Kentucky’s Obamacare debate might end in repeal under Trump

The debate over how Kentucky handles the Affordable Care Act might soon come to a swift end, along with the law itself.

President-elect Donald Trump and Republican congressional leaders say that repealing the federal health care law is one of the first items on their to-do list for early 2017. They’re supported by Kentucky Gov. Matt Bevin, who has eliminated the state’s health insurance exchange and asked the federal government for permission to impose premiums, benefits cuts and work requirements on its expanded Medicaid population.

“Obamacare is a disaster,” Bevin told WVLC-FM in Campbellsville Wednesday. “Well, guess what? The American people sent a powerful message last night. We have the presidency. We have the U.S. Senate. We have the U.S. Congress. We have states like ours and governors like myself that are saying enough of this. We’re rejecting it. We want it gone. It’s going to be gone.”

But if the law is eliminated, what happens to the estimated 22 million Americans — including roughly half a million in Kentucky — who would lose health coverage without it? And is there any point in Bevin pursuing incremental changes in the state’s expanded Medicaid program if the whole thing would disappear along with the rest of the health care law?

The short answer is, nobody knows yet.

“These are significant issues where the dynamics and the politics have completely changed as of Tuesday,” said state Senate Health and Welfare Committee chairwoman Julie Raque Adams, R-Louisville. “I’ve been trying to process it myself.”

For now, the Bevin administration says it will keep pressing the waiver request that would let it add restrictions to the expanded Medicaid program covering about 440,000 Kentuckians who live just above the poverty line. The federal government was expected to respond to the waiver next year.

“Until changes occur at the federal level, the Bevin administration will continue to work within the confines of federal law as written,” said Doug Hogan, spokesman for the Kentucky Cabinet for Health and Family Services. “To that end, the Bevin administration will continue to negotiate in good faith with the U.S. Department of Health and Human Services regarding the Kentucky HEALTH waiver. As changes take place on the national level to deal with the failed Obamacare experiment, we will respond accordingly.”

The Affordable Care Act established health insurance exchanges and tax subsidies to make it easier for Americans to buy private plans, and it allowed states to expand their Medicaid programs to cover the working poor with public benefits. It also set certain requirements for insurance, such as mandatory coverage for people with existing health problems.

Kentucky embraced the law enthusiastically under Democratic Gov. Steve Beshear, opening a state exchange called Kynect to sell individual plans and expanding Medicaid. The moves helped cut Kentucky’s uninsured rate to 6 percent of the population, one of the sharpest drops in the nation. But Bevin, a Republican elected a year ago, has criticized the Affordable Care Act, saying it will cost tens of billions of dollars the state cannot afford. Bevin shut down Kynect, redirecting Kentuckians this month to the federal exchange, HealthCare.gov.

Likewise, Republican leaders in Washington have called for an end to the law since it was enacted without their support six years ago. GOP majorities in the House and Senate approved a measure in January to effectively kill the law, including the Medicaid expansion, by defunding it over the next two years. (By making it a spending bill, which only requires 51 Senate votes, Republicans avoided the usual 60-vote hurdle necessary to overcome a threatened Democratic filibuster.)

President Obama vetoed that measure, saying it “would reverse the significant progress we have made in improving health care in America.” Trump, however, has promised to sign a repeal of the law after he takes office Jan. 20.

Not everyone wants the law to disappear. In Eastern Kentucky, new revenue generated by Affordable Care Act coverage has enabled Mountain Comprehensive Health Corp. to add dental, vision, behavioral health and nutrition services and create 80 jobs, said chief executive Mike Caudill. The nonprofit serves Letcher, Perry, Owsley, Harlan and Bell counties with freestanding and school-based clinics.

“The Affordable Care Act has allowed us to treat people who had a lot of deferred health problems and chronic diseases,” Caudill said. “We’re seeing good results from that. If the law is repealed and it is not replaced with something that provides comparable coverage to our patients, it will have a significant adverse impact on our patients, on us and on our communities. There will be a reversal in what we are able to provide.”

It will be important to see what, if anything, Trump proposes for the millions of Americans who previously lacked access to health insurance, said Ben Chandler, a former Democratic congressman from Central Kentucky who now heads the nonprofit Foundation for a Healthy Kentucky.

“It’s anybody’s guess what President Trump and a Republican Congress will do. Just repealing the Affordable Care Act is not a serious option unless they have something to replace it with. But we have to wonder what that something might be,” Chandler said. “Right now, we don’t have a clear picture.”

House Republicans have offered several ideas for health care, such as making flexible Medicaid block grants to the states and allowing insurance sales across state lines. During his campaign, Trump promoted greater use of tax-free Health Savings Accounts, and he said Americans should be able to import cheaper pharmaceutical drugs from other countries. But none of this has taken the form of legislation yet, Chandler noted.

The next few months should be interesting, he said.

“The reality on the ground is that Gov. Bevin won his election in Kentucky and Donald Trump has now won his election nationally. It is incumbent on the rest of us to work with them in any way that we can to see that whatever they propose will hopefully make our people healthier. And I’ve got to believe that they want that same result,” he said.

This story was originally published November 10, 2016 at 2:28 PM with the headline "Kentucky’s Obamacare debate might end in repeal under Trump."