A sign advertising Obamacare at Univista Insurance in Miami, Florida. Photo / David Ovalle, The Washington Post
Republicans have tried more than 70 times over the past 15 years to weaken or kill Obamacare. But their campaign keeps backfiring.
The sweeping United States tax and spending Bill that President Donald Trump signed mid-year got his party closer to that goal than ever before.
Though never marketed as a repeal, it unravelled much of the law and is expected to eventually push millions of people who gained insurance since the Affordable Care Act’s passage off the rolls.
Even that legislative achievement is proving politically fraught.
As the partial US Government shutdown continues, the White House and a growing number of congressional Republicans are worried that Democrats’ demand to boost Obamacare as part of any bill to reopen the Government is proving salient with voters - including their own.
Republican voters will be disproportionately hurt by a spike in health insurance premiums if the measure is not included.
And many of them are well aware of what’s at risk.
Democrats have said they will not vote to fund the Government unless Republicans agree to extend pandemic-era subsidies passed under President Joe Biden that help low- and middle-income Americans purchase health insurance on the Obamacare individual marketplaces.
The subsidies are set to expire at the end of the year. Republican leaders have said they are willing to discuss extending them, but only after the Government reopens.
Democrats are betting on one of two things.
Either, the Republicans cave, realising the issue could cost them in next year’s Midterm elections. Or they stand firm and let Democrats use what has been one of their strongest issues to retake control of the House.
Millions of consumers on the individual marketplaces have already received notices that their premiums are expected to spike next year as open enrolment begins on November 1.
More than four million people are expected to lose health insurance over the next decade if Congress does not extend the subsidies, according to estimates from the nonpartisan Congressional Budget Office.
Longtime Florida insurance agent Alan Reynolds, 65, predicts many of his customers will allow their policies to lapse when the price hikes become clear.
An independent who leans conservative, Reynolds, of Port St Lucie, called Obamacare flawed but said he favours the continuation of the enhanced subsidies “and not pulling the rug out from under people”.
His family is also affected. The loss of his wife’s subsidy means she is likely to pay about US$1200 ($2090) or more each month, up from about US$500 in 2024, he said.
“I voted for Trump,” Reynolds said. “I didn’t expect this.”
More than half of enrolees live in Republican congressional districts, according to a report published last week by KFF, a health policy research organisation.
Enrolment in individual marketplace plans has more than doubled to 24.3 million people since 2020.
The subsidies have helped people in a handful of Republican-led states most.
In Florida, for instance, there are 10 congressional districts where at least 20% of the population is enrolled in a marketplace plan, according to KFF.
The top five congressional districts by marketplace enrolment are all in Florida, according to the report.
“As hard as it was for Republicans to try to weaken the ACA back in 2017, it’s even harder now as enrolment has grown, particularly in Republican states and districts,” said Larry Levitt, executive vice-president for health policy at KFF.
“In some ways, if Republicans had just left the ACA alone, it might still be unpopular. Every time Republicans try to weaken Obamacare, support for it solidifies.”
Many Americans initially held an unfavourable view of Obamacare because of how it upended the health system.
Its popularity spiked when Republicans made their first serious attempt to repeal it in 2017 during Trump’s first year in office.
More than 60% of Americans now hold a favourable view of the law, according to a health tracking poll from KFF.
Republicans have never voted to bolster Obamacare, instead vowing repeatedly to tear it down, making any concession to Democrats especially difficult.
Both Democrats and Republicans acknowledged when the law passed in 2010 that it would be extraordinarily difficult to repeal because Americans seldom approve of taking away an entitlement.
There has been similar outcry when politicians have tried to curb Social Security or Medicare spending - entitlements even Trump has previously been wary of targeting.
Highlighting the political peril, a Bill introduced by a small group of House Republicans in September would extend the subsidies for one year - enough to get through next year’s Midterm elections.
House Speaker Mike Johnson (R-Louisiana) and Senate Majority Leader John Thune (R-South Dakota) have acknowledged that some of their members are worried about the subsidies expiring.
In Florida, Georgia, Mississippi, and South Carolina, at least 10% of the population in all congressional districts is enrolled in a marketplace plan, according to KFF.
Those four states are among the 10 that did not expand Medicaid under Obamacare, making them more dependent on tax subsidies to help low-income Americans purchase affordable health insurance.
In heavily Hispanic Miami-Dade County, which Republicans flipped during last year’s presidential election for the first time in decades, Obamacare is popular.
Health insurance agencies have co-opted the blue-and-red Obama logo as part of their advertising.
Two House Republicans whose districts include the county, Carlos Gimenez and Maria Elvira Salazar, have signed on to the Bill that would extend subsidies.
Gimenez, in a statement, said the extension would mean “providing critical relief and ensuring millions of families can keep their coverage without facing massive cost increases”.
The community embraced the healthcare law - and the Covid-era subsidies - because local Republicans previously emphasised affordable access to healthcare over politics, said Karoline Mortensen, professor of health management and policy at the University of Miami Herbert Business School.
That reality may soon change as people shop for coverage next year or are alerted to steep price hikes, she said.
In Hialeah, a Republican stronghold that last year named a street after Trump, signs advertising Obamacare adorn bus benches, billboards and insurance agency cars.
At Braojos Insurance in Hialeah, owner Jose Luis Gonzalez said he is scrambling to inform clients that their rates will change.
Many are working-class Cuban Americans who might barely afford coverage without subsidies. Some have called him because they heard false rumours that Obamacare is ending completely.
One longtime client recently told Gonzalez that he wanted to cancel coverage for him and his wife because their plan may spike from no monthly payment to nearly US$200.
The man said he would simply go to Miami’s public hospital for care, under the mistaken belief it covers more than emergency services, Gonzalez said.
“I’m having to convince a lot of people that it’s important to have coverage,” Gonzalez said in Spanish.
Republicans included nearly US$1 trillion in cuts to federal Medicaid spending in their massive tax and spending Bill that is largely aimed at Obamacare’s Medicaid expansion.
The biggest health coverage losses come from imposing federal work requirements for adults aged between 19 and 64 - targeted only at the Obamacare Medicaid expansion population.
That includes those earning up to 138% of the federal poverty level - which amounts to US$21,597 for a single person and US$44,367 for a family-of-four.
The Obamacare individual marketplaces - and the tax credits to help make insurance more affordable - are meant to help those who are not eligible for Medicaid or who do not get health insurance through their jobs.
Ericka Cardoso, 39, a single mother from Hialeah Gardens, Florida, used to pay nearly US$300 a month for healthcare before she enrolled in Obamacare more than a decade ago.
Today, the therapist pays US$35 monthly for her and her son - an amount that may more than double if the enhanced subsidies expire.
Her savings help pay for her teenage son to participate in club soccer, an expense she might consider cutting if finances get too tight.
“It would be a step backward, not forward, for how people access healthcare,” Cardoso said of letting the subsidies expire.
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