"It definitely helps," Baxley said. "But it does change, and you either are on full Medicaid like the children or you are on 'share of cost' depending on your income from month-to-month, based on a formula.

"I could see someone older who may have Medicaid in addition to their Medicare not going to the doctor, just for the hassle of figuring it out."

With Democrat Alex Sink and Republican Rick Scott hammering away on each other in the race to become Florida's governor, one of them will soon be in a position to affect people like Baxley and her family.

Whichever one gets the most votes in the Nov. 2 election will have to work with members of the state legislative leadership who have said the state's share of Medicaid costs must be reduced.

Medicaid is a federal program that helps provide medical care to those below the poverty level, and in these harsh economic times, the number of people using it has grown, pushing up costs.

Baxley's family in Lakeland is only one of many in Polk County that need help.

Wanda and Michael Marvin, also of Lakeland, believe in hard work and family, keeping yourself self-sufficient. They say they have passed those values on to their three children.

But those beliefs couldn't stop a car wreck that injured Wanda, Michael and Michael Jr., 20, in early August. They were hurt so badly they haven't been able to work for weeks. With savings and sources of revenue gone and more medical treatment needed, the family turned to Medicaid for their medical help.

"I was so proud that my husband and I had been paying into the system. Now, to have to accept welfare, I'd rather be out there working. We don't believe in living off anyone," Wanda Marvin said last month after she had been turned down by seven surgeons because she was on Medicaid.

About 108,000 Polk residents, or 18.5 percent of the population, are covered by Medicaid. In 2005, the number of Polk residents on Medicaid was 82,495, or 15.2 percent of the county's population.

Lawmakers have complained the federally funded program is growing at an alarming rate, which means the amount of money Florida is required to match in order to get federal funding is also growing. As of Aug. 31, there were 2.8 million Florida residents on Medicaid. That's a 30 percent increase in five years. The total was 2.2 million in 2005.

CRITICISM OF BOTH CANDIDATES' PLANS

Republican candidate Scott has proposed creating a voucher program allowing those on Medicaid to buy their own health insurance, which he said would cut costs and waste.

Rep. Ed Homan, a Republican from Temple Terrace who is also a physician treating Medicaid patients, said it might be a good idea, but it has not been tried before.

Instead, he suggests, there are programs already in use in other states that are successful and should be implemented here.

Democratic candidate Sink said strong enforcement to eliminate Medicaid fraud would lower the state's costs, saying the state loses up to $3 billion annually because of fraud. She said she would insist on strong internal controls and reforms to crack down on fraud and abuse.

Sink said she also wants providers to adhere to a set of quality standards for patient care and to contain costs for predictable services, such as vaccinations and well-baby care, before providers can get paid, an aide said.

Some health care advocates are skeptical of both responses, which they describe as vague and not going far enough to solve the real problems.

"Correcting Medicaid costs the correct way is very good for the budget," said Karen Woodall of the Florida Center for Fiscal and Economic Policy.

Getting there is not easy.

The leadership in the Legislature has said that in the 2011 session it will consider a plan for placing Medicaid patients in private, managed-care programs - Medicaid HMOs. It is a plan that had been suggested by former Gov. Jeb Bush and which is being tried in pilot projects for Medicaid recipients in Duval, Broward, Baker, Clay and Nassau counties.

Some House leaders have said the program should now be expanded statewide because it is cutting costs.

Sen. J.D. Alexander, R-Lake Wales, the Senate's budget chief, has said something must be done about the rising costs for the state's share of Medicaid.

The expense is second only to education in the state budget, comprising a full 25 percent of the total state budget, he said during an earlier interview with The Ledger. That share is expected to rise to 27 percent in this new fiscal year, which began Oct. 1.

Despite requests from The Ledger, the Scott campaign did not answer questions on whether he supports the Bush plan for private, managed care for Medicaid.

Sink also appeared reluctant to deal with specifics on the Medicaid HMOs, but instead spoke of cut Medicaid fraud.

Woodall said Medicaid HMOs are not the best way to have both low costs and good care for those without health care.

"We prefer care-managed health care for Medicaid patients, as opposed to cost-managed health care," she said.

The phrase "care management" is not just a twist of phrases. Woodall said a North Carolina program in which care is patient-centered, rather than cost centered, has saved that state money in the Medicaid program and improved care.

"When you help a patient navigate through the health-care system and through their own care, there is a savings and an improvement in health," she said, because if health problems aren't managed, they turn into more costly treatments and emergency room visits.

Shannon Baxley, the Lakeland mom, said her advice to the gubernatorial candidates about Medicaid is straight-forward: Make it easier to navigate the system.

"It is such a hassle because the cost and the coverage is so variable from month to month," she said.

Many of the new federal health care programs and changes to Medicaid will not take effect until 2014. That means the next governor will be actively involved in decision-making at the state level.

Both Homan, the physician and legislator, and Woodall say they have not heard solid plans from either Scott or Sink.

MORE TO BE ADDED

By 2014, the state must be prepared to provide health care at 130 percent of the federal poverty level. It will cost the state $141 million more than it is now paying as its share.

That will, however, qualify it for $1.9 billion in additional federal money. Currently Florida pays about $3.4 billion for a federal matching grant of $16.6 billion.

"The new requirements (accepting those at 130 percent of poverty level) will be particularly tough for our state," said Woodall. "Florida has been so stingy with its Medicaid program, so getting to 130 percent will be harder for us than many other states that have kept up with the poverty level."

Rather than the Bush plan of putting Medicaid patients into for-profit managed care systems, which has support from legislative leaders, health care advocates say they are looking at the level of care.

"If you focus on saving money and give set payments to a for-profit, then it is not rocket science that they have to look someplace to make a profit," Woodall said.

Woodall said many health-care advocates are concerned the focus will be on denying some services.

She said that after almost four years of operation, those Florida test counties have not released results.

"They have not told us whether they are saving money because the services provided are costing less or because of denial of services; there is just no data," she said.

Still, Wanda Marvin of Lakeland said, a managed-care system with specific doctors might be a help to Medicaid patients who now have to call around to find doctors who will accept their Medicaid payments.

"At least there would be someone to see you. Now, you can't find a doctor if you are on Medicaid. I called seven orthopedic surgeons' offices today, and no one would take me. One woman said I would have to go to an emergency room and have them refer me. Well, that is costing the system extra money."

LITTLE VOTER INTEREST

Perhaps so little has been said by both Sink and Scott because Medicaid is apparently not a major concern for the average voter.

In a Florida Poll conducted by in July by The New York Times Co. in Florida and its partner, the University of South Florida, the issues of most interest to voters were jobs and the economy. Those accounted for 58.7 percent of the responses of those asked what was the most important problem the new governor would face.

The state budget came in second with 8 percent, the recent oil spill was 6 percent and education had 5 percent.

Health care of any form did not show up in the top five problems listed by those interviewed in the poll. But state lawmakers concerned with the burgeoning costs and social service advocates concerned with people getting the proper care, said the issue is nonetheless crucial to the next governor's administration.

Alexander, the Budget chief, said the 2011 Legislature will have to consider it as one of its top priorities.

Woodall said one of the problems with finding a doctor who will accept Medicaid could be made easier by the new federal health-care reform act. Although heavily criticized by opponents, a section of the act seeks what Rep. Homan and other doctors have suggested: Make payments for seeing Medicaid patients equal to what is paid for Medicare patients. The two plans often pay differing amounts for the same procedure or visit, with Medicaid paying less.

The Oklahoma and North Carolina "medical home" plans already do that, Woodall noted.

Scott was an early opponent of the federal health-care reform bill and continues to speak against "Obamacare."

Much of the reform does not take effect until 2014. Many of the provisions have been misunderstood or even misrepresented, supporters said.

Under provisions of the bill, for example, almost 2 million middle class Florida residents will qualify for tax cuts to help pay for private health insurance.

The fight in the race for governor has also turned into a battle over the lawsuit begun by Attorney Gen. Bill McCollum and attorneys general in 21 other states who are challenging a segment in the act that requires everyone to have health insurance.

Scott supports the suit and has said he will continue to pursue it.

Sink said the suit it is a waste of taxpayers' money and that the Florida Attorney General's Office should be pursuing mortgage and Medicaid fraud and recovering what she says is millions in lost money for the state.

In the meantime, the number of Florida residents on Medicaid is 15.4 percent of the population and growing, whether voters are noticing or not.