Last year, the Indian River County Hospital District helped pay for 230,000 medical visits, counseling sessions, prenatal checkups and other care for roughly 27,000 people, about 1 in 6 county residents, who otherwise couldn’t afford it. It paid for Meals on Wheels for seniors who can’t drive, dental and mental health care for children, hospice and the county’s share of Medicaid.

Nearly all of it was paid for with property taxes.

If voters approve Amendment 3 on Nov. 3, the hospital district can expect to lose about a third of that tax money, said Frank Isele, the district’s executive director. By his rough prediction, that would mean about 10,000 fewer people served.

“They’re going to forgo care,” he said.

Florida’s public hospital districts and health systems stand to lose about $323 million in the amendment’s first few years, estimates the Florida Policy Institute, a nonpartisan research group. 

But what those cuts will look like — which clinic adds a waitlist, which program closes — no one can yet say.

“We just know that it will mean less money going in,” said Scott Darius, executive director of Florida Voices for Health. “Every place is going to make decisions differently about what to prioritize and then how to make up the difference … and it just creates such chaos across every county that’s … faced with that fundamental question.”

What is clear, according to hospital district leaders and health policy experts across the state who spoke to The Florida Trib, and a Trib analysis of county and hospital district budgets, is that the state could be turning itself into one of the nation’s most inhospitable places for working sick people. Florida’s fragmented way of paying for care, along with an amendment that offers health care funding no protection, and a cascade of coverage losses at the federal level, may test what happens when a state with no income tax or Medicaid expansion creates deep cuts to the property taxes that pay for local care.

“The experiment has never been done anywhere, to my knowledge,” Isele said.

For starters, Florida has no single safety net. 

It has a patchwork built county by county over decades: 28 hospital districts with different powers and boards, a health care sales tax in seven counties, and in 41 counties, neither. “It’s difficult to get an understanding of how special districts focused on health care operate in the state of Florida,” Isele said, “because they’re all structured very differently.”

Second, health care has no protection in the amendment. For counties and cities, it limits what remaining property taxes can pay for public safety, schools, roads and a few other purposes. On health care, Isele said, the amendment is silent: It “doesn’t state that health care funding has to be maintained at any certain level.”

Third, the cut would land on top of others. Florida is one of 10 states that haven’t expanded Medicaid. Enhanced federal subsidies that made marketplace insurance affordable for millions expired nationwide at the end of last year after Congress failed to renew them. Florida, which has more people buying marketplace coverage than any other state, saw enrollment fall by more than 440,000, the largest drop in the country.

All of it falls on a growing group of people across the state: Floridians who don’t qualify for Medicaid, aren’t old enough for Medicare and can’t afford private insurance. Those are the people Amendment 3 will likely hit hardest, said Erica Monet Li, a health policy analyst at FPI, who has been studying how the property tax cuts would affect public health.

“It’s going to hit the people who are already in these coverage gaps,” Li said. “They’re sort of in this gray area.”

Florida’s version of that gap is especially wide. An adult without children can’t qualify for Medicaid based on income alone, and a parent in a family of three qualifies only if the household makes less than about a quarter of the federal poverty line, according to KFF, a health policy research group. In 2024, before the subsidies expired, about 572,000 low-income working-age Floridians, roughly 1 in 4, had no health insurance, according to U.S. Census Bureau estimates.

Most people in the coverage gap work. Across the 10 states that haven’t expanded Medicaid, 6 in 10 adults in the gap live in a family with a worker, KFF found. Of those who work, more than half are in service, retail or construction jobs. Next is the growing group Isele described: couples in their 30s to 50s paying a mortgage, car payments and child care, earning too much for help and too little to spare. “Health care is the thing that a lot of people forgo,” he said.

A patchwork safety net

Amendment 3 would raise the homestead exemption for non-school property taxes from $50,000 to $150,000 in 2027 and $250,000 in 2028. It would lower the annual cap on assessment increases on property that isn’t a primary residence from 10% to 5% and make new residents wait five years for the full exemption. 

State economists estimate the amendment would cut local property tax revenue by $4.9 billion in its first year, growing to $11.8 billion by 2031. Supporters say that money belongs to homeowners squeezed by insurance, grocery and utility costs. Gov. Ron DeSantis, who called the June special session that put the measure on the ballot, has accused local governments of “fear-mongering.” Critics say the amendment’s supporters – and the lawmakers who put it on the ballot – have neglected to consider the full range of consequences from this across-the-board cut. 

Of Florida’s 28 hospital districts, 11 collect property taxes that provide the bulk of their budgets, in eight counties home to about 5.3 million people, according to a Trib analysis of state financial reports. 

Most districts were created by the Legislature between the 1940s and 1960s in a series of “special acts” to serve places with no hospital or clinic, Isele said. Some run large hospital systems; others pay clinics and nonprofits to see low-income patients. Some boards are elected by voters, some are appointed by county commissions and many are appointed by the governor.

Each district can raise money only in the ways its special act allows. Indian River Hospital District’s can levy property tax up to 5 mills and nothing else, Isele said. “It’s all based on our individual special act.”

Seven counties, home to about 5.4 million people, pay for indigent care with a local sales tax Amendment 3 doesn’t affect, though Miami-Dade also funds its public hospital system with county property taxes. State law lets other counties ask voters for such a tax, but only in a general election, so not before November 2028, and many are already at the state’s cap on such taxes, including Indian River, Sarasota and Sumter, the Trib found.

Forty-one counties, home to 46% of the state’s population, have neither a hospital district nor a health care sales tax; 11 more have districts that collect no property tax. There, what help exists for the uninsured comes out of a county’s general budget, competing with sheriff’s offices, roads and libraries, budgets the amendment would also shrink.

“Each little county is so unique,” Li said. “There’s not one sweeping thing you could say about all of them, other than there will be a revenue loss.”

Who stands to lose most

How hard Amendment 3 hits a hospital district depends largely on one thing: whether it has any money besides property taxes.

The Trib analyzed the most recent annual financial reports that Florida’s 11 property-taxing hospital districts filed with the state, for fiscal year 2025.

Four hospital districts, in Indian River, Baker and parts of Lake and Volusia counties, get 95% or more of their revenue from property taxes. None runs a hospital; they pay other facilities to care for low-income residents. The Florida Policy Institute estimates Indian River’s district would lose about $8.9 million over the next three years.

The districts that run large hospital systems are  more insulated, because most of their money comes from patients and insurers. FPI estimates North Broward’s district would lose about $100 million also over the next three years, the most of any district, but property taxes make up only about 12% of its revenue, the Trib’s analysis found. Sarasota Memorial collected about $103 million in property taxes in fiscal 2025, about 4% of its $2.3 billion in revenue.

“A Sarasota County will stand stronger than an Indian River County,” Li said, “because Sarasota has so many more million-dollar properties to tax.”

While Sarasota doesn’t expect to lose all of that funding, the hospital that serves low-income, uninsured residents would still feel the cuts, said Kevin Cooper, who sits on the board of the Sarasota Memorial Health Care System. The district projects losing about $36 million over two years, almost exactly the cost of a cancer center expansion its board recently approved in Venice. “Things that you would otherwise do to expand geographically and to expand service capacity likely won’t get done, or will pace far behind community needs,” he said.

Where cuts could land

None of the leaders interviewed for this story would say exactly what they would cut, primarily because their boards haven’t decided. 

Districts could raise their tax rates, if they haven’t reached their taxation limit. Indian River’s is at 14% of its cap, Isele said, but an increase takes a board supermajority and other districts are closer to their ceilings. 

Treasure Coast gets about 14% of its funding from the Indian River Hospital District, said Heather Miranda, CEO of Treasure Coast Community Health, a federally qualified health center with seven clinics in Indian River County. The cut wouldn’t reach it until October 2027, and the health center already runs lean. “We don’t have a lot to cut,” she said. Currently TCCH is seeking donor and grant support  but “everyone else that’s involved in this situation is also going to do the same thing.”

“Could programs be cut? Yes. Could waitlists occur? Yes,” Miranda said. Without care, she said, people’s “health worsens, and then they end up in an emergency room.”

In West Volusia, where property taxes provide nearly all the authority’s money, the board would look first at its biggest line items, including $4.5 million a year for specialty care such as dialysis and cancer treatment, said Rakeem Ford, board chair of the West Volusia Hospital Authority. “There’s only two ways to balance the budget,” he said: “increase taxes, which no one likes, or remove services, which no one likes as well.”

The people in the gap

In 2024, about 1 in 4 low-income working-age Floridians had no health insurance, according to U.S. Census Bureau estimates. In some counties it was worse. In Collier County, which has no hospital district or health care sales tax, it was about 1 in 3.

Those are the most recent county figures available, and the people who run clinics say the numbers have grown since. Miranda said her staff began seeing the effects of the expired subsidies around May.

“We started seeing more and more people coming in uninsured,” she said. “They had their insurance, and then they couldn’t afford it.”

Hospital districts exist for exactly those patients. In Indian River, district money pays for care at Treasure Coast for uninsured residents earning up to twice the federal poverty level, Miranda said. West Volusia’s health card covers residents up to 150% of the federal poverty level who don’t qualify for Medicaid, Ford said.

Isele said the working households United Way calls ALICE, “asset limited, income constrained, employed,” now make up more than 40% of his county. “These are the people who we’re concerned about,” he said.

Health care doesn’t stand alone

Li said hospital district losses are only part of what Amendment 3 could mean for Floridians’ health.

Property taxes also pay for roads, sidewalks, libraries and parks, and cuts there carry health costs of their own, she said: neighborhoods that are harder to walk, fewer resources for literacy and schooling. “We’re looking at a lower quality of life and health for Florida citizens,” Li said. “Amendment Three is bad for health equity.”

Those cuts would arrive on top of others. Federal SNAP changes shift new food assistance costs to states beginning in 2027, and Florida recently lost its Fresh Access Bucks program, which let SNAP recipients double their benefits on fresh fruits and vegetables at farmers markets, Li said. Often the same families feel all of it at once: people in the coverage gap who may rely on SNAP, live in neighborhoods that depend on county services and get their health care through county-funded programs.

“This is bad for public health,” Li said, “especially those social factors that matter for people to be healthy.”

The effects may take time to show. Li pointed to the federal cuts to Medicaid and SNAP passed last year: “A year later, we’re barely starting to see some of that impact.”

More than a doctor’s office

The programs hospital districts pay for reach well beyond emergency rooms and primary care, and some of the most essential are the ones that lose money.

Obstetrics is one. “Maternity services nationally lose a lot of money,” Isele said, largely because of how insurers reimburse hospitals, and “a lot of maternity centers close.” Last year, his district worked to keep maternity care in the county after a countywide survey in which 91% of residents said they wanted it.

In Sarasota, Cooper said, the public hospital is “the only hospital in Sarasota County that delivers babies,” part of the community mission he said the hospital would never pull back on.

Where those services disappear, families feel it. 

In rural North Florida counties that have lost hospitals, Darius said, some pregnant women go without prenatal care “because there’s no one to see locally.” When his own wife went into labor in 2023, the Gainesville hospital was so backed up with patients from surrounding counties that she waited about a day and a half to be admitted. “We live 10 minutes from Shands,” he said, “but if I live an hour and a half from here, two hours from here … what a horrible experience.” 

Cooper described the public hospital as part of Sarasota’s identity, a place where it’s hard to find anyone who hasn’t been a patient, visited a loved one or worked. “It’s like you’re one degree of separation from Sarasota Memorial Hospital, if you live in this community,” he said. At its Venice campus, people come in just to have lunch.

At Treasure Coast, staff help patients apply for Medicaid, find specialists and fill prescriptions at steep discounts through a federal drug pricing program. When a patient can’t afford a life-saving medication, “we don’t let them leave without it,” Miranda said.

Isele described the district’s spending as prevention that saves money. “The least expensive hospitalization is one that never needs to happen,” he said.

If voters approve the amendment, the first cuts would show up in budgets written in 2027. Isele’s district is studying ways to earn money not tied to taxes, such as billing insurers as a health care provider. But that would take “a few years to get something like this up and running,” he said, and a cut to one program, he said, can ripple through all the others.

“Healthcare isn’t just one system or service or program. It’s an entire ecosystem,” Isele said. “It’s not just about lifespan. It’s about health span.”