Miami: Where ACA Repeal Would Be Felt The Most

WASHINGTON | Perhaps nowhere in America would so many people be as personally affected by the Republican-led repeal of Obamacare than Miami.

Three congressional districts - all represented by Republicans - have among the highest number of Affordable Care Act enrollees in the country, posing a bit of a wrinkle as those House members followed their Senate colleagues and voted Friday to begin the process of dismantling the 2010 federal law that has extended health insurance to as many as 20 million Americans.

There are 96,300 people enrolled in the Florida district represented by Rep. Ileana Ros-Lehtinen, the highest number in the country, according to estimates by the Kaiser Family Foundation.

Her district is followed closely by Rep. Carlos Curbelo, whose southwest Miami-Dade and Monroe County district has 92,500 enrolled in the insurance marketplaces created by the Affordable Care Act.

Rep. Frederica Wilson, who opposes rescinding the law, has the third-greatest number at 94,100, followed by Rep. Mario Diaz-Balart, whose Hialeah to Naples district has 83,300 enrolled.

"These numbers should give them pause," said Mona Mangat, Florida-based board chairman of Doctors for America.

"These are not just numbers, they're people," said Mangat, an allergist in St. Petersburg. "These are people whose lives have been saved or changed because of the Affordable Care Act."

Eight out of 10 people in South Florida qualify for the ACA's advanced premium tax credit, a federal subsidy that pays an average of $324 per month toward their marketplace insurance, said Florence French, South Florida regional director for Enroll America.

With the subsidy, recipients pay only $75 per month or less for marketplace coverage, French said.

"It would be a really, really devastating blow to these people to go back to the way it was in 2013 when they had no insurance and they were going into the emergency room to see a doctor rather than being able to have a primary care physician," French said.

But will the high take-up rates cause Ros-Lehtinen, Diaz-Balart and Curbelo to reconsider their support for repeal?

"It certainly is something they're going to be considering,' said Cynthia Cox, associate director for health reform and private insurance at Kaiser. "Especially if they start hearing from people who could lose their coverage. It's clear they're not all Democrats."

States that didn't expand eligibility for Medicaid are most likely to have larger marketplace enrollments.

But South Florida also has a large potential market of people who don't get job-based coverage, Cox said. Marketplace enrollment volunteers in South Florida targeted these people and others in areas where uninsured rates were highest. Their efforts paid off.

In 2014 and 2015, Kaiser surveys found South Florida had the highest sign-up rates for marketplace-eligible individuals among states that use the federal marketplace; over 90 percent, Cox said.

All three Republicans voted for a budget resolution that instructs congressional committees to begin writing the legislative language to scrap President Barack Obama's signature law. The bill passed the House with a 227-198 vote. No Democrats voted in favor and nine Republicans, many who wanted a simultaneous repeal and replace, voted in opposition.

Ros-Lehtinen acknowledged that many in her district are worried about losing what she called the "positive aspects" of the law, including keeping children on their parents' insurance through 26 and covering pre-existing conditions.

But Ros-Lehtinen argued that Obamacare - which she has consistently voted to oppose - "has been in an unsustainable downward spiral" since it started. She said the program needs "extensive changes" to sustain it, including eliminating the individual and employer mandates, which Democrats argue are key to expanding care to people who can not afford insurance.

Ros-Lehtinen cited a plan authored by Rep. Pete Sessions, R-Texas, as a potential starting place.

But Democrats warn that Republicans, who have yet to coalesce around a replacement plan for Obamacare, are courting disaster in the insurance markets by looking to take apart the law. Democrats were planning a "Day of Action" on Saturday in various cities to mobilize grassroots opposition to the plan to roll back the act.

"While the Republicans may have an ideological opposition to the Affordable Care Act, they have to understand what it means in cost to their constituents' cost in benefits, cost in quality of service, cost in access and cost in dollars," said House Minority Leader Nancy Pelosi, D-Calif. "We're hoping that they will listen."

Diaz-Balart, who has also voted repeatedly to repeal the law, said he has been listening to his constituents and hears mostly complaints: Costs are increasing and doctors are increasingly unwilling to accept people with Obamacare, he said.

"You know why they come to see me? They come to see me when they have to actually go to a doctor," Diaz-Balart said. "The deductibles are exceedingly high and then they realize, 'Hey, this is a bit of a fraud.'"

He said tinkering around the edges, as Democrats have proposed, won't work: "This concept that bureaucrats in Washington know best for the American people's health needs, this central planning concept is failing one more time."

But Mangat said 15 percent to 20 percent of her patients have marketplace insurance "and these people are scared" about repeal taking their federal subsidies that help them afford coverage.

She said one patient, an asthma sufferer, asked her not to disclose the information in her medical file because she didn't want it listed as a "pre-existing condition."

The Affordable Care Act barred insurers from denying coverage for pre-existing conditions, but that provision could disappear with repeal.

President-elect Donald Trump has pressured his Republican colleagues to move quickly on gutting and replacing the law, but Diaz-Balart said he hopes for a legislative process that involves public hearings - something he accuses the Democrats of scuttling in their haste to impose Obamacare.

"It's going to take awhile, but I want to do it right," he said. And Republicans are aware of the political pitfalls, he said, contending that Republicans will ensure that current enrollees won't lose benefits.

Curbelo, who didn't vote for Trump and whose Democratic-leaning district re-elected him but also went for Hillary Clinton, is similarly nonplussed by the vote.

"We want something better for all of these people," said Curbelo, adding that his office fields complaints about rising costs and declining choices.

Curbelo was appointed last week to the influential House Ways and Means committee and said he plans to be engaged in writing legislation to replace the health care plan. He expected some replacement provisions could be enacted quickly and that no one would lose coverage because of the Republican repeal.

"This is our opportunity to offer Americans the health care system that we believe they deserve," Curbelo said.

Freddy Balsera, a Democratic political consultant who is close to Curbelo and supported his candidacy, noted that many in the district viewed Curbelo as a "moderate, willing to work across the aisle."

"He needs to be careful," Balsera said. "If he votes to end a program that so many thousands in South Florida depend on, he better be quick to offer a solution."

The area's strong enrollment numbers send a "very clear signal that people appreciate and benefit from their coverage," said Elizabeth Hagan, senior policy analyst at Families USA.

"Whether that sways votes is another question," she said.