premiums.<\/p>\n
As this year began, Florida had more enrollees in ACA plans \u2014 some 4.5 million \u2014 than any other state, largely because of its higher concentration of small businesses, the self-employed and early retirees. Among them are people like Julee Ellison, 61, who owns a handbag-making business in Manatee County, along the state\u2019s Gulf Coast south of Tampa Bay.<\/p>\n
Ellison bought marketplace insurance for the first time last year for $762 a month, but at the time she didn\u2019t realize that premium was subsidized. She\u2019s now paying roughly $1,700 a month for a plan that covers the doctors she needs.<\/p>\n
\u201cRight before Covid hit, I was in the hospital really, really sick, probably with Covid,\u201d said Ellison. \u201cMy pancreas, my liver, everything got attacked. So health care is extremely important to me. I\u2019ve got to have it.\u201d<\/p>\n
Ellison considers herself fortunate that she and her husband, who is on Medicare, have the financial flexibility to afford her coverage. If need be, \u201cwe\u2019ll sell a stock,\u201d she said. Some people she knows have dropped health insurance entirely, she said.<\/p>\n
Florida had the fourth-highest rate of uninsured among US states in 2024 at 13.6%, compared with a national average of 9.8%, according to KFF. The state is one of 10 that didn\u2019t expand Medicaid following passage of the ACA, leaving hundreds of thousands of adults in a coverage gap: unable to qualify for marketplace subsidies in many cases, but ineligible for Medicaid.<\/p>\n
This year, the number of Floridians who\u2019ve decided to forgo health coverage has ticked up. Through Jan. 15, ACA enrollment was down 4%. More people are likely to drop their coverage as premium payments pile up in the months ahead.<\/p>\n
Congress failed last year to agree on a deal to extend the enhanced ACA subsidies, which were put in place under President Joe Biden. The Trump administration has said that changes to Medicaid in the One Big Beautiful Bill Act will strengthen the program while eliminating waste, fraud and abuse, enforcing work requirements and removing immigrants who aren\u2019t eligible for coverage, among other steps.<\/p>\n
Hard Choices<\/p>\n
While the federal cutbacks are forcing many Florida households to make difficult decisions about how much health care they can afford, hospitals and health systems around the state are facing similar hard choices.<\/p>\n
Miami\u2019s county-run Jackson Health System, which has received about $100 million a year, on average, from treating patients insured through the ACA, is holding off on hiring more therapists and psychiatrists who would help stabilize patients outside the hospital. The public safety-net system already loses $20 million a year on behavioral health care, according to Jackson Chief Executive Officer Carlos Migoya.<\/p>\n
Migoya, who plans to leave his post on May 31, said Miami-Dade County has about 1 million people enrolled in ACA plans. He estimates as many as a third could lose coverage because of the end of the enhanced subsidies. As a result, Jackson must keep its ambitions modest, he said.<\/p>\n
\u201cIt doesn\u2019t make a whole lot of sense for us to go expand some of these services and then have a tsunami hit us and have to pull them back,\u201d Migoya said.<\/p>\n
Jackson relies on county funds to plug its annual operating deficits, meaning the cost of caring for more uninsured people will ultimately fall to local taxpayers. In a January report, credit-rating company KBRA flagged the risk of more uninsured patients to hospitals and local governments.<\/p>\n
Nationally, hospitals could see $68 billion in lost revenue and reimbursements this year and in 2027, according to estimates from hospital purchasing group Premier Inc. Florida accounts for an estimated $8.8 billion of that, second only to Texas among US states.<\/p>\n
West of Miami in Collier County, where beachfront homes sit a few miles from communities of farm laborers, Naples Comprehensive Health sees most of the county\u2019s Medicaid patients who need hospital care, according to CEO Paul Hiltz.<\/p>\n
With funds from private donors, NCH is adding urgent-care centers, freestanding emergency departments and same-day primary clinics \u201cso that people can get care in lower-cost settings in the neighborhoods in which they live,\u201d Hiltz said.<\/p>\n
The hospital group works closely with the county\u2019s only safety-net health center, Healthcare Network, which provides prenatal care for many low-income women prior to NCH handling their deliveries.<\/p>\n
Healthcare Network is seeing more patients coming in without insurance, and it\u2019s feeling the strain. To fund its operations, Healthcare Network relies on government grants, Medicaid and Medicare reimbursements, and philanthropy. Patients pay for its services on a sliding scale, depending on their income.<\/p>\n
To make up for lost revenue, Healthcare Network is contemplating raising its rates, boosting the minimum cost of an office visit from $45 to $55. It\u2019s also tapping donations. However, CEO Jamie Ulmer said that can\u2019t substitute for stable payments from insurance. And Healthcare Network closed a newly opened pediatrics site as workforce challenges also pressured the system.<\/p>\n
\u201cWe\u2019re shifting services to a new health hub and to another nearby pediatric location that has the capacity to take on those patients,\u201d said Ulmer. While the now-closed site was opened to address disparities, he said families are still close enough to the hub. \u201cAccess to care is still there, we\u2019re just consolidating services a bit.\u201d<\/p>\n
Bigger hospital systems are better positioned to absorb the financial blow. HCA Healthcare, the nation\u2019s largest for-profit hospital operator with almost 50 hospitals in Florida, projects a profit hit of $600 million to $900 million, which it plans to partially offset with other cost-savings, the company told investors on an earnings call in January. The company declined to comment beyond what it said on the call.<\/p>\n
Charity Care<\/p>\n
Some Democratic-led states have funded enhanced ACA premiums themselves, but that\u2019s a nonstarter in GOP-dominated Florida. Opening up Medicaid to more people is also off the table. In March, Florida\u2019s legislature again rejected Medicaid expansion \u2014 a proposal it has turned down every year since the ACA\u2019s adoption in 2010, citing taxpayer cost \u2014 despite 90% federal funding for new enrollees.<\/p>\n
\u201cIt\u2019s like DEI. You can\u2019t even talk about it,\u201d said Melanie Williams, a policy director at the advocacy group Florida Health Justice Project.<\/p>\n
Compounding the financial pain many Florida hospitals are facing, the state\u2019s application for $7.8 billion in additional federal funds meant to help hospitals cover shortfalls in Medicaid has been pending at the Centers for Medicare and Medicaid Services since May. An agency spokesperson said CMS doesn\u2019t comment on the applications until they\u2019re finalized.<\/p>\n
BayCare Health System, based in the Tampa Bay area, is seeing a sharp uptick in people applying for charity care, including from people who earn too much to qualify. The median household income in Tampa was $75,475, according to 2024 US Census data, but a significant portion of the population lives paycheck-to-paycheck due to the high cost of living. More than 15% live at the poverty line, compared with the national average of 10%.<\/p>\n
As a result of more middle-class earners requesting assistance, the hospital system has increased denials, said John Learn, BayCare\u2019s government relations manager, even though he said it has among the most generous charity-care programs in the region.<\/p>\n
For many Floridians, rising health and insurance costs are arriving at the same time that they are grappling with higher prices for other essentials like food, shelter and energy. Health-care costs are one part of a broader affordability crisis squeezing the middle class nationwide, advocates say.<\/p>\n
\u201cThe health-care conversation isn\u2019t happening in a vacuum,\u201d said Scott Darius, executive director of Florida Voices for Health. \u201cI can\u2019t pay rent with a Medicaid card. I can\u2019t buy food with a Medicaid card.\u201d<\/p>\n
Hillsborough County, which includes Tampa, operates a public health plan for about 25,000 low-income residents who don\u2019t qualify for Medicaid. Applications jumped by 15% after ACA subsidies expired, and the program expects more to come, said Kevin Wagner, the county\u2019s director of health-care services.<\/p>\n
He estimates that the program, which is funded by a county sales tax, has enough money to accommodate up to 10,000 more people. But that\u2019s a sliver of the number of residents who are expected to lose ACA coverage.<\/p>\n
\u201cWe\u2019re preparing for the wave,\u201d Wagner said. \u201cBut we know we won\u2019t be able to catch everyone.\u201d<\/p>\n