BOONEVILLE — The 66 percent of Owsley County that gets health coverage through Medicaid now must reconcile itself with the 70 percent that voted for Republican Governor-elect Matt Bevin, who pledged to cut the state's Medicaid program and close the state-run Kynect health insurance exchange.
Lisa Botner, 36, belongs to both camps. A Kynector — a state agent representing Kynect in the field — recently helped Botner sign up for a Wellcare Medicaid card for herself and her 7-year-old son. Without that, Botner said, she couldn't afford the regular doctor's visits and blood tests needed to keep her hyperthyroidism in check.
"If anything changed with our insurance to make it more expensive for us, that would be a big problem," Botner, a community college student, said Friday at the Owsley County Public Library, where she works. "Just with the blood tests, you're talking maybe $1,000 a year without insurance."
Yet two weeks earlier, despite his much-discussed plans to repeal Kynect and toughen eligibility requirements for Medicaid, she voted for Bevin.
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"I'm just a die-hard Republican," she said.
Owsley County Judge-Executive Cale Turner, a Democrat, said the election results didn't surprise him. His constituents wanted to express their opposition to Democratic President Barack Obama and what they perceive as "the liberal agenda" on social issues, Turner said.
"To be honest with you, a lot of folks in Owsley County went to the polls and voted against gay marriage and abortion, and as a result, I'm afraid they voted away their health insurance," Turner said. "Which was their right to do, I guess. But it's sad. Many people here signed up with Kynect, and it's helped them, it's been an absolute blessing."
The community's largest-circulation newspaper, the Three Forks Tradition in Beattyville, did not say much about Kynect ahead of the election. Instead, its editorials roasted Obama and Hillary Clinton, gay marriage, Islam, "liberal race peddlers," "liberal media," black criminals and "the radical Black Lives Matter movement."
"The people I talk to, health care wasn't even mentioned," said Gary Cornett, chairman of the Owsley County Republican Party. "In Southeast Kentucky, the social issues are important. We're a small, traditional, tight-knit community, and there are certain ways we do things."
The trend seemed to hold across the state. At Transylvania University, political scientist Andrea Malji said she has crunched state data and found a "99 percent confidence level" between the counties' Medicaid enrollment levels and their gubernatorial choices. The larger the Medicaid numbers, the more likely they were to back Bevin, she said. The lower the Medicaid numbers, the more likely they were to favor the Democratic nominee, Attorney General Jack Conway.
So Bevin — who said during the campaign that "the fact that we have one out of four people in this state on Medicaid is unsustainable" — racked up votes in rural, mostly poor counties where far more of the local population than that holds a Medicaid card. This was true even in traditional Democratic Party strongholds, such as Pike and Breathitt counties.
Malji, who is from Pulaski County, where Bevin captured 72 percent of the vote, said she heard people back home denounce "Obamacare" while thousands rushed to sign up with Kynect. They didn't seem to realize that Kynect, Kentucky's response to the federal Patient Protection and Affordable Care Act, is the same thing as Obamacare, she said.
"There's either voter disconnect here, where the people weren't thinking about or weren't aware of Bevin's stance on health care, or these counties just have higher levels of social conservatives who thought it was more important to vote on social issues," Malji said.
Owsley County, one of the nation's poorest places, neatly fit the trend. Nearly 1,000 of its 4,508 residents got health insurance after Democratic Gov. Steve Beshear established Kynect two years ago and expanded Medicaid to include people up to 138 percent of the poverty level, which is $16,105 a year for an individual.
Newly insured people started to visit the Owsley County Medical Clinic on the outskirts of Booneville. They desperately needed medical care. Even by Kentucky's lax standards, Owsley has high rates of obesity, smoking and poor nutrition, and as a result, greater than normal incidences of cancer, heart disease and diabetes. Some patients wept with relief as longtime ailments finally were treated, clinic officials said.
"Our doctors were telling us they were seeing people who had never had health care before, so they were pretty sick," said Teresa Fleming, chief financial officer at nonprofit Mountain Comprehensive Health Corp., which runs the clinic in Owsley and others in Perry, Harlan and Letcher counties.
Mountain Comprehensive Health's Eastern Kentucky clinics saw a 5.3 percent increase in patients in the first year after Beshear established Kynect and a 12.5 percent increase in visits. The number of "self-paid patients" — those without insurance, for whom the clinics usually had to swallow financial losses — dropped 9 percent as Kentuckians obtained coverage.
These changes brought enough revenue into the clinics to pay for "ambitious new services," such as dentistry and optometry, said chief executive officer Mike Caudill. The clinics also have launched a "Farmacy" program, where families get vouchers for fresh fruit and vegetables at local farmers markets.
Now, however, Caudill said he's watching closely to see what Bevin does after he takes office next month.
"I'm very concerned about any changes to the Affordable Care Act in Kentucky and how they would impact us," Caudill said. "During this past two years, we've been able to take some positive steps. I don't want us to lose that."
Bevin has tried to reassure people like Caudill, saying he will address the issue of insurance coverage in "a deliberate and thoughtful fashion" after "consulting with Kentucky's health care stakeholders." After Kynect is eliminated next year, he says, Kentuckians can buy insurance through the federal exchange, HealthCare.gov. As for Medicaid, his plans are still a work in progress, but he definitely expects Kentucky to spend less money.
There is plenty at stake. Roughly 500,000 of Kentucky's 4.4 million people obtained health insurance through Kynect, about 425,000 of them through Medicaid. Expanded Medicaid costs billions of dollars a year. Until now, the federal government paid for it. Starting in the next fiscal year, though, states that expanded their Medicaid programs are expected to pay a growing share of that tab, up to 10 percent by 2021.
"I do not intend to re-enroll people at the same level going forward," Bevin told reporters several days after his election. "There is not going to be a continuation of enrolling people at 138 percent of the poverty level. That is not going to happen."
Bevin says he wants Kentucky to ask the federal government for Medicaid waivers, as Indiana did, letting the state impose restrictions and costs on the people enrolled. In Indiana, Medicaid enrollees can be asked to pay a monthly premium of $3 to $25 a month, depending on their income, and co-pays for doctor's visits and other services. Enrollees who miss payments can be temporarily locked out of the program.
Nothing should be entirely free, Bevin says.
"Because in reality, it has been increasingly proven that if you have skin in the game, if you have a vested interest in the outcome, you are more likely to make wise decisions that ultimately effect your health. Studies have shown that people on Medicaid have worse health outcomes than people who have no insurance at all," Bevin said at a town hall forum in September.
Critics — including Beshear — say that transferring Kentuckians to the federal health exchange would mean a loss of state oversight, slower response time and the disappearance of the Kynectors who promote insurance plans in communities, to say nothing of wasting the $283 million in federal funds spent to establish Kynect just two years ago.
"It's inconceivable to me, why, just to make a partisan political statement, Kentucky would want to go backward and become the first state to decommission a successful exchange," Beshear said at a news conference Friday
Imposing costs and restrictions on Medicaid patients, as Indiana does, "could prevent low-income people from getting the care they need, making health problems costlier down the road and creating barriers to sustaining the health coverage gains Kentucky has made in recent years," the Berea-based Kentucky Center for Economic Policy wrote in a report this summer.
Back in Owsley County, Botner, the Medicaid recipient who voted for Bevin, said she wouldn't object to a little skin in the game — just not too much.
"I have always said I am willing to pay a little bit to keep these benefits," Botner said. "In order to keep health insurance for me and my son, I'd pay $20 a month if that's what they asked me. I'd pay $5 each time I went to the doctor. Of course, if you start to get up to $50 or $60 a month, in that range, that would be more than we could afford."