Carolyn Bouchard, a diabetic with a slowly healing shoulder fracture, hurried to see her doctor after Matt Bevin was elected governor this month.
Bouchard, 60, said she was sick of politics and had not bothered voting. But she knew enough about Bevin, a conservative Republican who rails against the Affordable Care Act, to be nervous about the Medicaid coverage she gained under the law last year.
“I thought, ‘Before my insurance changes, I’d better go in,’” she said as she waited at Family Health Centers, a community clinic here.
Over the past few years, Kentucky captured the nation’s attention as the only Southern state to wholly embrace the health care law, most significantly by expanding Medicaid in 2014 to cover an additional 425,000 people so far. Now, with Bevin promising to “repeal the expansion as it currently exists,” Kentucky may become a laboratory for the kind of rollback the law’s opponents have so far only dreamed of.
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Nationally, both parties saw the governor’s race as a crucial political test for the Affordable Care Act months after it survived a second major challenge before the Supreme Court.
Republicans were elated by Bevin’s sound defeat of Jack Conway, the state’s Democratic attorney general, seeing it as a blatant rejection of the health law and proof that it remains a giant liability for Democrats heading into 2016. Bevin won all but a few counties, including those with the largest percentage of residents on Medicaid.
For Democrats, Conway’s loss illustrated the challenges they may face motivating voters in next year’s presidential and congressional races, not least those the health law is helping. Low-income people, the beneficiaries of the expanded Medicaid program, are the least likely to vote, research has found. And the turnout this month in Kentucky, one of the poorest states, was particularly low: 31 percent.
The stakes for the new Medicaid beneficiaries — 10 percent of the state’s population — were on vivid display as patients churned in and out of exam rooms at Family Health Centers this month. Finus Jefferson, 56, had new coverage that allowed him to get a CT scan the previous week when he experienced shortness of breath; Candace Rivera, 20, used her insurance to have a painful growth surgically removed last spring; and Jonathan Osborne, 36, left with a referral to a spine specialist who would not have seen him had he still been uninsured.
Bevin has said all along that he would dismantle Kynect, the state’s successful insurance exchange where people shop for private coverage, and shift its customers to HealthCare.gov, the federal exchange serving 38 states. But his statements about Medicaid have shifted over time. Early in his campaign, he said he would reverse the Medicaid expansion completely. More recently, including in several interviews since Election Day, he has said he would seek federal permission to tighten eligibility for the program and impose more rules and costs on the expansion population.
Many patients at Family Health Centers said they had heard little about any of his health care plans. But with Bevin preparing to take office, they were starting to ask questions.
One state that may offer a view of their future is neighboring Indiana. There, Gov. Mike Pence, also a Republican, agreed to expand Medicaid to people earning up to 138 percent of the poverty level, but only after winning federal permission to impose requirements on recipients that go well beyond the program’s normal rules.
Most significant, Indiana requires enrollees with incomes above the poverty level to make monthly payments, averaging about $11, toward their coverage. If they stop making these payments, they can lose dental and vision coverage or even be dropped from Medicaid temporarily.
For now, Kentuckians on Medicaid owe nothing for their coverage except minimal co-payments, typically $1 to $4, for certain drugs and services. But Bevin has repeatedly pointed to Indiana as an example of how Medicaid should work.
Jefferson, who works temporary jobs for minimum wage and has fallen into homelessness twice over the last two years, said his ability to pay would depend on how much work he could find and whether his chronic pain from working as a mover when he was younger would get in the way. He said he might be able to afford $30 a month.
“When I do find work, you’re talking roughly 50-some dollars a day,” Jefferson said. “But maybe, maybe I could do it.”
Osborne, who suffers from chronic pain from a series of on-the-job falls, said he had not worked recently because of a diagnosis of bladder cancer last year. But he had an offer from a boatbuilding company, and had come to ask for a doctor’s note attesting that he could perform the work. Medicaid, he said, had saved his life when he used it for kidney stones care last year and the doctor found bladder cancer.
“It didn’t cost me a dime — the specialists, the hospitals, the surgery,” he said. “And at the time — no money, no job, no nothing — I couldn’t ask for better.”
Although Bevin has softened his tone on the expanded Medicaid program, he has continued to say that the expansion as it stands now is unaffordable. The federal government is paying the full cost through next year, but Kentucky will have to start bearing a small share of it in 2017, growing to 10 percent by 2020.
The administration of his Democratic predecessor, Steven L. Beshear, has estimated that Kentucky’s cost of covering the new Medicaid enrollees will start at $74 million in 2017 and grow to $363 million by 2021. But Bevin has called those estimates, from a state-commissioned report by Deloitte Consulting, “nonsense.” He has also dismissed Deloitte’s finding that the expense of covering the new enrollees would be more than offset by the positive economic effects of expanding Medicaid.
For Bill Wagner, chief executive of Family Health Centers, Bevin’s election was “a blow to the gut.” The number of uninsured patients at the organization’s seven clinics had dropped to 17 percent, he said, from 51 percent in 2013.
While better than a complete repeal of the Medicaid expansion, the Indiana model might lead to financially fragile people losing coverage, Wagner said. Several studies have shown that charging premiums to Medicaid recipients leads to declines in enrollment.
While Bevin did not win Louisville, a Democratic stronghold, Conway did not win by nearly as big a margin here as Democrats usually do. William Benton, a Family Health Centers patient who voted for Conway, said he was not an inspiring candidate even for committed Democrats.
“A lot of people felt really justified not voting,” said Benton, a musician and part-time bakery worker who signed up for Medicaid this month to get help for his depression.
And in a state where approval of President Barack Obama hovers around 34 percent, enthusiasm for the health law is lacking even among some who stand to benefit from it. Rick Prario, 54, learned at Family Health Centers this month that he was eligible for Medicaid after losing his longtime job at a hardware store. But he was still furious about having to pay the law’s tax penalty for going uninsured in 2014, when he was still working.
“They could take Obamacare and get rid of it, and it would never bother me one bit,” said Prario, who had been skipping treatment for diabetes, high blood pressure and arthritis.
Prario, who did not vote in the election, said he hoped to qualify for disability soon because he saw it as a surer thing than Medicaid.
At another Family Health Centers clinic, Laura Miles, 49, was trying to sign up her husband for a subsidized private plan through Kentucky’s online insurance exchange, and hating the law more with each passing minute. Her problem was a glitch that barred her husband from getting premium subsidies because the law considers her employer-sponsored insurance affordable. But adding her husband, a salvage yard worker with debilitating headaches, to that plan would bring her portion of the cost to $650 a month — impossibly expensive, Miles said.
“It’s not fair, and it’s not right,” said Miles, a Democrat who voted for Bevin.
Such sentiments are familiar to Osborne. He said he knew a lot of people who despise the Affordable Care Act because they have to pay for their health insurance and resent people getting it for free. Having been on both sides, he has a different view.
“When I go back to work and have to pay something for my insurance, I won’t holler and pout about it,” he said. “I'll remember the time this government insurance saved my life.”