Loss of ACA sub­si­dies poses risk for GOP

2016 con­tenders face ma­jor dilemma if high court guts Oba­macare

The Washington Post Sunday - - POLITICS & THE NATION - BY KATIE ZEZ­IMA AND LENA H. SUN katie.zez­ima@wash­post.com lena.sun@wash­post.com Niraj Chok­shi, Jose A. DelReal and Tom Ham­burger con­trib­uted to this re­port.

west mi­ami, fla. — Around the cor­ner from Sen. Marco Ru­bio’s house and a few miles from for­mer Florida gover­nor Jeb Bush’s, an in­sur­ance agency at a strip mall ad­ver­tises the Af­ford­able Care Act.

Ban­ners with a logo rem­i­nis­cent of the one Pres­i­dent Obama used dur­ing his cam­paign hang on the ex­te­rior of the Eli In­sur­ance Agency. An ad above a win­dow dis­play tout­ing trips to Punta Cana in the Do­mini­can Re­pub­lic says in Span­ish that Oba­macare could be avail­able for $0 a month. “Oba­macare $0 men­sual,” it reads. “Cen­tro de apli­ca­ciones aqui” — Ap­pli­ca­tion cen­ter here!

Those signs may not last much longer. Depend­ing on how the Supreme Court rules in King v.

Bur­well this month, they might dis­ap­pear — re­placed by a ma­jor po­lit­i­cal dilemma for Eli In­sur­ance’s pres­i­den­tial-con­tender neigh­bors.

The press­ing prob­lem for the 2016 Repub­li­can field falls into the “dog catches car” cat­e­gory: It’s one thing to call for the Af­ford­able Care Act to be re­pealed or to prom­ise an Oval Of­fice sign­ing cer­e­mony for its re­peal. It’s another to en­dorse pulling in­sur­ance sub­si­dies used by more than 6 mil­lion peo­ple in 34 states, in­clud­ing at least 1.3 mil­lion Florida res­i­dents.

A rul­ing that sub­si­dies pro­vided to con­sumers to help them pur­chase health in­sur­ance are not le­gal could spark chaos in the in­sur­ance mar­ket­place and help shape the elec­toral land­scape in sev­eral key swing states. Be­yond those vot­ers di­rectly af­fected, many more could see their premi­ums in­crease if the law un­rav­els, driv­ing up the num­ber of unin­sured.

The ad­min­is­tra­tion has said it has no Plan B if the court rules against it. The sit­ting gover­nors and sen­a­tors in the GOP pres­i­den­tial field would be among those who need to im­ple­ment an emer­gency fix that helps peo­ple re­main in­sured. The rest of the can­di­dates would be called upon to of­fer pol­icy al­ter­na­tives. All of them would need to bal­ance de­mands that they sup­port an emer­gency restora­tion of ben­e­fits with the de­mands of a con­ser­va­tive base that wants to seize any op­por­tu­nity to gut Obama’s sig­na­ture do­mes­tic pol­icy achieve­ment.

“The pol­i­tics of this for Repub­li­cans are ex­tremely tricky and treach­er­ous, and most Repub­li­cans pri­vately would like to see the Supreme Court take a pass on this one,” said John Ul­lyot, a Repub­li­can strate­gist.

As the de­ci­sion date in the case edges closer, de­bate within the GOP has been split be­tween those who see a po­lit­i­cal op­por­tu­nity and those who see a loom­ing dis­as­ter. Repub­li­cans have been fu­ri­ously meet­ing on Capi­tol Hill this week to ham­mer out pro­pos­als as a court rul­ing looms.

The 2016 con­tenders cur­rently in Congress will be the ones “in the cru­cible,” he said — they will have to take votes or make pro­pos­als “that might not be as po­lit­i­cally pure as needed dur­ing a Repub­li­can pri­mary.”

On the other side of the spec­trum, the Demo­cratic pres­i­den­tial con­tenders lie in wait. “Hil­lary Clin­ton can im­me­di­ately pivot not to de­fend­ing the ACA,” said Repub­li­can strate­gist Rich Galen, but “can im­me­di­ately be­gin say­ing, ‘ The Repub­li­cans won’t fix this; I will’ — and I think that’s a big, big bow that the Repub­li­cans shouldn’t hand to her.”

Most of the ma­jor plans con­gres­sional Repub­li­cans and con­ser­va­tive think tanks have pro­posed to ad­dress a hy­po­thet­i­cal loss of sub­si­dies would of­fer some tem­po­rary re­lief — but only in ex­change for a re­peal of the re­quire­ment that most Amer­i­cans have in­sur­ance, the linch­pin of the law.

“Repub­li­cans need to unify around a spe­cific set of con­struc­tive, longer-term so­lu­tions and then turn the 2016 pres­i­den­tial elec­tion into a ref­er­en­dum on two com­pet­ing vi­sions of health care,” Sen. Ben Sasse (R-Neb.), who pro­posed one of the plans, wrote in the Wall Street Jour­nal in Fe­bru­ary.

Although most states are con­sid­er­ing their op­tions, even talk­ing about them pub­licly be­fore the de­ci­sion is risky.

“The Repub­li­can gover­nors have very lit­tle rea­son to put them­selves at po­lit­i­cal risk if they don’t have to,” said Caro­line Pear­son, a vice pres­i­dent at Avalere Health, a con­sult­ing firm.

Florida, home to Ru­bio and Bush, and Texas — home state of pres­i­den­tial can­di­dates Rick Perry, the state’s for­mer gover­nor, and GOP Sen. Ted Cruz — have the largest num­bers of peo­ple at risk.

Gracita Beause­jour, 62, of Mi­ra­mar, Fla., said she re­ceives more than $400 a month in sub­si­dies and pays $30 monthly for her pre­mium. She said she lost her job at a hos­pi­tal four years ago and has not been able to find work since; she re­ceives $590 a month in So­cial Se­cu­rity.

If she loses her sub­sidy as a re­sult of the court rul­ing, “I’m go­ing back to hav­ing no in­sur­ance again,” she said. Re­fer­ring to Repub­li­can law­mak­ers in Congress, she said: “Peo­ple who are higher don’t care for lower peo­ple.”

The rul­ing would land hard in a string of gen­eral elec­tion bat­tle­grounds, leav­ing next year’s GOP nom­i­nee po­ten­tially fac­ing hun­dreds of thou­sands of vot­ers who lost sub­si­dies in each of these states: North Carolina, Penn­syl­va­nia, Vir­ginia, Wis­con­sin, Ohio and In­di­ana. If the sub­si­dies do dis­ap­pear, premi­ums in those states are pro­jected to more than dou­ble, at a min­i­mum.

Cruz, who has said that his cam­paign is a “ref­er­en­dum on re­peal­ing Oba­macare,” signed a brief from mem­bers of Congress sup­port­ing the chal­lengers in the court case.

“The goal is to pro­vide an off-ramp for our peo­ple to es­cape this law with­out los­ing their in­sur­ance, and all con­ser­va­tives in Congress should work to­gether to­ward this goal,” Ru­bio wrote in a Fox News op-ed in March. He called for a re­fund­able tax credit peo­ple could use to pur­chase health in­sur­ance, re­form­ing in­sur­ance reg­u­la­tions and putting Medi­care and Med­i­caid on “fis­cally sus­tain­able” paths.

Cruz has a health care pol­icy team that is gam­ing out pos­si­ble out­comes at the Supreme Court, ac­cord­ing to an ad­viser.

“I don’t think the an­swer is to ex­tend the Oba­macare sub­si­dies,” Cruz said af­ter an event in Red Oak, Iowa.

If the court rules against the gov­ern­ment, Congress should step in and say, “This isn’t work­ing, let’s re­peal it and start over,” he said. “And at a min­i­mum, in the wake of King v. Bur­well, I be­lieve Congress should al­low states to opt out.”

The Texas Repub­li­can has said that health care re­form should in­clude be­ing able to pur­chase across state lines, ex­pand­ing health sav­ings ac­counts and un­link­ing in­sur­ance from em­ploy­ment.

In Wis­con­sin, where 166,142 peo­ple are re­ceiv­ing sub­si­dies, premi­ums could jump 252 per­cent, ac­cord­ing to a Kaiser Fam­ily Foun­da­tion anal­y­sis. Gov. Scott Walker (R) has said the so­lu­tion needs to come from Congress, not the states. In Ohio, where 161,011 peo­ple would lose their sub­si­dies, Gov. John Ka­sich (R) said the state would “have to fig­ure some­thing out” and has not ruled out cre­at­ing a state ex­change.

Bush men­tioned the Af­ford­able Care Act dur­ing his an­nounce­ment speech only in the con­text of a court case where an or­der of nuns chal­lenged the law be­cause of a man­date that re­quires em­ploy­ers to of­fer in­sur­ance plans that cover con­tra­cep­tives; he did not men­tion re­peal­ing it.

No where would a rul­ing against the law af­fect more peo­ple than in his home state of Florida, where premi­ums could sky­rocket by an av­er­age of 359 per­cent, ac­cord­ing to the Kaiser anal­y­sis. An Avalere anal­y­sis found that Florida res­i­dents would have to pay on av­er­age $3,500 more a year for their premi­ums.

Brian Bal­lard, a Repub­li­can lob­by­ist in Tal­la­has­see, noted that Ru­bio and Bush have been stead­fast in their op­po­si­tion to the Af­ford­able Care Act, some­thing that will help them with the con­ser­va­tive base.

“In a Repub­li­can pri­mary I would ar­gue that be­ing any­where around sup­port­ive of Oba­macare would be toxic to a can­di­date,” Bal­lard said. But he ac­knowl­edged that there would be con­se­quences.

“We’re go­ing to have what­ever back­lash there is from those peo­ple re­ceiv­ing the en­ti­tle­ment. There’s no doubt that’s go­ing to be there,” he said. “That’s go­ing to be built into the frame­work of the elec­tion.”

“The so­lu­tion is not to take away the Oba­macare,” said Maylin Portell, who works at the in­sur­ance agency, where photos of Cuba and a wooden carv­ing of the is­land hang on bright or­ange and yel­low walls. Portell said the agency has helped more than 300 peo­ple of all ages sign up for cov­er­age. There have been glitches, such as pa­per­work that needs to be re­pro­cessed. But it would be fi­nan­cially dev­as­tat­ing if con­sumers lost the sub­si­dies, she said.

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