Last week concluded the 2023 open enrollment period for the federal health insurance marketplace created by the Affordable Care Act (ACA). The program has been in place for more than 10 years, and last year, Florida was the state with the highest ACA enrollments in the country. In Miami-Dade, the state’s most populous county, the program is especially popular.
The New York Times recently reported on this “improbable” reality: that “Obamacare,” initially coined as a pejorative label, has become a key marketing tool for health insurance vendors in South Florida. Indeed, the logo is sprinkled across strip malls and storefronts, especially in Miami’s predominantly Latino neighborhoods.
It may seem surprising that Miami, of all places, should take such a liking to the program, given that the county has swung increasingly red. In the 2022 elections, residents voted overwhelmingly to elect Republicans to represent them at the local, state and national level. Republican leaders have condemned federally subsidized health insurance, appealing to Latino voters — who make up two-thirds of Miami-Dade’s population — with a message that likens liberal health policies to the “socialism” they left behind in their home countries.
But the history of health care in Miami tells a different story. In fact, recent studies have shown that Miami has long been at the forefront of changes that have sought to make American health care more affordable and accessible to diverse populations.
Take, for instance, another landmark health policy from 50 years ago: the Health Maintenance Organization Act of 1973, which created the HMO model to expand access while reducing health care spending. A health maintenance organization provided medical insurance and health services for a prepaid, fixed fee, focusing on integrated and preventive care.
At the time the policy was enacted, many people were wary of the implications that a prepayment structure would have on American medicine — which had long been based on the fee-for-service model. But Miami had shown that such a system could work.
In the 1960s, when hundreds of thousands of Cubans fled their country and came to Miami, the city’s existing health-care system had been unequipped or unwilling to absorb the newcomers’ basic health needs. So Cubans created their own systems of care.
In areas like Little Havana, there emerged the clínica, or as English-language media called it, the Cuban clinic. These private, unregulated storefronts offered affordable health insurance coverage and primary care through a system of prepaid care. At a typical clínica, an individual could subscribe to a plan of 24-hour, unlimited outpatient services for just $5 a month, and a family for $12 a month. For higher rates ranging from $24 to $28 a month, subscribers could also get insurance for hospital treatment.
These clínicas resembled the system of health care that had been popular in Cuba before the 1959 Revolution, where individuals and families similarly belonged to “quintas de salud.” Having originated in the 19th century as mutual aid societies for Spanish immigrants, by the mid-20th century they had developed into important health care establishments. There was el Centro Gallego, el Centro Asturiano and more — social clubs where members also received medical attention.
Along with the quintas’ financing structure and outpatient health services, this mingling of the social and the medical also came to Miami with the storefront clínica. It became part of why clínicas not only survived but flourished in Miami’s diverse medical marketplace. Patients commented on how they preferred their clínica to the American medical office or hospital, which they saw as cold, inaccessible and overly expensive. At clínicas, patients were seen by health providers who they often knew on a personal level — and who spoke to them in Spanish by default.
Yet, these unlicensed and unregulated storefronts were the bane of the mainstream American medical community. Doctors, including leaders of professional medical associations, attacked clínicas for hiring unlicensed Cuban physicians and providing what they called an inferior quality of care. Also disturbing was the challenge to the fee-for-service model, which helped fuel the rising costs of care but served doctors’ financial interests. The prepaid health system meant that doctors could not make more money by ordering more tests or doing more procedures, for example.
The organized medical community lobbied the Miami-Dade and Florida governments to shut down the unlicensed clinics, which they likened to a form of socialized health care. But the clínicas filled an important need in the community, serving hundreds of thousands of low- and middle-income Spanish-speaking residents. And so, neither policymakers, nor the medical community, could not simply do away with them.
Meanwhile in Washington, the rising costs of medical care were an urgent problem in need of federal action. Under the Nixon administration, a bipartisan coalition of policymakers and health planners devised a new HMO payment system. Among the places they looked for examples of how HMOs would work was Miami and the prepaid health system of the clínicas.
Thus, it’s not surprising that in Florida, the state’s first registered HMO was Clínica Asociación Cubana — a family-owned clínica in Miami, founded by Benjamin León.
Little by little, clínicas registered as HMOs, gaining the legal status that shielded them from the attacks of organized medicine and regulating bodies that threatened to shut them down.
Over time, however, many of these clínicas-turned-HMOs would be unable to keep up with the rising costs of medical care. Beginning in the 1980s, the rise of managed care made it more appealing for surviving clínica owners to shift their focus entirely to the Medicare population — rather than the working- and middle-class immigrant families they had once served — and join the managed care industry.
The trajectory of Clínica Asociación Cubana serves as a prime example. Benjamin León Jr. sold the family-owned business in 1991 and in 1996, he founded Leon Medical Centers, not an HMO but a Medicare Advantage health-care provider, that is, a Medicare-approved private company. Today, at seven different clinic locations, the health care corporation manages the care of more than 40,000 Medicare recipients in South Florida.
Much like the quinta of prerevolutionary Cuba, Leon offers not just medical care but also a vibrant social environment for elderly Latinos. Members congregate at the clinic’s coffee counter, where they can enjoy coffee and pastries and converse with others while waiting for their free transportation back home. While the corporation has made huge profits managing government health care funds, its model has also been acclaimed by health policy experts for its success in keeping patients relatively healthy, happy and out of hospitals.
Indeed, Obamacare isn’t the only government health program that South Florida’s increasingly right-leaning Latinos take advantage of. Medicare is extremely popular among the 65-and-older age group. In Florida, Miami-Dade has the highest Medicare enrollments in the state. And the rates have been climbing steadily over the last 10 years, especially as the population ages.
With such a thriving Medicare program in Miami-Dade, what seems more improbable is that a slogan like “Medicare-for-all” does not have widespread public support among its voters. In fact, today, Florida is one of a handful of states that has not even accepted federal Medicaid expansion, leaving billions of federal dollars on the table and nearly a million eligible Floridians without health insurance coverage. Elected officials in Florida have proved so successful at transforming the complex issue of affordable health care into the boogeyman of “socialism” that they overlook some of the most basic demands and needs of their voters.
Rather than attempting to translate “Medicare-for-all” in all kinds of ways that feed into a polarizing political discourse, our leaders might learn from the histories and on-the-ground realities of places like Miami, where the need — and desire — for health insurance transcends political allegiances.