These Miami cities love Trump — and lead the U.S. in Obamacare enrollment. Here’s why

By Michelle Marchante and Alyssa Johnson

On January 12, 2024

No community in the country would be more affected by former President Donald Trump’s call to repeal and replace Obamacare than the neighborhoods surrounding his Miami-Dade golf resort — where support for the former president ballooned in the years after he tried to repeal the Affordable Care Act.

Last year, the zip code that includes Trump National Doral Miami topped the nation in Obamacare marketplace enrollees. Second in the nation: the zip code in Hialeah where thousands gathered in November to cheer on Trump’s campaign to reclaim the White House.

Nearly 14 years after it became law, the Affordable Care Act — labeled by conservatives during its inception as “Obamacare” and big government run amok — is more popular in Miami-Dade County than anywhere else in the country. Last year, nearly three-quarters of a million people enrolled in the health care marketplace in Miami-Dade, and the numbers are expected to grow in 2024, with enrollment for the new year open through Tuesday, Jan. 16.

The program’s ubiquity here is something of a curiosity. When Obamacare emerged in 2010, Republicans said the Affordable Care Act and its now-defunct mandate that every person carry health insurance was tantamount to socialism, an attack that appeared to resonate in the Miami area, where hundreds of thousands of Hispanic voters settled after fleeing nations governed by leftist regimes. And yet, it’s Hialeah, where some three in four residents are Cuban, and Doral, known as “Doralzuela” because of its Venezuelan expats, that lead the nation in enrollment numbers.

But even as voters in those communities lurch to the right and the race for the Republican presidential nomination picks up, the popularity of Obamacare and Trump — the GOP frontrunner, who says he’s “seriously looking at alternatives” for health care coverage — appear to be enduring.

“If you look at the trends of voting in Miami-Dade County, and specifically in those cities from 2016 to 2020, they become more and more Republican and Obamacare plans become more popular,” said Mike Hernandez, a political analyst for NBC and Telemundo. “It is in fact quite confusing because they’re not linear in their thinking when it comes to health insurance and their politics.”

Experts and consumers say the prevalence of Obamacare in South Florida is due to a “uniquely Miami” set of circumstances, including its economy, high immigrant population and a highly efficient funnel of advertising, word-of-mouth and non-profit organizations steering new consumers to Obamacare.

Plus, Obamacare — which isn’t a public health insurer but rather a government-run marketplace for health insurance — isn’t nearly as polarizing as politicians make it out to be. And the demand for the program is undeniable.

Last year, 746,987 Miami-Dade residents enrolled in the marketplace, helping to make Florida the top state in the nation for marketplace enrollments, a place the state is likely to hold onto in 2024.

On Wednesday, the Centers for Medicare and Medicaid Services released updated enrollment numbers for this year, showing that the country has already hit a record, with more than 20 million people signing up for a health plan through the marketplace since open enrollment launched on Nov. 1. Florida is leading the pack, with more than 4 million people signing up for health insurance under ACA, an increase of about 25% from 2023. County-level data is not available yet.

Florida typically has some of the highest percentages of enrollment among people eligible for health insurance through the marketplace, said Cynthia Cox, a vice president at KFF, a non-profit that specializes in health policy research. “Even though we don’t have a 2024 estimate, I would not be surprised at all if Florida is still among the top states,” said Cox

WHY DO DORAL, HIALEAH HAVE SO MANY OBAMACARE ENROLLEES?

The Affordable Care Act, passed in 2010, required insurers to provide coverage to people with pre-existing conditions without charging them more and created a government-run insurance marketplace, with the goal to make affordable health insurance available to more people through the creation of tax credit subsidies. The law also gave states the ability to expand Medicaid to cover more adults with income below the federal poverty level, though Florida is among 10 states that have chosen not to do that.

Health policy experts, health insurance navigators, nonprofit executives and political scientists who spoke with the Miami Herald say there are several reasons why Miami-Dade has led the U.S. in Obamacare enrollments:

• There are robust and effective outreach efforts, including in Spanish and Creole, by registered and licensed agents, brokers, insurance companies, health providers, nonprofits and the federal government. Word-of-mouth between friends, families and colleagues is also key.
• Florida’s decision to not expand Medicaid through the Affordable Care Act, along with the Medicaid disenrollment that is currently occurring in the state following the end of the national COVID-related health emergency, leads many to Obamacare.
• Small businesses, which often don’t offer health insurance for employees, make up the majority of the workforce in Miami-Dade’s service-driven economy, including in areas where Obamacare is most popular. About 77% of Miami-Dade’s more than 260,000 businesses have fewer than 4 employees, according to the Miami-Dade Beacon Council. Only about a quarter of small businesses in Florida offer some form of health insurance, according to a 2022 survey by the agency for Healthcare Research and Quality, which is part of the U.S. Department of Health and Human Services.

In Doral and Hialeah, where Obamacare enrollment is highest, the number of small businesses is even more pronounced. The Beacon Council, which defines small businesses as those with fewer than 50 employees, reports that about 98% of the businesses in Doral and about 99% of the businesses in Hialeah fit the definition.

Before the new year, the center had already surpassed last year’s 638 new Obamacare enrollments and expected to enroll more people before open enrollment ends in Florida on Jan. 16.

For Franklin Orozco, 58, it was a radio ad, along with the recommendation from his roommate’s colleague, that led him to visit the Florida Blue Center in Hialeah to ask if he was eligible for any type of health insurance. His Florida Blue agent helped enroll him in Obamacare.

Orozco, who moved to South Florida 30 years ago from Colombia and is a naturalized citizen, said it will be the first time in a decade that he’ll have health insurance. His current job doesn’t offer it, he said. Now that he’s older, Orozco, 58, said he wants to make sure he can visit doctors and get care when needed.

“I feel secure having insurance,” Orozco said in Spanish.

In Hialeah and Doral, there are “two uniquely Miami things” that have helped increase Obamacare enrollment, said Dr. Olveen Carrasquillo, an expert on the Affordable Care Act at the University of Miami Miller School of Medicine.

“At the macro level, many of these small businesses don’t offer health insurance for people — for their employees,” said Carrasquillo. He also cited “very successful grassroots efforts to get people enrolled, but also people themselves spreading the word.”

Some of the players involved in enrolling people into Obamacare — like brokers and insurance agents — receive compensation, which according to the Centers for Medicare and Medicaid Services can include commissions and fees. But various nonprofit organizations, some enlisting federally paid workers called Navigators, also help inform people on their healthcare options and get them enrolled into Obamacare.

That’s what led Roxana Azuaje, 42, to enroll in an Obamacare plan for the second time in her life.

After being laid off from her job and going a year without health care, the photographer, who came to South Florida from Venezuela in 2002 and is a naturalized citizen, enrolled in December with the help of a nonprofit called Catalyst Miami, which offers free appointments with certified counselors to find health insurance as part of its mission to improve equity in the community.

“Accessing good healthcare benefits even when you have an employer can be hard sometimes, like if you want to include your family. It’s very expensive,” said Azuaje. “So this past year, it was very uncomfortable to not have health insurance. I had some health concerns that I had to wait on.”

Outreach and education efforts have been critical in bolstering health care coverage under Obamacare.

The federal government pours money into national multi-language campaigns and provides funding to select organizations to help promote and educate people on how to enroll in Obamacare online, by phone or in-person. Often, hospitals and community health centers can also help patients learn about the different health options available to them. It’s not uncommon to see enrollment booths in front of supermarkets, stores and in shopping centers during open enrollment.

In Miami-Dade, where more than half the population was born in another country, many immigrants are eligible to enroll in a health plan through the marketplace. Under the law, U.S. citizens, nationals and others who are lawfully present in the country and are not incarcerated in jail or prison can sign up for a health plan through the marketplace. This includes residents, asylees, refugees and those with temporary protected status, though some additional criteria may apply.

Venezuelans like Azuaje, especially newer arrivals, are specifically targeted by campaigns to enroll people in Obamacare plans, said Eduardo Gamarra, a political science professor at Florida International University.

“Venezuelans are really a very large group and they’re facing an enormous problem because the ones who are arriving are not as wealthy as the ones who came in the early part of the century, or even five, six years ago, and they have no health care,” he said. “Those are the groups that are being courted by these insurance brokers — by these Obamacare brokers.”

Scott Darius, executive director of Florida Voices for Health, said that another reason why the Doral and Hialeah zip codes may have high enrollment numbers could be because those who come from places like Cuba and Venezuela are already familiar with some kind of universal healthcare.

REPEAL OR IMPROVE? In Miami-Dade, Trump’s mission to rid the U.S. of Obamacare sticks out amid a sea of campaigns and efforts to get people into the marketplace.

Trump, who held an anti-Obamacare event outside Trump National Doral Miami days before the 2016 election, tried to replace Obamacare during his time in office and failed, though Republicans eliminated penalties under the Affordable Care Act for people without health insurance. Even so, from 2016 to 2020, Trump won dramatic increases in support in Miami-Dade County, and in Hialeah and Doral, specifically.

Now the favorite to win the GOP nomination for 2024, Trump said he’s committed to finishing the job, saying in November on the social media site Truth Social “we should never give up!”

Trump’s frustrations with Obamacare might have sympathetic ears from some in the marketplace in Miami-Dade County. Freddie Sufran, 53, is grateful that he has health insurance under the Affordable Care Act, but he wishes his health plan was better. The South Miami-Dade cargo driver has had insurance under the ACA for two years, but getting care isn’t easy, he said.

He’s struggled to schedule appointments with doctors and, most recently, has had issues getting a referral for a specialist, he said. He’s tried different Obamacare plans to see if things would improve.

But there’s “always a roadblock” in getting care, Sufran said.

U.S. Rep. Mario Diaz-Balart, the congressman who represents both Doral and Hialeah, said in a statement that, since it was created, Obamacare “has been nothing more than a government takeover of healthcare that has taken our country down the path of bankruptcy by increasing the costs of premiums, killing jobs, and raising taxes on small businesses.”

Opposition to the Affordable Care Act isn’t unanimous among Miami Republicans. U.S. Rep. Carlos Gimenez told the Miami Herald he’d prefer to improve Obamacare rather than repeal it, and U.S. Rep. Maria Elvira Salazar expressed similar sentiments during the 2020 campaign in which she won her Miami-area seat.

Consumers who spoke to the Miami Herald said they aren’t interested in the politics of Obamacare — just functional health care.

“I’m thinking about the services I need … What benefits me and my family,” said Azuaje, a Democrat.

Gamarra, the FIU professor, said that voters’ perception of Obamacare has changed over the years. While some may have viewed it as communist or socialist at its inception, he believes it’s now seen with the same level of normalcy as Social Security, which was also once viewed as radical.

“Our great representative from South Florida, Claude Pepper, he was one of the ones who introduced Social Security and he was called ‘red pepper’ because Social Security was perceived as a communist program … There is no serious Republican now that would consider running on abolishing Social Security,” said Gamarra.

And while Miami-Dade has gone from deep-blue bastion to Republican-friendly, with the county in 2022 supporting Republican Gov. Ron DeSantis — like Trump a presidential candidate who wants to repeal Obamacare — Gamarra said health care doesn’t appear to be one of the issues pushing Hispanic voters to the right.

Gamarra said that based on his research, which includes the 2023 Annual Hispanic Public Opinion Survey, he believes that immigration and foreign policy are two topics that the Republican Party has successfully used to win over more Latinos.

“It’s all political,” said Sufran, one of the Obamacare consumers the Herald spoke with, about the debate over health insurance that arises during election season. Sufran declined to say whether he identified with a political party. “We just need people to really listen to the community.”

WHAT THE FUTURE OF HEALTH COVERAGE LOOKS LIKE IN FLORIDA

While the future of the Affordable Care Act is unknown, the dynamics playing out in Florida’s safety net health program is expected to push more people onto Obamacare. Florida is checking people’s Medicaid eligibility again now that the federal COVID emergency that automatically re-enrolled people in the health insurance program is over. So far, more than half a million Floridians have already lost their Medicaid.

Others are expected to fall into the Medicaid access gap, in which their incomes are too high for Medicaid eligibility but too low for the Obamacare marketplace. Florida’s leaders in the state Legislature have once again made clear that they do not intend to expand Medicaid access.

At the Doris Ison Health Center just off Florida’s Turnpike in South Miami-Dade, officials are concerned about the number of people who will fall into the Medicaid access gap.

“There were a lot of families, individuals and families that got on Medicaid and stayed on Medicaid during the public health emergency,” said Peter Wood, the vice president for planning and government affairs at Community Health of South Florida, which operates the Doris Ison Health Center. “And then when those folks are having to re-enroll, many of them are falling off, and the level of their healthcare access is definitely going to drop particularly as it relates to access to specialty care and hospitalization.”

Predominantly Spanish-speaking clientele without health insurance are a common sight at the center, located at 10300 SW 216th St. The flagship and largest health center of the Community Health of South Florida, the Doris Ison Health Center serves as a one-stop shop of care for its patients and offers a variety of services, including primary care, pediatric, urgent care, cardiology, behavioral health and women’s services.

About half of its patients don’t have insurance, and about 35% of its insured patients have health coverage under Obamacare, said Wood.

Carrasquillo, the UM health policy expert, also expects more people will turn to Obamacare following the disenrollment of millions of Floridians from Medicaid, a health insurance program run jointly by the federal government and the states. He thinks Florida’s best move to improve health care would be to expand Medicaid, but said there are cost issues with Obamacare that the federal government could improve.

“Having Obamacare is a lot better than not having Obamacare, but it still has challenges and it still has issues,” said Carrasquillo.

Hernandez, the Telemundo analyst, expects the Affordable Care Act to remain as popular as ever, regardless of what happens in the November election.

“Most voters — red, blue or in between — are pragmatic … Even if they’re going to vote for President Trump, I believe millions of them, especially in Florida, are hoping that Obamacare either stays the same or is improved somehow,” he said. “And I seriously doubt that President Trump even being reelected could overturn it.”

This piece was republished from the Miami Herald.