"The other question is if Florida is not going to play in the Medicaid expansion, is there some other creative way that we can leverage those dollars back to the state—because they're really Florida dollars?," he says. "I believe we are in the best position right now that we may ever be in to negotiate a deal with the feds. They want us to be successful. They have already left the door open to do something outside of traditional Medicaid, where you might be able to use the money to buy insurance for these people. That is a good thing."
Nathan believes that 2014 will be a challenging but manageable year at Lee Memorial because the health system has spent the last three years trimming about $125 million in various costs. The impact of DSH cuts will be felt in the years after.
"In 2015 and 2016, it starts to become very a big wild card for us with the changes in insurance and the shift to value-based reimbursements and the big insurance companies needing to do something dramatically different because of the laws they are under," he says. "The unknowns of the exchanges, the unknowns of the expansion, shifting all of Florida to Medicaid managed care virtually overnight—even though we haven't proven yet that it works—will make 2015 and 2016 really major transition years. It is not going to happen like a light bulb on and off instantly, but it could be pretty rapid because three years is really no time when you put it in that context."