What would a Desantis presidency look like for health care?

KFF Health NewsNov 24 2023

On the presidential campaign trail, Republican Ron DeSantis touts himself as a champion of medical freedom, outlawing vaccine mandates and protecting doctors who refuse to provide certain medical treatments on moral grounds.

His record as Florida's governor suggests a presidency that would prioritize individual freedom over public health, but his push for such freedoms ends when it comes to abortion and treatment for gender dysphoria. In Florida, he has pushed restrictions on those medical services.

Critics contend those were the wrong priorities in a state where 7.4% of children had no medical insurance as of 2022. Since then more than 250,000 Florida children have lost the health insurance they had through Medicaid.

The DeSantis campaign did not return multiple requests for comment on the governor's health policy campaign plans.

As he sets his sights on the White House, here's a recap of his health care record:

Public health

At campaign stops, DeSantis talks often of his handling of the covid-19 pandemic even as the issue has largely disappeared from the public's radar.

DeSantis initially followed federal health guidance and ordered a statewide lockdown in April 2020. But the governor quickly changed course, beginning a phased reopening of Florida just one month later. Around then, Florida's then-surgeon general, Scott Rivkees, was hustled out of a news conference and hardly seen for months after he said residents might have to socially distance themselves from others and wear masks until vaccines became available.

Florida was one of four states that reopened schools in August 2020, and DeSantis banned cities and counties from enforcing mask mandates. He later suspended local pandemic restrictions and outlawed vaccine passports.

DeSantis did initially champion covid-19 vaccines, especially for Florida's older adults. That changed in 2021, when DeSantis appointed Joseph Ladapo as his next surgeon general. A Harvard-trained doctor, Ladapo had gained prominence as a skeptic of the scientific consensus on how to treat and prevent the spread of the virus.

Subsequently, Florida was the only state not to preorder covid-19 vaccine doses for children under 5 when those became available in 2022. At news conferences, DeSantis publicized covid-19 treatments such as monoclonal antibodies but didn't urge residents to get vaccinated.

Later, DeSantis' health department recommended against vaccines for young men and against people under 65 getting updated vaccines, guidance that contradicted that of the U.S. Centers for Disease Control and Prevention.

DeSantis as president would likely downplay the importance of the CDC, which is an advisory body, and instead might require states to invest more in public health infrastructure, said Jay Wolfson, a public health professor at the University of South Florida.

The pandemic exposed that Florida's public health system had been underfunded and largely ignored by successive administrations, including DeSantis', Wolfson said. Having led Florida through hurricanes Ian and Idalia, DeSantis may want a similar response to public health emergencies like covid-19, where states take the lead and the federal government's role is to support them, he said.

Abortion

DeSantis has said he supports a "culture of life." As governor, he's signed the most anti-abortion modern-day legislation Florida has seen. But he has faced pushback from the anti-abortion crowd for his initial reluctance to endorse a federal ban and from other anti-abortion Republicans for signing a ban on most abortions after six weeks of pregnancy, which some have said is too extreme.

That bill, which DeSantis signed this year, has exceptions for rape, incest, and human trafficking up to 15 weeks into the pregnancy if the woman seeking an abortion has documentation proving her circumstances.

That bill has not taken effect, because of a pending court challenge over Florida's current 15-week abortion ban, which DeSantis signed in 2022. That law does not have any exceptions for victims of rape or incest but does have exceptions for the health of the mother.

Opponents of Florida's abortion restrictions say the threat of a felony arrest for violating the law makes it difficult for a doctor to provide an abortion they think is necessary.

After months of declining to directly answer whether he would support a nationwide abortion ban, DeSantis said during the second GOP presidential primary debate that he would sign a 15-week federal abortion ban.

The issue remains a difficult one for Republicans. A recent successful ballot measure in Ohio suggests that preserving abortion rights remains an effective issue for Democrats to drive turnout.

With Florida's ban held up in legal challenges, the state continues to be one of the biggest providers of abortions in the Southeast. About 65,000 abortions have been recorded by the Florida Agency for Health Care Administration so far this year. Almost 6,000 were for out-of-state residents.

Medicaid

Even as states long opposed to Medicaid expansion such as South Dakota and North Carolina have recently reversed course, Florida remains in a group of 10 holdout states that refuse to expand the program as part of the Affordable Care Act.

The act provides extra federal funding to states that increase eligibility. In Florida's case, doing so would help an estimated 514,000 residents gain health coverage, according to an October analysis by the Urban Institute.

Florida has had one of the highest child uninsured rates for many years, higher than poorer states such as neighboring Alabama, another state that has refused to expand Medicaid, said Joan Alker, executive director at the Georgetown University Center for Children and Families.

Almost 823,000 Floridians have lost Medicaid coverage since April, when states could remove recipients for the first time since the pandemic began. That includes at least 250,000 children. It's unknown how many of those children are now covered through their parents' insurance. But despite the state's reassurance that kids who lose coverage would be referred to child health insurance programs like KidCare, Democratic state and federal lawmakers point to enrollment in the state program rising by only 25,000 children.

Florida is also the only state that has not taken advantage of federal waivers that would enable the state to keep more people on Medicaid while it transitions back to normal Medicaid operation.

Wolfson said Florida's position reflects DeSantis' belief that the program has become "an expensive and overextended giveaway" that discourages people from working hard to better their lives.

"We're not going to be like California and have massive numbers of people on government programs without work requirements," DeSantis said during the second Republican debate when asked why Florida's uninsured rate — 11.2% in 2022, according to U.S Census Bureau estimates — was higher than the national average, which was 8%.

DeSantis has, however, approved bills that expanded Medicaid coverage based on needs, an approach that may be more illustrative of his handling of the health insurance program should he end up in the White House.

In 2021, DeSantis signed a bill to extend postpartum Medicaid coverage to up to 12 months. This year, he approved legislation for Medicaid to cover glucose monitors and for family members who are 18 or older to be able to be trained and paid under Medicaid as home health aides for medically fragile child relatives.

DeSantis also signed a bill to make more lower-income families eligible for KidCare, a set of child health insurance programs.

Gender dysphoria care

Like other GOP-led states, Florida has restricted the rights of transgender minors to access treatments such as puberty blockers and hormone therapy.

Florida health officials in 2022 approved rules prohibiting minors from accessing treatment for gender dysphoria. They then in 2023 prohibited minors from accessing that treatment even in clinical trials.

This past legislative session, Florida lawmakers passed a bill codifying that rule, which DeSantis signed into law. The decision runs counter to recommendations from major medical organizations. The legislation also requires that, for adults, gender dysphoria care, which the state calls "sex-reassignment prescriptions or procedures," can be administered only by a physician.

In 2022, DeSantis' administration published a report that created the foundation for a rule that prohibited Medicaid from covering gender dysphoria treatments for both minors and adults. To create the report, the Florida health agency veered from its standard protocol and brought in consultants who had known views that ran counter to major medical organizations' guidance.

A judge has since struck that Medicaid ban down, but lawyers are arguing in court that DeSantis' administration has been willfully defying the order and has continued to implement the Medicaid ban.

Medical freedom

Earlier this year, DeSantis declared Florida the "medical freedom" state as he signed into law protections for medical providers who turn away patients on "conscience" grounds.

The law provides similar protections for insurance companies.

Opponents of the legislation worry it will allow doctors to discriminate against LGBTQ+ people or other groups. The legislation does not allow someone to opt out of providing care because of "race, color, religion, sex, or national origin."

Federal laws protect health care workers from having to provide abortions if doing so goes against their personal beliefs. Florida's new law is much broader, allowing a medical professional to deny nearly any procedure if it goes against their conscience.