In Florida, where Republican Governor Rick Scott has been an outspoken critic of Obamacare, the tax is projected to cost the state as much as $1.2 billion over a decade, Milliman said.

Seeking Options

“Unfortunately, if you have to pay a tax like this, it has to come out of something else,” Michelle Dahnke, a spokeswoman for the Florida Agency for Health Care Administration, said in a phone interview. “We may have to let something else go.”

Insurers should “pay their fair share,” said Ryan Carey, a spokesman for the Senate Finance Committee, whose Democratic majority helped write the Affordable Care Act’s tax provisions. He didn’t say whether states should be reimbursing the fee.

“From the very beginning, every group that stood to gain from 25 million newly insured Americans was going to pitch in and help make the law work,” Carey said in an e-mail. “That’s the way the law was designed, and it shouldn’t change now.”

WellPoint Inc., the insurer with the biggest Medicaid enrollment, defended the request on a conference call with analysts Jan. 29.

“The states are really understanding the need for a viable program required this fee to be passed on,” said Joseph Swedish, chief executive officer at Indianapolis-based WellPoint. “They understand the need for a sustainable Medicaid program, and this is part of sustainability”

2014 Profit

For some insurers, shifting the fee is “critical” for 2014 profit, said Carroll, the Stifel Nicolaus analyst. At about 2 percent of premiums, the tax is equal to the entire increase Medicaid insurers get in most years, he said. Because the levy isn’t deductible from corporate income taxes, its impact will be magnified, he said by telephone.

“It could absolutely be a big chunk of profits” for some insurers, Carroll said.