2016 GOP contenders face major political dilemma in health-care ruling

WEST MIAMI, Fla. — Around the corner from Sen. Marco Rubio’s house and a few miles from former Florida Gov. Jeb Bush’s, an insurance agency at a strip mall advertises the Affordable Care Act.

Banners with a logo reminiscent of the one President Barack 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 health care 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 may 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Republican field falls into the “dog catches car” category: It’s one thing to call for the Affordable Care Act to be repealed or to promise an Oval Office signing ceremony for its repeal.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.

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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.

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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.

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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 Sen. Ted Cruz, R-Texas, — have the largest numbers of people at risk.

Gracita Beausejour, 62, of Miramar, Florida, 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, a Republican, has said the solution needs to come from Congress, not the states. In Ohio, where 161,011 people would lose their subsidies, Republican Gov. John Kasich 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 it requires employers to offer insurance plans that cover contraceptives; he did not mention repealing it.

Nowhere 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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Washington Post staff writers Niraj Chokshi, Jose A. DelReal and Tom Hamburger contributed to this report.