Hillsborough County officials presented commissioners with options Thursday for a large and growing reserve in the county's Health Care Plan, urging deliberation before any changes. Kevin Wagner, director of the county's Health Care Services Department, told the Board of County Commissioners the plan is projected to hold about $531,000,000 at the end of fiscal 2025 and laid out scenarios to use or reduce that reserve.

Wagner said the plan, created in 1991 under "ordinance 91 19" and shaped by state statute cited in the presentation, remains a payer-of-last-resort for county residents who lack other coverage and is designed to divert medically needy people from costly emergency-room care into primary care. He told commissioners the county currently budgets about $129,000,000 for medical services and about $38,000,000 for administration within the plan.

To "soften the landing" for the large balance, Wagner presented a spend-down "Scenario 1" that would fund expansions and provider requests: up to $12,000,000 additional for the county's level-1 trauma center, up to $5,500,000 for level-2 trauma support, a capital matching program (up to $10,000,000 on a roughly 50% match basis), and $5,300,000 in service funding for a community step-down facility. Wagner said some items are already approved and budgeted (for example, inmate health care and ambulance transport). He said projections show that pursuing the fully loaded Scenario 1 would reduce the fund balance to about $326,000,000 by 2030.

Commissioners pressed staff on the rules that govern HCHCP spending and on enrollment and spending trends. Commissioner Willstone asked repeatedly whether surtax dollars go to undocumented residents; Wagner said enrollment requires proof of Hillsborough County residency and documentation and that an internal review of 52,553 unduplicated applications initially found 28 with missing documents, later reduced to five after supervisory review. "So I think we have a very strong record" of documentation, Wagner said.

Willstone also pressed why expenditures rose sharply in a short period despite what he said were long-standing, relatively flat membership figures. Wagner and other staff pointed to several causes: broader eligibility (the board increased eligibility to 175% of the federal poverty level in recent years), higher reimbursement rates for primary care and specialty services approved by the board, and addition of new programmatic expenditures such as inmate health care and ambulance transport.

Other commissioners urged caution. Commissioner Cohen said revenue is projected to flatten while expenditures will continue to climb, creating uncertainty, and recommended proceeding "gingerly" until more information arrives about federal programs and state policy changes. Several commissioners said they want more program-level data showing what share of each provider's budget comes from HCHCP before committing to large new recurring grants.

On the question of changing the health-care surtax itself, Wagner reminded the board of procedural limits he cited in the presentation: reductions in the current sales surtax would require a two-thirds vote; increasing the surtax again would require a referendum under current statute. He also noted statutory limits on which items may be funded by the surtax and said the county attorney had reviewed the use of funds for mandatory Medicaid contributions and other categories.

No formal votes or motions were taken at the workshop. Commissioners asked staff to return with more detailed analyses, program-level budget impacts, and clearer forecasts before the board considers a policy change.

What happens next: staff will provide the requested data and the board will continue deliberations; any change to the surtax or long-term commitment of new, recurring funding would require future board action and, where statutorily required, a referendum or supermajority vote.

Sources: Presentation and Q&A at the Hillsborough County Board of County Commissioners Health Care Plan workshop. Quotes and figures are drawn from county staff and the providers who presented.