In 2008, while Democrats were declaring that the time was right for national health care reform, Marco Rubio, the speaker of the Florida House, had a ready response: Florida should build a market-based system that would help contain the cost of insurance and make it more available.

Rubio pushed his no-mandate health insurance exchange, dubbed Florida Health Choices, through the state Legislature that year. “It’s about competition, it’s about choice, and it’s about the marketplace,” he told The Palm Beach Post at the time.


Florida Health Choices, which finally opened last year, now covers 80 people.

Obamacare, which Rubio wants to repeal, covers 1.6 million in Florida alone. And 93 percent of them are subsidized.

Rubio started pushing his vision well before Barack Obama entered the White House and began work on what would become the Affordable Care Act. But by the time Florida Health Choices launched post-Obamacare, the response by Floridians was tepid. The newly declared GOP presidential candidate didn’t include it in his campaign’s vision for how to repeal and replace the federal law. Nor did he mention it in a recent Fox News op-ed headlined “My three part plan for the post-Obamacare era.”

By the Feb. 15 Obamacare enrollment deadline, Florida Health Choices had signed up 56 individuals, and as of the middle of this week it had gained 24 more, CEO Rose Naff said in an interview. The state has set aside $2.4 million for the exchange since 2008 — an initial $1.5 million infusion that year and $900,000 in 2013.

Rubio spokeswoman Brooke Sammon said the senator continues to support a “true free-market exchange,” and she blamed Obamacare’s subsidies for luring buyers away from Florida Health Choices.

“What’s in Obamacare is neither free-market or truly an exchange,” she said. “It is unfortunate that this disastrous health care law is impacting the Florida Health Choices program, which is exactly the kind of consumer-based health care solution Americans are looking for.”

But critics say the struggles of the Florida plan illustrate the vast hurdles that Rubio and other Republican presidential candidates would face in seeking to replace Obamacare with a market-oriented plan — their usual answer to how they would cover the millions of people now insured under the Affordable Care Act. The Florida plan may be voluntary. It may be an easy way to shop online, either for health insurance or smaller dental or vision policies. But it doesn’t subsidize low-income or middle-class families the way Obamacare does.

“It makes sense that he doesn’t talk about it right now,” Ron Pollack, executive director of Families USA, a consumer advocacy group that supports Obamacare, said of Rubio. Referring to the subsidies, Pollack added, “The notion of promoting coverage in a way that does not enable people to get one of the significant benefits of the Affordable Care Act … is really harmful and would cause millions of people to be far worse off than they are today.”

Florida’s Naff has a different perspective, saying, “I know the numbers seem small, but it’s been steady.” She added, “There is really no rational comparison between HealthCare.gov and Florida Health Choices. We’re not giving it away.”

Obamacare’s been big in Florida, which has signed up more people than any other state. And that happened even though Republican Gov. Rick Scott and the Legislature have refused to set up a state exchange that meets ACA requirements or expand Medicaid.

Rubio included Florida Health Choices in his 2006 book, “100 Innovative Ideas for Florida’s Future.” In the state Legislature, he clashed over it with then-Gov. Charlie Crist, who Rubio would go on to defeat in the 2010 Senate race. A report from Rubio’s office when he was Florida House speaker said his plan relied on “sound market principles” and “challenges the way health care is currently financed and purchased.”

Exchanges as a concept have garnered backing from Republicans for years. In Massachusetts, then-Gov. Mitt Romney built the state’s health care reform plan around exchanges in a system that was the precursor to Obamacare. Former Mississippi Gov. Haley Barbour pushed for his state to create an exchange before Obama was in the White House. Utah also had a version for small businesses.

But that backing of exchanges didn’t translate into support for Obamacare. To the contrary, conservatives saw the ACA exchanges as a corruption of their idea, too heavily regulated, too filled with mandates.

Rubio has long called for repeal of the Democrats’ health law, and he stressed that again as he formally announced his 2016 presidential run in Miami on Monday evening. He has also pitched broad outlines of a “replace” plan, drawing on ideas often floated by conservatives like letting people buy insurance across state lines. But his outline doesn’t make any mention of incorporating exchanges, even a slimmed-down version akin to Florida Health Choices.

In the Fox News op-ed, Rubio called for “advanceable, refundable tax credits that all Americans can use to purchase health insurance.” He also suggested he would target the current tax breaks for job-based insurance and set up high-risk pools to help people with costly pre-existing medical conditions get coverage.

Obamacare will almost certainly still be an issue in the 2016 campaign. But how it plays out five years after passage, and what kind of detail voters will be seeking from candidates, is not yet clear.

Jamie Burnett, a Republican strategist based in the crucial primary state of New Hampshire, said Obamacare will still resonate in the campaign, but health care will likely be talked about in the broader context of the economy rather than a singular battle cry.

State Sen. Aaron Bean, who played a large role in creating the Florida exchange. | AP Photo

“I think people will want to talk about where things stand today. Is this really what we should have done, and is there a better way to get at it while preserving some common things that people agree on?” Burnett said. If a Republican candidate doesn’t have a clear and compelling message for moving beyond the Affordable Care Act, he added, “I think that’s going to be very problematic for them and their candidacy.”

A Democratic nominee could potentially use the low enrollment figures from Florida Health Choices against Rubio should he secure the nomination, but the state-focused issue may not matter to most voters, Burnett said.

Other Republicans in Florida say they aren’t worried about the low enrollment figures.

“If I’m selling hamburgers, and across the street they’re selling hamburgers for free or subsidized, I know my outlook is not going to be as good,” said state Sen. Aaron Bean, who played a large role in creating the Florida exchange. “But who knows where [the ACA’s] going to end up.”

Ironically, some health care experts think the Rubio-envisioned state exchange could be Obamacare’s salvation in Florida if the Supreme Court rules against the Obama administration in King v. Burwell — which would result in 34 states, including Florida, being cut off from the law’s subsidies.

That would mean the subsidies could flow only through state exchanges. Florida Health Choices could pave the way for that state-run exchange, but not without some pretty big changes.

“It is a base state exchange that the state could work from or use as a rapid contracting vehicle,” said Cindy Gillespie, a senior managing director at McKenna Long & Aldridge who worked on the Massachusetts exchange. But Florida would need to pass legislation to make it fully compliant with the ACA, she said.

Some Florida lawmakers, like Bean, have no intention of doing that.

“This gives us our independence,” he said of the current program. “This is Florida’s version.”