What Kentucky is teaching us about Obamacare

The relative success of the new health care law in red-state Kentucky has been rhetorical gold for the Obama Administration. The president and his team regularly praise the Bluegrass State’s implementation, which has included a well-functioning website and high enrollment, with more than 200,000 now signed up there.

But a deeper look reveals both the promise and some of the challenges that exist for the health care law, even in one of the places where it is operating largely as conceived. Here’s what we are learning from Kentucky:

1. When encouraged to do so, Republicans are enrolling.

There is no national database of who in America has health insurance on any given day or year. So it’s very hard to determine exactly how many people did not have health insurance in 2013, but who do now because of Obamacare. And since newly-insured people are not required to provide much demographic information beyond where they live and their age, it’s also very difficult to tell if conservatives, who strongly opposed the law’s adoption, are enrolling. (This lack of data also makes it difficult to determine how many blacks or Latinos, two groups who were disproportionately uninsured before the law was signed, have enrolled in large numbers.)

In fact, there are signs that in states where Republican-controlled governments are strongly opposed to the law, enrollment has been slower. For example, Louisiana has a slightly larger population than Kentucky and a higher percentage of uninsured people. But according to data from the federal government, about 33,000 people have purchased private insurance plans (as opposed to getting Medicaid) over the last four months in Louisiana, compared to nearly 50,000 in Kentucky. Louisiana Gov. Bobby Jindal, a Republican, is a strong opponent of the law and has done little to encourage people in his state to enroll.

In Kentucky, where Democratic governor Steve Beshear is an Obamacare enthusiast, there is strong evidence Republicans are participating in the program. We can’t be certain without doing individual interviews, but here’s the data we do have: in some counties in rural, conservative Eastern Kentucky, there are more people who have enrolled in Medicaid over the last four months than voted for Obama in 2012.

For example, in Perry County, deep in Kentucky’s coal country, Obama earned 2,047 votes in 2012, about 20 percent of the county’s voters. According to state data, 2,287 people are newly enrolled in Medicaid since October.

In some counties in rural, conservative Eastern Kentucky, there are more people who have enrolled in Medicaid over the last four months than voted for Obama in 2012.

I took a recent trip to Perry County to check out my hunch that some of these 2,287 people voted for Mitt Romney. There, I met a number of Republicans who had a long list of reasons they don’t like President Obama, who they cast as an enemy of the coal industry, but wanted to enroll in the new insurance. And this was entirely voluntary for many of them: there is a requirement to buy insurance under the law, but that does not apply to people whose income is so low that they don’t have to file a federal income tax return.

“Before, I had to go to the free clinic and get services,” a woman named Tammy Clark told me in the waiting room of a hospital in Perry County. “Now, I can go to a real doctor. It’s a lot better.”

Clark, who is a housewife, said she had never had insurance before but liked the Medicaid benefits she gets now.

But Clark, who is a Republican, said she remained strongly opposed to President Obama.

“He promised change,” Clark said. “And I come from a long line of people who worked in coal mines. He destroyed the coal mines…If I had to think of one thing good about him, it’s the insurance.”

2. As Republicans feared, Medicaid enrollment is growing fast.

There are really two different Obamacare insurance programs: the new private health market created through the exchanges and the huge expansion of Medicaid under the law to basically all low-income adults.

Nationally, it’s difficult to tell exactly how well those programs are doing. So far, states and the federal government have released very imprecise data on enrollment. While federal officials say this data will improve over time, so far the Medicaid numbers lump both sets together:  those who just enrolled in the program with those who were already eligible for Medicaid but only signed up this year because of all the attention surrounding Obamacare. Obama administration officials have said 6 million people had been determined eligible for Medicaid in the last four months, but some studies have suggested only about a third of those people are getting insurance because of the health care law.

The successful roll-out of the law in Kentucky “has done nothing to move the needle” in the U.S. Senate race.

Kentucky officials told me the data they have released includes only newly-enrolled Medicaid recipients and Medicaid enrollment there is booming. About 80 percent of the estimated 230,000 people who have become covered under Obamacare in Kentucky are on Medicaid, compared to about one in five people who are in a new private insurance plan.

For conservatives, this is exactly what they feared. Since the Supreme Court ruled in 2012 that states could choose to opt out of the Medicaid expansion under the law if they wanted, 25 states, nearly all of which have GOP-controlled legislatures or Republican governors, have refused to expand Medicaid despite strong political pressure from the Obama administration. Fiscally, it’s a good deal for states, as the federal government is footing the bill for this Medicaid expansion, but many Republican lawmakers and voters are ideologically opposed to putting more people on a government-operated health care program like Medicaid.

The Kentucky numbers may reinforce their concerns, as a small increase in the number of people with private insurance has been accompanied by a huge bloc of people relying on the government for their insurance.

3. Policy success on Obamacare is not an automatic boon to the political prospects for Democratic candidates.

Kentucky has a nationally-acclaimed roll-out of the health care law, highlighted in the New York Times, the Washington Post and by Obama during his State of the Union address. Yet, Republican Sen. Mitch McConnell, running for re-election, constantly attacks the law and calls for its repeal.

On the other hand, Kentucky Secretary of State Alison Grimes, his Democratic opponent, does not mention the health care law on her website and almost never talks about it unless prompted by reporters. Her aides acknowledge she will campaign on less politically-risky issues, like raising the minimum wage.

The praise of Kentucky’s roll-out by Obama has done little to change impressions there about the law. Kentuckians were deeply skeptical of Obama and Obamacare before October and remain so. A recent poll in Kentucky showed a plurality of voters (49 percent) favored repealing Obamacare, compared to only 44 percent who oppose repeal. The president’s approval rating in Kentucky is 34 percent, significantly lower than his standing nationally, but about the same as he was in the Bluegrass State before the law went into effect.

Conservative voters in Eastern Kentucky who already have insurance through their jobs are wary of putting more people on Medicaid, arguing it will encourage people in the region who are currently jobless not to look for work.

The successful roll-out of the law in Kentucky “has done nothing to move the needle” in the U.S. Senate race, said Ryan Alessi, a longtime political reporter in the state who hosts a television program there called “Pure Politics.”

He added, “I think everyone knows that McConnell is opposed to it, and I think Grimes has tried to walk that line of saying there are problems with the Affordable Cart Act that need to be fixed, but the goal of getting more people covered is the right way to go.”

Polls show that the Medicaid expansion is actually the most popular part of the law, even in Kentucky. But even this is controversial. In interviews, conservative voters in Eastern Kentucky who already have insurance through their jobs are wary of putting more people on Medicaid, arguing it will encourage people in the region who are currently jobless not to look for work.

“Some people here think, ‘I don’t have to work, I’m going to get a check, like my mommy and daddy did,’” said Dennis Wagers, a school bus driver in Manchester, an eastern Kentucky town near Hazard.

“There are people who don’t work, but they could,” said Bridgett McWhorter, a teacher in this area.

Republican politicians in the state are aware of these anxieties. Both McConnell and Kentucky’s other Republican senator, Rand Paul, have repeatedly emphasized the high percentage of the newly-insured Medicaid recipients, looking to tap into the anti-big government leanings of voters here.

Overall, the early stages of the Kentucky experience suggest the health care law is dramatically expanding health insurance to low-income citizens, one of the law’s chief goals.

“You’ve got a lot of people who can’t access their coverage in the same way; they’re not in the same network as their doctor. This is having an extremely disruptive, negative impact on a lot of families and the governor running around touting Medicaid sign-ups is not going to change that,” said Josh Holmes, a top McConnell adviser.

Overall, the early stages of the Kentucky experience suggest the health care law is dramatically expanding health insurance to low-income citizens, one of the law’s chief goals. But the evidence is much less clear about its impact on people with higher incomes who don’t qualify for Medicaid.

And the political story bears close watching. If Democratic candidates like Grimes are distancing themselves from the health care law this early in the 2014 campaign cycle, they will face pressure later this year to propose changes to Obamacare that benefit them politically in the short term, but fundamentally alter the law in the long term.

I’m working on a project at New America to chronicle the law in states in the South, which have some of the highest percentages of uninsured people in the country, but also have been the most opposed to President Obama’s agenda, including the health care law. Please reach out to me on twitter @perrybaconjr, and see my reporting here at my New America page.

About the Author

Perry Bacon, Jr.
As a fellow with New America Perry Bacon, Jr. will explore the implementation of the Affordable Care Act in the American South. He is also currently a political editor for NBC’s theGrio.com and an on-air political analyst for MSNBC.