ACA signups spike in Florida as GOP-led Legislature resists Medicaid expansion

Millions of Florida families rely on the Affordable Care Act (ACA) for coverage as the state's leadership resists widening Medicaid's reach. But residents may soon be priced out of their coverage if congressional Republicans let Democratic-backed subsidies expire.

Why it matters: All of Florida's Republican congressional delegation opposed the enhanced subsidies. With many of them facing re-election in 2024 and the subsidies set to lapse in 2025, their constituents stand to lose the most if these enhancements aren't renewed.

By the numbers: Florida leads the nation in ACA plan enrollment — both in absolute numbers and as a percentage of its population, according to a recent Raymond James analysis. There are 3.2 million residents enrolled as of 2023, nearly 15% of the state's population.

• Enrollment in ACA across the U.S. increased by 43% from 2020 to 2023, as first reported by Axios Pro. Florida and Texas alone accounted for half the national increase, enrolling over 2.5 million.

Between the lines: Florida is among 10 states that haven't expanded Medicaid. That's left people who would've qualified for such coverage in expansion states to enroll in ACA plans — which for now offer expanded coverage options for those above the federal poverty level.

• Since April, Florida has removed over 600,000 people from Medicaid, according to data from KFF. Experts tell Axios that families who lost Medicaid coverage this year may qualify for marketplace subsidies.
• Subsidies are a "huge contributing factor" in Florida's spike in enrollment, says Jodi Ray, program director of Florida Covering Kids & Families, a USF-based initiative that helps families enroll in public insurance programs. "We saw people very surprised they could suddenly get coverage they could afford."

Yes, but: "For the expanded subsidies to continue, Congress needs to pass legislation. … We are skeptical this happens unless Democrats have complete control of the White House, House, and Senate after the 2024 elections," writes Raymond James analyst Chris Meekins.

What they're saying: "Tampa Bay has seen a significant and continued increase in the number of individuals migrating to our region, many in need of health insurance," Katie Roders Turner, executive director of the Family Healthcare Foundation, tells Axios. The foundation provides free assistance for Tampa Bay residents navigating health care options.

• "A lack of Medicaid expansion may contribute to the high rates of enrollment in the Health Insurance Marketplace and the high utilization of the ACA subsidies," she adds.

The intrigue: Republican state Rep. Joel Rudman — a family physician and ally of Gov. Ron DeSantis — says it's time Florida takes a serious look at expanding Medicaid. His position stands in contrast to staunch opposition from Florida's GOP-controlled Legislature.

• Florida Democrats tried and failed to advance Medicaid expansion when the Legislature convened for a special session earlier this month. Rudman voted against it, telling Axios they were "playing politics" by pushing the issue during a session on unrelated topics and, ultimately, "set Medicaid expansion back."
• Rudman says no Medicaid legislation will come from his desk in the next session, which begins in January. But he didn't rule out co-sponsoring a Democrat-led bill. "If someone comes to me with a good idea we could take to the people of Florida and make an honest argument, I'm all ears."

The bottom line: Affordable coverage for millions of Floridians could hinge on whether congressional Republicans renew enhanced ACA subsidies or their GOP counterparts in Tallahassee expand Medicaid.