ACA opponents boosted by Kentucky, Virginia elections

A year ago, President Barack Obama struggled to explain why so many white working-class Americans oppose his healthcare reform law, even those who benefit from it. He blamed the perception that the ACA mostly helps minority and poor people.

Kentucky, he said, “is one of the best states in using the Affordable Care Act to insure huge numbers of working-class white voters. It's just they don't call it Obamacare. They call it something else.”

But the law's success, along with Democrats rebranding it, wasn't enough to save Kentucky Attorney General Jack Conway from its unpopularity in the state's gubernatorial election last week. He stressed that the state's Medicaid expansion and the state-run Kynect exchange—which together extended coverage to more than half a million residents—were home-grown. Many Democrats called it Beshearcare, after the state's popular two-term Gov. Steve Beshear, who implemented both programs through executive order.

The coverage expansions cut Kentucky's uninsured rate in half to under 10%. Charity care at eight Kentucky hospital systems fell 38% in 2014, while uncollectable debt fell 12%, according to the Modern Healthcare Financial Database.

Nevertheless, in an election closely followed by the national media, Republican businessman Matt Bevin unexpectedly routed Conway to become the state's next governor. Bevin initially had promised to undo the Medicaid expansion, which accounted for 4 out of every 5 Kentuckians who received new coverage. He now plans to seek a waiver like Indiana's, halt new enrollment, and tighten income eligibility criteria. He also vowed to shut down Kynect and turn its functions over to the federal exchange.

That wasn't the only political drubbing Obamacare took Tuesday. GOP victories in Virginia's state legislative elections snuffed out Democratic Gov. Terry McAuliffe's hope of expanding Medicaid. “By holding onto the state Senate, Republicans have ensured that Medicaid expansion will not happen in Virginia in the near future,” said Geoffrey Skelley, a University of Virginia political analyst.

ACA supporters fear these election results will encourage Republicans to campaign aggressively against the law in the 2016 elections in the belief most voters have little sympathy for those newly covered. Polls show the general public remains about evenly divided on the law.

Last week's ballot results were a bitter pill for Obama and the Democrats, who had hoped the ACA would help them hold the White House and recapture the Senate in 2016. They had thought ACA provisions aimed at the general public—such as guaranteed coverage for those with pre-existing health conditions—would give them a powerful political boost.

But numerous polls and media interviews show even people eligible for ACA coverage don't always appreciate the law's benefits. “I don't love Obamacare,” Louisville resident Amanda Mayhew told the New York Times last year, even though she had been to the dentist five times to save her neglected teeth and gums after becoming eligible for Kentucky's expanded Medicaid program.

GOP strategists are already looking to capitalize on Bevin's victory. It “will embolden Republicans and give momentum to repealing and replacing Obamacare as a 2016 campaign issue,” said Bradley Blakeman, a GOP strategist and principal at the 1600 Group.

The next test of the public's mood will come on Nov. 21, when Louisiana voters choose between Democrat John Bel Edwards and Republican David Vitter for governor. Current Gov. Bobby Jindal, a GOP presidential candidate, has fiercely opposed the ACA and Medicaid expansion. Edwards says he would straightforwardly expand Medicaid, while Vitter says only that he would consider some form of expansion.

Bevin benefited from low turnout by lower-income people who gained most from the coverage expansion. ACA foes “were more likely to be activated and more likely to turn out,” said Glen Mays, a professor of health services at the University of Kentucky. Less than a third of registered voters cast ballots.

Last month's closure of the Kentucky Health Cooperative, a not-for-profit co-op plan created under the ACA, also may have helped Bevin, who said it demonstrated Obamacare's failure. The plan's shutdown means 51,000 Kentuckians must switch plans for 2016.

Given that Bevin's anti-Medicaid expansion stance softened during the campaign, reform advocates are now hoping much of the coverage expansion will remain in place once he takes office. “Kentucky's Medicaid expansion has been popular,” said Nicole Huberfeld, a law professor at the University of Kentucky. “I would be surprised if he undoes all of the work that the Beshear administration has performed so well.”