TALLAHASSEE -- Florida's 2013 legislative session practically started and ended with Medicaid expansion at the center of debate, with House Republicans blocking a plan to use federal dollars to reduce the number of uninsured Floridians.
This year, House Republicans pledge to tackle issues that have long lingered on the back burner, such as more independence for highly trained nurses, increasing the number of medical students who go into primary care and regulating virtual doctor visits.
But even as the focus shifts from Medicaid expansion, Democrats say it remains a top priority.
"I don't think they'll have it in their agenda but it's on our agenda," said House Minority Leader Perry Thurston, D-Fort Lauderdale. "So we will be talking about it. And if they want to pretend it's a big elephant in the room that's not really there, then it's up to them."
State Sen. Joe Negron, a Stuart Republican, disagrees. He crafted the plan House Republicans rejected to use $51 billion in federal funding to purchase private insurance for
poor Floridians. The House and the Senate had the same goals but after "spirited, full and fair debate" were unable to reach an agreement, Negron said.
"I don't know how productive it would be to simply film the same movie over again," he said. "... I think the fact there are so many other health care issues is an indication that the Legislature has moved on to other issues where we can make progress."
Proponents of Medicaid expansion are working behind the scenes to come up with an alternative House Republicans will allow, but it's a steep, uphill battle.
All sides agree other topics deserve attention.
House Speaker Will Weatherford created a special committee to gauge health care workforce needs and recommend changes in Florida law. The committee has focused most on Florida regulations for advanced practice nurses, the most restrictive in the nation.
"Florida is really behind the curve on addressing the workforce issues; many other states throughout the nation have made some of the changes that were suggested here today with tremendous success for many years," state Rep. Jose Oliva, R-Miami Lakes, said Friday after a committee meeting.
Nurses with post-graduate training want to prescribe controlled substances, sign death certificates and practice independently from medical doctors. The Florida Medical Association, a powerful advocacy organization for doctors, has fought against proposals to give these professionals more duties outside of physician supervision.
Telemedicine -- the emerging practice of using technology and the Internet to facilitate virtual doctor-patient visits -- is also a field where other states have outpaced Florida. Some Florida hospitals and doctors, especially in rural areas and certain specialties, are using telemedicine for evaluations and check-ups.
Right now, a state Board of Medicine rule requires face-to-face meetings in order for a doctor visit to be reimbursed except in some instances where drugs are being prescribed.
Proposals in the House and the Senate would require insurers to pay for services regardless of whether they are provided in-person or via services like Skype. Lawmakers will also discuss whether telemedicine should be reimbursed at the same rate as face-to-face visits.
And, of course, there are the perennial requests for more health care spending.
The state increased funding for medical residency slots to $80 million last year, but hospitals say more is needed. The Florida Medical Association is also lobbying for a loan forgiveness program to encourage new doctors to go into primary care instead of more lucrative specialities.
"We come out of school with an incredible amount of debt, and it would be easy to be a radiologist and get that debt paid off faster but we really want to be family doctors," said Dr. Bob Raspa, the Jacksonville-based board chairman of the Florida Academy of Family Physicians.
Even with all of these new topics, many old ones will still need attention, such as Medicaid funding for hospitals and ongoing implementation of the Affordable Care Act.
For example, the federal government provided 100 percent of the funding for states to boost reimbursement rates for Medicaid doctors through the end of 2014. If states want to keep those higher rates in 2015 and beyond, they will have to shoulder at least some of the cost. The Florida Medical Association estimates Florida's share to be $150 million a year, money that would have to be reflected in the 2014-15 budget crafted during the 2014 session.
The president of the South Florida Hospital and Healthcare Association believes all of those topics worthy of discussion, but not at the expense of Medicaid expansion.
"We haven't given up on it," Linda Quick said.
Health care groups have started engaging the business community to make the economic case for reducing the number of uninsured Floridians. Florida is not only rejecting billions of federal dollars, they argue, but allowing businesses with low-wage, full-time workers to shoulder the health insurance costs while stifling the creation of tens of thousands of jobs the federal funding would have created.
Nothing is more important than providing health care for the 764,000 Floridians who make too much to qualify for Medicaid under current standards but not enough to qualify for subsidies to buy insurance on the federal health exchange, Quick said.
The nurse practitioner and telemedicine conversations are worth having, she said, but amount to small peanuts in the grand scheme of things.
"I don't see them as controversial or hotly contested," she said, "so I would like to think that (legislators) could come to some consensus on those issues relatively early in session and then do the work that will be required to craft an expansion option that everyone could agree to."