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From Beshear to Bevin: The Rise and Fall of the ACA in

Ellen Baker Brown University

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Baker, Ellen, "From Beshear to Bevin: The Rise and Fall of the ACA in Kentucky" (2019). Annual Undergraduate Conference on Health and Society. 2. https://digitalcommons.providence.edu/auchs/2019/panel4/2

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5/1/2018

From Beshear to Bevin: The Rise and Fall of the ACA in Kentucky

On July 17, 2012, Kentucky issued 587,

“Relating to Establishment of the Kentucky Health Benefit Exchange,” in compliance with the

Affordable Care Act (ACA).1 In May 2013, Governor Beshear officially announced as the new state-based healthcare marketplace.2 Kynect achieved early success, as 413,410 people purchased private insurance or enrolled in through the portal during the first open enrollment period. 75% of these people were previously uninsured.3 Through the ACA, Beshear was also able to expand Medicaid to include those whose income is at or below 138% of the poverty line.4 This increased Medicaid enrollment in the state by 570,000 people by December

2015, a 94% increase.5 But in November of 2015, only two years after kynect’s launch,

Kentucky had a gubernatorial election. The winning candidate, , ran on a promise to dismantle kynect and eliminate or change the Medicaid expansion.6 He has since made good on both of these promises. But what issues did he have with the implementation of the ACA in

Kentucky, and why did people vote for a man who had sworn to turn back the seemingly successful changes of the past few years?

By all measures, kynect and other ACA related actions were extremely successful for

Kentucky. Before the ACA, Kentucky had an uninsured rate of 20.4%; by the end of 2015 it had fallen to 7.5%, significantly lower than the national average. The state was publically praised as a model for state-based ACA implementation, and even seemed to be working better than the federally run exchange.7 But despite national praise, kynect connected to “Obamacare,” an

1 unpopular concept in Kentucky,8 and Matt Bevin played upon this in in his campaign for the governorship. President Obama was wildly unpopular in Kentucky in 2015. His disapproval rating leading up to the 2015 gubernatorial election was close to 70%.9 The ties between kynect and the ACA also soured the state exchange in the minds of Kentucky voters, contributing to

Bevin’s large victory by a margin of 8.7 percentage points.10

After being sworn in as Governor on December 8, 2015, Matt Bevin immediately began work to dismantle kynect. And as of November 1, 2016, all Kentuckians who enrolled in private health insurance or Medicaid through kynect were forced to re-enroll using healthcare.gov or benefind.ky.gov, respectively.11 The Bevin administration launched the Benefind website on

February 29, 2016 in order to serve as a portal for accessing public benefits in Kentucky. But

Vickie Yates Brown Glisson, Bevin’s Secretary of Health and Family Services, said specifically at a press conference that the website “will not be advertised to inform the public of its existence.”12 This decision indicates that Bevin and his staff do not want more people signing up for public benefits. The decision to dismantle kynect was met with significant backlash from

Governor Beshear and other state health acdvocates,13 and approval rates were much higher than disapproval rates.14 This raises the question, who voted for Matt Bevin? Did they dislike kynect?

Did they dislike Obama? Or did they simply not know what Bevin planned to do once elected?

It took more time for Bevin to accomplish what he wanted to do with Medicaid. On

August 24, 2016, Governor Bevin submitted an application to the Centers for Medicaid and

Medicare Services (CMS) for a Section 1115 waiver.15 This waiver went through numerous periods of review and public comments, but the Trump administration finally approved it on

January 12, 2018.16 The waiver, known as Kentucky HEALTH (Helping to Engage and Achieve

Long Term Health), will be fully active in July of 2018.17 The waiver outlines many restrictions

2 to Medicaid and is a direct response to the expansion that Beshear authorized under the ACA.

The largest change is that a work requirement will now be instituted for Medicaid enrollees.

Beneficiaries between 19 and 64 must meet an 80-hour per month work quota in order to remain eligible for benefits.18 Exemptions are made for people with disabilities, pregnant women, and others who are unable to work, but this requirement is still likely to prevent many people from having consistent access to health insurance. The waiver will also eliminate “dental and vision coverage for the ‘able-bodied’ population but members would be allowed to earn points for such services through a ‘My Rewards’ program by volunteer work, attending classes or other activities.”19 In the application for the waiver, Matt Bevin estimated that 95,000 fewer people would be enrolled in Medicaid after five years of his new program.20

Making the situation more precarious for those who have gained insurance under the earlier Medicaid expansion, Governor Bevin threatened to revoke the Medicaid expansion implemented in 2012 if a court decision strikes down any portion of the Kentucky HEALTH waiver. His spokesperson, Woody Maglinger, said in early January that Bevin “has signed an executive order to terminate Kentucky’s Medicaid expansion in the event that a court decision prohibits one or more of the components of the Section 1115 waiver from being implemented.”21

The Governor’s threat caused great concern among important Kentucky officials.

Congressman , the only Democrat representing Kentucky in Washington, deeply criticized Bevin’s actions: “If the Bevin administration has made any errors or drafted this reckless Medicaid waiver in a way that doesn’t meet legal standards, they could redraft and resubmit the request. Instead, the governor will punish the more than a half million Kentuckians by entirely eliminating their health care coverage. It’s hard to imagine anything more spiteful and less rational than that.”22 The other five Republican Representatives from Kentucky agreed

3 with Bevin, seeing as they were in support of repealing the in 2017 (though

Congressman didn’t vote for one House Bill because he didn’t think it went far enough.)23 But Republican Senator Mitch McConnell has said that the state exchange in

Kentucky should be treated separately from “Obamacare.”24

This paper explores the implementation of the ACA in Kentucky and the changes that have been made under Governor Bevin. It describes the sentiment in Kentucky surrounding healthcare that led to Bevin’s election in 2015. Did people vote for Bevin because of his health care plans? Do voters think more about policy or ideology when they choose candidates? Does the state of Kentucky support the changes Governor Bevin has made? Will Bevin begin a new wave of Republican dominance in Kentucky, or will his decisions on health care contribute to a defeat in the 2019 gubernatorial election? Have we seen the true end of Democratic health reforms in the state of Kentucky?

Beshear: The Implementation of the ACA in Kentucky

The Affordable Care Act (ACA) was signed into law on March 23, 2010. One of its many actions was to require all states to either create their own Health Benefit Exchange or become part of the federal Health Benefit Exchange by January 1, 2014.25 In June 2010, Carrie Banahan, the Executive Director of Kentucky’s Office of Health Policy, excited by the opportunities the

ACA presented, began writing an application for a grant to begin ACA implementation in

Kentucky.26 On September 30, 2010, Kentucky received a $1 million grant from the federal government for the purposes of establishing a state health care exchange. Steve Beshear, the democratic at the time, was quick to begin research on how best to comply with this statute. On April 18, 2011, a letter was sent to 45 stakeholders (providers and insurers mostly) asking for feedback on how to proceed with the creation of the exchange. 15 out of the

4 18 people/companies who replied to the question “Should Kentucky design and operate its own exchange?” responded in the affirmative.27 This shows that from the start there was broad support in the healthcare industry for Kentucky creating its own marketplace. The comments and responses to the other questions in the survey also indicate widespread positivity among providers and insurance companies towards the implementation of the ACA in Kentucky.28

After receiving such state-oriented feedback from stakeholders, Beshear decided to move forward with the creation of a state-based health benefit exchange. Most Southern states went in a different direction, choosing to simply default to the federally facilitated healthcare.gov.29 But those other states did not have Democratic governors, and Beshear was not ready to let his power go to waste. However, with a Democratic majority in the state House of Representatives, but not in the state Senate,30 Beshear found a legislative approach to kynect to be quite challenging.

After the passage of the ACA, the Republican led Senate passed two bills that would have required the governor to obtain legislative approval before creating a state health exchange or expanding Medicaid, but the bills never passed in the House.31 A divided legislature made any kind of quick legislative approach impossible. This was an issue for Beshear, because the ACA required states receiving grants to have an exchange up and running by 2014.32

Many of the citizens of Kentucky also actively disapproved of the ACA. In 2012, 50% of

Kentuckians had an unfavorable opinion of the ACA, with only 34% having a favorable opinion.33 This demonstrates that creating a state exchange under the ACA would likely not have been a popular move for the legislature to make, and many of them would be running for re- election at some point. But Governor Beshear was in his second term, and would not be legally allowed to run for a third. This gave him a greater ability to make potentially unpopular decisions. So, on July 17, 2012, Beshear skirted around the legislature and issued Executive

5 Order 587, creating an “American Health Benefit Exchange” in the state of Kentucky. The order established that the Kentucky exchange would be a one-stop shop for small businesses and individuals, and would provide access to private insurance, Medicaid, the Kentucky Children’s

Health Insurance Program (KCHIP), and any other federal or state health care programs.34 And so, kynect was born, though it would not get its name until almost a year later.

On May 15, 2013, Governor Beshear officially launched kynect and introduced it to the state. He announced that the first open enrollment period would begin on October 1, 2013, and would last until March 31, 2014, with coverage starting as early as January 1, 2014.35 When

Beshear issued the executive order to create a state marketplace, he also created the Kentucky

Office of the Health Benefit Exchange (KHBE) to oversee its operations and execution.36 This office was funded by federal grants but meant to be self-sufficient by 2015. This is important to note, because the upkeep costs once federal money was removed would become one of Matt

Bevin’s greatest concerns with kynect, even though the exchange was, in fact, self-sustaining.37

When enrollment started in October, it was immediately successful. This is surely in some part due to the 622 “Kynectors” hired to work directly with Kentuckians on how to use the website to sign up for health care. Unlike the navigators who helped with healthcare.gov, the

Kynectors were able to enter people’s homes and create longer lasting relationships with customers.38 Beshear’s administration poured everything into making this program work. $60 million were spent on website construction and operations, $8.9 million allotted to these outreach workers, and many more millions were dedicated to “market research, heartwarming television spots, and eye-catching bus ads.”39It was important to Beshear that every single person in

Kentucky knew how to access health care. Information about kynect was distributed well to the people who needed it most: the uninsured. The 2013 Kentucky Health Issues Poll (KHIP) asked

6 people how much, if anything, they had heard about kynect. 24% of adults and 25% of the uninsured said they had heard a lot. 77% of Kentucky adults had heard at least a little about the marketplace. And 36% of uninsured people reported seeking more information about kynect.40

The resources Beshear used clearly helped reach the right people. His dedication to publicity likely contributed to the extreme early success of the kynect platform.

Only three days into the first enrollment period, 11,000 people had completed applications for health insurance through the kynect system, and nearly 5,000 had officially picked a plan and signed up for coverage.41 After the first enrollment period ended in March

2014, 413,410 people had either purchased private insurance or enrolled in a publically funded program through kynect. For three out of four of them, this was the first time they had health insurance. Out of these people, 82,795 chose private insurance and 330,615 enrolled in

Medicaid.42 This trend of the majority of residents using kynect to access Medicaid would later be used by Governor Bevin to criticize the Kentucky marketplace as redundant.

Kynect continued to increase health coverage in subsequent enrollment periods, until it was fully dismantled at the end of 2016. When it comes to private insurance, nearly 94,000 people were enrolled through kynect by the time it ended. This represents 38% of the potential marketplace, 43 a number that is pretty high given population size and could surely increase if given the time to attract more people. Enrollment in Medicaid grew by 570,000 in just two years under the kynect system.44 Kynect was a fully integrated online portal that allowed Kentucky residents to search all available public and private plans for the one that best suited them.

Customers could put in their information, find a plan, and apply for insurance, all in one sitting.

This was one of the key things that made the platform so accessible and so successful. For many,

7 it was seen as a better version of the federally run exchange. It will be interesting to explore why

Matt Bevin opted to shift operations over to the federal government’s healthcare.gov.

Though many Kentuckians opposed the ACA (calling it “Obamacare”), kynect was received rather positively. A poll conducted by the Kaiser Family Foundation and the New York

Times in April 2014 found that while 59% of Kentuckians polled disapproved of the way Obama was handling health care, 53% said the health insurance marketplace in Kentucky was working

“very well” or “somewhat well.” Only 23% of respondents said that kynect was working “not too well” or “not at all well.”45 This shows that kynect even managed to gain the support of people in the state who opposed Obama’s actions as President. The popularity of this exchange among

Kentuckians begs the question, why did the state, just a year later, elect a man who actively planned to eliminate this system? Are elections more about policy or ideology?

Kentucky’s health benefit exchange wasn’t just popular in the state, but it was also held up as a national example of excellent ACA implementation. compiled a slideshow in October 2013 titled, “Kentucky Is Ahead in Health Insurance Enrollment.” It includes several images of people signing up for insurance and many descriptions of how

Kentucky has pushed ahead of other states.46 On November 22, 2013, Fortune wrote an article about kynect called “One Health Exchange Success Story.” Kentucky was praised for being more successful than the federal health exchange (proportionally) and for beating out in number of enrollees much bigger states such as , Minnesota, and .47 Even Mitch

McConnell, one of Kentucky’s Republican Senators and the current Senate Majority Leader, in a campaign debate in 2014 voiced his support for kynect remaining active in Kentucky while still criticizing the ACA: “The best interest of the country would be achieved by pulling out

Obamacare, root and branch…Now, with regard to kynect, it’s a state exchange. They can

8 continue if they’d like to.”48 Animosity for the ACA remained in Kentucky, but kynect quickly became well respected and admired.

Governor Beshear accomplished his goals with the creation of kynect. The rate of uninsured people in Kentucky dropped from 20.4% to 7.5% in just two years. But this was also

Figure 1: Sonka, Joe. "Report: Kentucky's Uninsured Rate Drops to 7.5 Percent, Well below National Average." Insider Louisville. January 05, 2018. due in large part to the expansion of Medicaid that Beshear was able to institute through the

ACA. The ACA allowed states to expand Medicaid access to people at or below 138% of the federal poverty level (FPL) and in February 2012, Beshear announced that Kentucky would implement this expansion. In Kentucky, Medicaid and KCHIP had previously only been available to families with children at 200% of the FPL or below, adults with disabilities, and pregnant women.49 This expansion vastly increased the number of single people and couples without children eligible for Medicaid.

Significant research was done on this policy before instituting it. An analysis was conducted by the and Price Waterhouse Coopers. They found that expanding Medicaid would likely add $15.6 billion into the state’s economy over the next six

9 years and create 17,000 new jobs in the state, mostly in the healthcare industry.50 This expansion had a huge impact on enrollment in the state of Kentucky. In fact, as of December 2017, the number of people enrolled in Medicaid and KCHIP monthly has reached 1,272,976, a 110% increase from before the implementation of the ACA.51 Though viewed by many democrats as a great success, conservatives like Matt Bevin tend to see these numbers in a more negative light.

In his book, The Conservative Heart, Arthur Brooks illustrates this “difference in ideology with a great example:

“We have seen how the number of Americans on federal nutritional assistance (“food stamps”) has skyrocketed in recent years. Some look at those figures and see great success. They say, “Hey, look! We helped all these people! Isn’t that fantastic?” But conservatives in touch with their hearts will reply with incredulity: “We have sixty-some percent more people on food stamps five years after the end of the recession than we had at the beginning? That isn’t success. It is failure.”

Matt Bevin seems to take this more conservative approach when looking at the number of people we enroll in Medicaid.

Even with criticism from the right, there is no denying some of the amazing successes that Medicaid expansion in Kentucky has brought about. A study in the Journal of American

Medical Association compared Medicaid expansion in Kentucky and Arkansas to the lack of expansion in Texas and found huge improvements to health, access, and financial security.52

They found that Medicaid expansion led to a 39% increase in people reporting to be in excellent health and a 15% decrease in the number of people who have screened positive for depression.

They found that 21% more people had a personal physician, and they found a 64% decrease in the number of people relying on the emergency room for primary care. They also found a 33% decrease in the number of people having trouble paying medical bills and a 30% decrease in the number of people who skipped medications because they couldn’t afford them.53 This expansion also increased the use of preventative services in the state, with breast cancer screenings up

10 111%, dental services up 116%, and physical exams up 187%.54 For a state that was ranked 44th in the nation in 2012 on

“America’s Health Rankings,”55 this increased focus on health is a big step forward.

In addition to the positive effects that the Medicaid expansion had on Kentucky’s health, it also has had a significant impact on the state’s economy. In a 2015 op-ed by then Governor Steve Beshear, he stated, “The facts in Kentucky demonstrate that not only can states afford to expand Medicaid, but they also really can’t afford not to do it.”56 Backing up this claim,

Beshear cites an analysis conducted by Consulting Figure 2: Aron-Dine, Aviva. "ACA's Medicaid Expansion a Huge Success in Kentucky." Center on and the University of Louisville Budget and Policy Priorities. October 11, 2017.

Urban Studies Institute (a study which he says supports his previous prediction for expansion outcomes). The study found that in the first year of the expansion, more than 12,000 healthcare related jobs were created in Kentucky.57 From January 2013 to the time the op-ed was written in

August 2015, the unemployment rate in Kentucky also dropped by 37%, much larger than the

11 16% drop in , a neighboring state that chose not to expand Medicaid when Kentucky did.58 They also noted that Kentucky health providers received $1.16 billion in new Medicaid revenue during 2014, and they predicted that the expansion would have a $30 billion positive impact on Kentucky’s economy across the next eight years.59 Sadly, with the approval of Bevin’s

Section 1115 waiver, it seems we will never get to see this prediction pan out.

The Medicaid expansion was received well by the general public in Kentucky. The 2013

Kentucky Health Issues Poll (KHIP) found that 51% of Kentuckians strongly favored the

Medicaid expansion and 28% somewhat favored it. This means that 79% of Kentucky citizens favored the decision to expand Medicaid.60 And when asked “How important is it to you that

Kentucky Medicaid provides health care coverage to low-income individuals?” 87% of respondents said it was either “very important” or “somewhat important” to them.61 So how was

Matt Bevin able to win a gubernatorial election in Kentucky on an anti-Medicaid platform?

2015: Bevin Surprises Kentucky

Coming into the 2015 Kentucky gubernatorial election, the Democrats had a solid candidate in , the state Attorney General at the time, who had lost a Senate election to in 2010. But the Republican Party seemed to be torn between three candidates: Hal

Heiner, , and Matt Bevin. Heiner, a former member of the Louisville Metro

Council, had previously lost in the 2010 Louisville mayoral election to Democrat, Greg

Fischer.62 Comer was the Kentucky Agriculture Commissioner at the time (and is now a member of the United States House of Representatives from Kentucky’s First District). And Matt Bevin, a businessman originally from New Hampshire,63 rose to the scene in July of 2013 when he announced that he would challenge Senator Mitch McConnell in the Republican primary for the

2014 senatorial election.64 Even then he argued for the complete repeal of the ACA,65 but he was

12 handily defeated by McConnell in the primary, gaining 35.4% of the vote while McConnell received 60.2%.66

While all three candidates agreed about rolling back the Medicaid expansion in

Kentucky, Bevin was the most vocal about dismantling kynect and transitioning to the federally run exchange. In an interview with The Courier Journal in May of 2015, Bevin said “The

Medicaid expansion enacted under Obamacare is unaffordable for the taxpayers of Kentucky and should be repealed. This program is projected to cost Kentucky in excess of $150 million per year after 2016. ... I would facilitate the transition of enrollees onto the federal health care exchange during the open enrollment period in 2016 and then dismantle the kynect state exchange.”67 Comer seemed mostly concerned with the fact that 80% of people used kynect to enroll in Medicaid.68 And Heiner said that the Medicaid expansion was financially unsustainable,

“But it is important to remember that dismantling kynect alone will not have any budgetary impact. We need to bring accountability and personal responsibility into Medicaid to bring down costs.”69 It was clear the Bevin was the most concerned of the candidates about kynect in addition to Medicaid.

With the most conservative views and the least connections to the establishment, Bevin seemed unlikely to attain victory. Each candidate was found to be ahead by different polls leading up to the election. But polls conducted in the two weeks before the primary showed the three being almost tied. had Comer ahead with 28% of the vote, compared to Heiner with 27%, and Bevin with 25%.70 Survey USA found Bevin with 27%, Comer with

26%, and Heiner with 25%.71 And when Election Day came, the race proved just as tight as predicted. Heiner was the first one down, gaining a respectable 27% of the vote, but not enough to overtake his opponents.72 However, at the end of election night Bevin was only leading Comer

13 by 83 votes, both clocking in at 32.9% of the vote.73 Only separated by .04% (well within the typical margin of error of 2% associated with hand counting ballots), people could not be sure who had actually won the nomination.74 Though Comer immediately asked for a recanvass,

Bevin eventually came out victorious. And so, a businessman with no prior political office went on to the with less than a third of Republicans actually having voted for him and no clear mandate. So how did he manage to emerge victorious in November?

Bevin seemed to rise to the top of the Republican pool with his extreme feelings about healthcare in Kentucky, and this issue would become one of his primary talking points in the general election as well. Jack Conway, the Democratic candidate, supported the way Beshear implemented the ACA in Kentucky, calling kynect “a cheaper, more efficient way to allow people to purchase health insurance.”75 He further asserted that kynect and the Medicaid expansion had helped the economy grow, something statistics show to be true: “When you actually get more compensated care in an emergency room, the entire health care sector does better, when you get more healthcare workers employed, that is money into the economy.”76

Conway repeatedly demonstrated that, if elected, he would let things stay the same. And he strongly believed that Bevin’s plan for the healthcare system was wrong.

During a debate in October of 2015, the two candidates were asked, “If elected governor, what adjustments will you make [to kynect and Medicaid] and how many of the people enrolled now will still be enrolled after the next enrollment period?”77 Conway had this response:

“The people that are enrolled now will be enrolled in the future. What Governor Beshear has shown us, is that if we do health care reform the Kentucky way, and put all the Washington rhetoric aside, that we can actually make it work. Kynect has been a shining example of how we can show competence in allowing people to enroll in health insurance. It’s three times more efficient than a federal exchange, which is what my opponent favors…Now, I agree we have too many people on Medicaid. But people come off of Medicaid when they get better paying jobs and our economy gets humming. But what I’m not going to do is what my opponent has said he would do on day one of his

14 administration, and that’s kick nearly a half-million people off of their health insurance based on what we can and can’t afford in six years. If we can’t afford something down the road, we’ll readjust. But to kick them off now would be callous.”78

It is clear that Conway was trying to make Bevin seem cold and harsh when it came to health care, but what is notable is the way he distanced himself from Washington, D.C., and by extension, President Obama. Conway knew that Kentuckians loved kynect, but hated

“Obamacare,” so he made sure to separate the two as much as possible. After hearing the answer that Conway had to this question, Bevin responded:

“What you’re hearing are more of the very same lies you’ve been hearing all along…We do have a need however to being sure that we can pay for the very things that we promised people…In fact to call kynect a shining example is another blatant lie…This very kynect program is collapsing to the tune of $150 million that is going to fall ultimately back on the taxpayers…It is not a shining example. It’s not working. We need 1115 waivers to ensure that we can provide the same coverage to more folks but at a more affordable cost to the taxpayers of Kentucky.”79

Bevin was already planning to dismantle kynect and change the nature of Medicaid in Kentucky.

And he relied heavily on the costs when arguing against these programs.

The healthcare exchanges that were created under the ACA received grants from the federal government to fully fund their creation and operation costs. But these grants were not meant to last forever. State exchanges were required to be self-sufficient/self-funded from

January 1, 2015 onward.80 This meant that the costs of exchanges would be transferred to the states after this point. The federal government was also covering the full costs of the Medicaid expansion from 2014 to 2017, but will gradually decrease their contributions until they cover

90% of costs in 2020.81 The loss of federal money was Bevin’s greatest concern when it came to kynect and Medicaid. He simply believed the state could not afford it and it would cost the taxpayers large amounts of money. In a July debate, he said of the subsidies from the federal government that the state was “spending money that’s not real,” and “It’s ultimately coming

15 down on the heads of you and your employees and your children and your grandchildren. So let us not chase that fake money; this is like getting excited by a tax refund.”82

But all predictions showed Bevin to be incorrect. Kynect was a national example of exchange excellence, the Medicaid expansion had given 570,000 new people health insurance,83 and both had managed to increase jobs and expand the economy in Kentucky.84 A year after federal funding expired for kynect and other state exchanges, the Acting Administrator for the

Centers for Medicare and Medicaid Services, Andy Slavitt, said, “All states are sustainable today.”85 And a report from Deloitte, partnered with the University of Louisville, found that the

Medicaid expansion would “generate a net positive impact of nearly $820 million to state and local government budgets.”86 The State Budget Officer, Jane Driskell, said that studies had found the expansion created savings and revenue more than double the amount that the state needs to pay for it.87 So, if cost wasn’t a real issue, why did Matt Bevin claim it was? Why did people listen to him? And why did people elect a man who planned to dismantle a system that was, by all measures, successful?

It is important to remember that healthcare was not the only key issue facing voters during this election. In an October 2015 poll, more Kentuckians said that it was “extremely important” or “very important” for the next Governor and the Kentucky Legislature to work on

“Improving the Economy,” “Improving K-12 Public Education,” and “Improving the Job

Situation,” than said that it was important to work on “Reducing Cost of Healthcare,” or

“Improving Health of Residents.” But the numbers were still high for these health issues. 83% of respondents said it was extremely or very important that the next Governor work on “Reducing

Cost of Healthcare,” and 81% said it was extremely or very important that the next Governor work on “Improving Health of Residents.”88 Though it may not have been the top issue,

16 healthcare was clearly a factor on people’s minds. However, this poll brings up an interesting distinction. “Reducing Cost of Healthcare” could mean many different things. To Democrats, it likely means lowering costs for patients; to Republicans, it likely means lowering costs for the government as well. For members of both parties, “Reducing Cost of Healthcare” is imperative,89 but they have different priorities and ideas for how to accomplish this task.

For Matt Bevin, decreasing the costs to the state was his top priority. And he believed that by lessening the government involvement, the reductions in cost would reach the taxpayers as well.90 He often claimed “This program is projected to cost Kentucky in excess of $150 million per year after 2016,”91 presumably to scare people into thinking kynect and the Medicaid expansion were unsustainable. He used this “$150 million” estimate when referring to kynect and the Medicaid Expansion at different times, and I have not been able to find a source for it.

Either way, multiple studies and sources have demonstrated that, although some costs would be transferred to the states eventually, the exchange and the expansion working together would produce enough benefits and revenue to outweigh the costs.92 But regardless of the validity of

Bevin’s statements, his rhetoric about escalating costs likely contributed to his victory in

November. Eight in ten Republicans said it was extremely or very important for the next

Governor to work on “Reducing Cost of Healthcare,”93 and Matt Bevin promised that dismantling kynect and changing the Medicaid expansion would do just that.94

When trying to understand why Matt Bevin won the 2015 gubernatorial election, it is also important to look at who voted for him, and how people were predicted to vote. In October 2015, all polls conducted had Conway leading Bevin.95 A Survey USA poll released on October 26th had Conway ahead with 45% of votes, Bevin with 40%, (the Independent

Candidate) with 6%, and 10% were Undecided.96 So how did the polls have it so wrong? In the

17 Figure 3: Bump, Philip. "Why Were the Polls so Wrong?, Kentucky Governor Edition." . November 04, 2015. actual election, Matt Bevin received 52.5% of the votes, Conway received 43.8%, and Curtis received 3.7%.97 Fewer people voted for the Independent Candidate than expected, and Conway drew a little less support than polls predicted, but Bevin either received all of the Undecided votes, or Republican voter turnout was underestimated.98 The latter is more likely.

The total voter turnout for the 2015 Kentucky General Election was 30.7% of eligible voters. This is low, but according to the Washington Post, “not bad for an off-year general election.”99 And when polls are conducted, they typically poll “likely voters,” meaning people

18 who voted in recent elections. In the 2015 election, it seems that the polls were so wrong because

“unlikely voters” turned out to vote for Matt Bevin, while Democratic voters stayed home because they believed that Conway wouldn’t lose. But the real question is why did this happen?

Why did Democrats feel safe and why did more Republicans than usual show up to vote for Matt

Bevin? And how did opinions about health care play a role in this?

A big cause behind Matt Bevin’s gubernatorial victory is the shifting focus of elections.

In the past, many people voted based on the issues, which candidate had the policy initiatives they agreed with the most. And local politics was considered separately from national politics.

But Political Scientists from Emory University, Alan Abramowitz and Steven Webster, have found that more people are voting based on “anger at and fear of the opposing party, rather than enthusiasm for one’s own party.”100 Studies have discovered that, from 1978 to 2008,

Republicans and Democrats view their own parties the same way, but regard the opposing party significantly less highly.101 People were asked to rank their feelings about their own party and the opposing party on a scale of “1 to 100.” In 1978, Democrats rated the Republican Party, on average, at a 48. In 2008, they rated the Republican Party at a 33. The same trend appears in

Republicans. In 1978, Republicans rated the Democratic Party at an average of 47, and that had dropped to 37 by 2008.102 Disdain for the opposition has clearly increased. This has huge effects on the way people vote in local and state elections.

19

Whereas, in the past,

Republicans would feel comfortable voting for a local

Democrat they agreed with, like Steve Beshear, now they are more likely to tie state and local Democrats to the federal politicians they dislike. And Democrats would do the same to state and local Republicans. This means that, when assessing

Jack Conway in the gubernatorial election, many

Republican voters would see him in the same light through which they viewed President

Obama. And President Figure 4: Ehrenfreund, Max. "Why Matt Bevin's Win in Obama was not very popular Kentucky Could Be the Future of American Politics." The Washington Post. November 04, 2015. in the state of Kentucky. His disapproval rating in Kentucky 2015 was close to 70%.103 The animosity that Kentuckians had toward Obama was one of the main reasons Governor Beshear branded the state exchange as

20 “kynect,” making it seem as homegrown and unconnected to the Federal government as possible.

Greg Stumbo, the Deomocratic Speaker of the Kentucky House of Representatives in 2015 said,

“I’d tell em [Kentuckians] we’ve got Beshearcare, and they’d be fine with that.”104 But if you connect kynect back to “Obamacare,” people may react differently.

Bevin used this to his advantage in the election against Conway. In the final two weeks leading up to the election, the Republican Governors Association ran an advertisement that said,

“Our families can’t afford four more years of the liberal policies of President Obama and career politicians like Jack Conway. Can you really trust Obama and Conway to make things better?”105

They also quoted Obama from the 2014 midterm elections saying that, although he was not on the ballot, “these policies [his policies] are on the ballot. Every single one of them.”106 By using the words “can’t afford,” the group supporting Bevin was able to once again connect liberal policies, including kynect and the Medicaid expansion, to increased costs. And by making the advertisement about Conway and Obama, the RGA inextricably linked the two figures in the minds of many voters. Overall, the election of Matt Bevin seems to be less a result of his own policies, and more a result of his lack of connection to President Obama. Beshear’s healthcare policies were extremely popular in Kentucky. 53% of people felt kynect was working “very well” or “somewhat well,” with only 23% believing it was working “not too well” or “not at all well.”107 And 79% of Kentuckians favored the decision to expand Medicaid.108 But that mattered less than the strong disdain for President Obama and any candidate who was tied to him. Matt

Bevin’s victory was part of a larger trend toward voting based on ideology rather than policy.

Bevin: Axing “kynect” and Altering Medicaid

In his campaign for Governor, Matt Bevin called kynect “redundant” and said it “adds no value.”109 When he was sworn in as Governor in December 2015, he set out to keep his promise

21 to dismantle the exchange and switch over to federally run healthcare.gov as quickly as possible.

He notified the U.S. Department of Health and Human Services (HHS) of his intentions on

December 30th, 2015, and they responded by outlining the steps he would need to take for the state to be ready for the switch to the federal exchange by the next open enrollment period in fall of 2016.110 In their response on January 28th, 2016, Andrew Slavitt, the acting administrator of

HHS at the time, said, “ceasing kynect will create a number of challenges that must be addressed to ensure that access to affordable health coverage continues for Kentucky’s consumers.”111

Slavitt listed many tasks that would be required of the Bevin administration in the coming year, including providing “a detailed plan for how Kentucky will continue to meet its obligations as an

SBM [state-based marketplace] through the 2016 plan year,” and facilitating “discussions between CMS [Centers for Medicare and Medicaid Services] and the issuers participating in kynect.”112 Slavitt also informed Bevin that the remaining $57.5 million of the federal grant that

Kentucky had received for kynect could not be used to fund the transition to the federal exchange.

After receiving the letter, Bevin made every effort to comply with its stipulations. In July

2016, he even issued an executive order to renew authorization for kynect, so that there would not be a period of time when Kentuckians did not have access to any exchange.113 Jim Waters, the President of the Bluegrass Institute, a conservative think tank in Kentucky, had previously called Beshear’s executive order creating kynect “unconstitutional.” But he praised Bevin’s executive order doing the same thing: “It’s hard to unscramble an egg—especially one this big…Rather than bounding like a bull through the china shop, the Governor and his administration appear to be thoughtfully and strategically addressing the issue while still moving in the right direction.”114 Despite Bevin’s reauthorization of kynect, his spokeswoman Amanda

22 Stamper assured people that they “continue to meet all major milestones and are on track to transition to healthcare.gov for open enrollment this fall [2016].”115

One of the biggest differences between kynect and healthcare.gov was that the state exchange allowed people to enroll in Medicaid/KCHIP, and the federal exchange does not. The letter from HHS made it clear to Governor Bevin that he would need to immediately contract a vendor to build a separate portal for Medicaid/KCHIP enrollment and “build new system functionality that enables bi-directional exchange of applications between the FFM [federally- facilitated marketplace] and Kentucky’s Medicaid/CHIP systems.”116 On February 29, 2016, the

Bevin administration launched “Benefind,” a new website through which Kentuckians could sign up for many public programs, including Medicaid/KCHIP, the Supplemental Nutritional

Assistance Program (referred to as SNAP or “food stamps”), and Temporary Assistance for

Needy Families.117 However, Bevin’s Secretary of Health and Human Services specifically stated that the website “will not be advertised to inform the public of its existence,”118 still clearly trying to discourage new people from enrolling in Medicaid. But, in addition to doing something kynect had already accomplished, Benefind was, unfortunately, a catastrophe.

Governor Beshear was actually the one to spearhead Benefind, approving the consulting firm Deloitte to build a $100 million system back in 2012. His health cabinet even trained workers to operate the system before he left office at the end of 2015.119 But Benefind was never meant to include health insurance. It was only after Bevin took office that Medicaid services were hastily tacked on between December 8, 2015, and February 29, 2016. The 570,000 people who were enrolled in Medicaid through kynect were transferred over to Benefind without notice, but not all of their account information successfully transferred. This led to a backlog of more than 50,000 cases, and at least 25,000 enrollees being sent automated letters telling them their

23 health insurance would be cut off.120 Some people were also asked to provide information, such as proof of income or citizenship, which had already been provided through kynect. Jackie

Engle, the Director of Outreach and Enrollment for Family Health Centers in Louisville, said one family lost health coverage completely when Benefind failed to identify them as legal residents, a status that had been confirmed through kynect.121

This terrible lapse in service made some people concerned about Governor Bevin’s intentions when adding Medicaid/KCHIP into Benefind. Democratic State Representative Joni

Jenkins said, “I’ve heard terrible things about wait times. It makes me suspicious that the end game is to make it impossible to get into Medicaid and save money.”122 She also expressed dismay over the transition from kynect to the Benefind system: “It’s just crazy to me that we’re going from a system that works to one that obviously has great difficulty getting basic services to people.”123 A hotline for assistance did exist, but many callers were put on hold for long periods of time or simply disconnected. Further, the hotline was only available from 8am to 3pm, making it nearly impossible for people with jobs to access it.124 Connie Holt, a disabled woman who doesn’t own a computer, said she lost her Medicaid coverage under Benefind and was forced to call the hotline day after day, trying to get the coverage reinstated. She went without health insurance for two months, unable to afford doctors visits or medication costs. About the situation, she said, “I would sit on the phone and cry. It was so frustrating, I would just cry myself to sleep.”125

Making the situation more difficult, “Kynectors” were not able to sign anyone up for coverage who had ever received other state benefits, severely limiting the pool of people the

“Kynectors” could help. In a report by State Auditor, , released in February 2017, he said, “This change severely limited the ability of ‘Kynectors’ to assist citizens with applying

24 for benefits and placed a heavier burden on CHFS [Cabinet for Health and Family Services] staff to address concerns.”126 The Bevin administration repeatedly tried to blame Governor Beshear for Benefind’s failures. Michael Goins, the Communications Director for Republican Auditor

Harmon, claimed, “There had not been proper testing by the prior administration…and then once the system was implemented by the current administration, these problems that had not been tested for by the prior administration cropped up.”127 However, the primary issues with Benefind involved access to Medicaid/KCHIP benefits, something Governor Beshear’s administration never intended to include on the portal. Further, a document distributed to Bevin’s Department for Community Based Services on February 25th, four days before the Benefind launch, entitled

“Worker Portal Defect Workaround Guide” proves that the Bevin administration knew there would be serious issues with Benefind and chose to roll it out anyway.128 After the failed launch of Benefind, Bevin also adamantly assured Kentuckians that Benefind “was absolutely intended to be a vehicle through which people signed up for every single benefit that they might need…that would include Medicaid.”129 This statement is patently false, considering that

Beshear originally approved Benefind and he was fully supportive of kynect remaining the state portal for all health insurance enrollments.

Over the summer of 2016, 91 workers from the Department of Community Based

Services travelled to Frankfort and worked through the entire 50,000 case backlog over the course of a few weeks, but some problems still exist for programs such as Medicaid Long-Term

Care and refugee services.130 And even in February 2018, Benefind was causing issues for the

Child Care Assistance Program.131 It is clear that this program has not had the same early success as kynect. Bevin rushed into Benefind. The program was not ready, but he wanted so badly to switch people off of kynect that he moved forward with it anyway. Though Benefind’s costs

25 were already initiated by the Beshear administration, Bevin’s carelessness cost many people the security and access to care that they previously had. And these would not be the only costs put forth by Bevin in his battle against kynect.

Though Bevin consistently complained during the 2015 election about the costs kynect and the Medicaid expansion imposed on the taxpayers,132 he had no qualms about the amount of money it would take to dismantle the successful kynect system. The Beshear administration estimated that it would take $23 million to shut down kynect, all coming from the state’s general fund.133 Bevin would not be able to use any federal money for this endeavor, according to the letter from HHS.134 In addition to direct costs for dismantling, the transition to the federal exchange will place a 3.5% assessment on all plans bought through it. This cost is much higher and more concentrated than the 1% assessment on all insurance premiums that existed in

Kentucky under kynect. This could make premiums much higher for people, but Bevin’s spokeswoman, , argued that this would make things fairer for people who do not use the exchange.135 No matter what you believe, it cannot be denied that Bevin was comfortable increasing costs in order to accomplish his goals, something he had so often criticized Beshear and other Democrats for doing as well.

In addition to not being able to use the federal exchange to sign up for Medicaid,

Kentuckians also found that the federal exchange was slower and involved more steps than they were used to with kynect. Kynect allowed people to determine eligibility and apply, all in the same sitting; but healthcare.gov requires consumers to enter eligibility information, wait for a reply, and then send in an application for coverage.136 In a letter to the Courier Journal on

November 3, 2016, Louisville resident Holly Radcliff sarcastically “thanked” Matt Bevin for dismantling kynect. She said, “I have tried healthcare.gov three times in two days (three hours

26 spent) without success.”137 Many officials feared that the increased wait time would cause citizens to temporarily go without coverage. In an October 2016 letter to Matt Bevin from Andy

Slavitt, the Acting Administrator of the Department of Health and Human Services (HHS),

Slavitt expressed concerns for the fate of those previously insured through kynect:

“We remain concerned that kynect’s transition to the federal platform may disrupt the seamless system of coverage that kynect established. As a result, eligible people may face delays in or lack of access to the coverage for which they are eligible…Following the transition, many applicants will begin their application in one place and then experience a waiting period while their application is transferred and processed. They will then have to complete that application and enrollment on a different platform…Changes in system functionality may result in confusion for Kentucky consumers; it is therefore essential that the transition be clearly and effectively communicated to Kentucky consumers to ensure that they have the information they need to enroll in coverage on healthcare.gov starting November 1, 2016.”138

As of November 1, 2016, the approximately 94,000 Kentuckians who had enrolled in private insurance through kynect were forced to re-enroll on the federal exchange in order to keep their coverage.139 Although in December 2015, only a month after Bevin was elected, 52% of

Kentuckians wanted the new governor to keep kynect (with only 26% preferring to switch to the national exchange),140 Bevin was able to quickly come in and sweep away years of successful

ACA implementation.

Bevin’s efforts against Medicaid took longer to enact. In the same December 2015 study, the Kaiser Family Foundation found that 63% of Kentuckians had a favorable view of the

Medicaid expansion. 72% preferred to keep the Medicaid program as it is rather than alter it to cover fewer people. And even 54% of Republicans and 43% of people who said they voted for

Bevin wanted to keep the Medicaid expansion as it was.141 This demonstrates once again that many people did not vote Bevin in based on his actual policies. However, with public opinion overwhelmingly leaning against him, Bevin attempted to initiate changes to Medicaid in

27 Kentucky. On August 24, 2016, he submitted an application to the United States Centers for

Medicaid and Medicare Services (CMS) for a Section 1115 waiver, which would allow him to alter the Kentucky Medicaid program.142

Governor Bevin first released his proposed waiver on June 22, 2016, and it went through a state level comment period until August 14, 2016. The state received 1,428 comments, but few changes were made.143 The waiver is called Kentucky HEALTH (Helping to Engage and

Achieve Long Term Health), and it was sent to CMS on August 24, 2016. The Trump administration expressed interest in possible waiver policy changes in a letter to state governors in March 2017. On July 3, 2017, Kentucky submitted an amendment to its application, and CMS opened a federal comment period for the amended waiver.144 The amended Kentucky HEALTH waiver was ultimately approved by the Trump administration on January 12, 2018.145

The original waiver proposed many changes that would make it more difficult for those above 100% FPL (Federal Poverty Level) to access Medicaid. This was a direct response to the

Medicaid expansion initiated by Beshear through the ACA, which made it possible for people between 100% and 138% FPL to enroll in Medicaid.146 Under Kentucky HEALTH, people between 100% and 138% FPL will have to pay their first premium before coverage is effective and will pay more in premiums than people below 100% FPL.147 People above 100% FPL will also be disenrolled if they fail to pay a premium after 60 days. And they will not be able to re- enroll in Medicaid for six months unless they pay all past and current premiums and complete a financial or health literacy course.148 And non-emergency medical transportation will not be available for enrollees above 100% FPL.149 There are also many changes that affect all Medicaid recipients. People who do not renew their Medicaid eligibility in a “timely” way will lose coverage for six months unless they complete a financial or health literacy course. The waiver

28 adds a state-funded high deductible health savings account to existing managed care coverage,150 and it eliminates dental and vision coverage for able-bodied people, but allows members to earn points toward these services by engaging in volunteer work, attending classes, or completing other activities.151 But the biggest change is definitely the work requirement.

The original waiver included a provision for requiring able-bodied adult (ages 19-64)

Medicaid users to work a certain number of hours each week, but the July 2017 amendment laid out the specific details of this requirement. The amended Kentucky HEALTH waiver requires

Medicaid recipients to conduct 20 hours per week of employment activities in order to remain eligible for coverage. Employment activities include “volunteer work, employment, job search, job training, education, or caring for a non-dependent relative or person with a disabling chronic condition.”152 People with disabilities, pregnant women, and others who are unable to work are exempt from this provision.153 The amended waiver will also disenroll beneficiaries who do not report changes to their income or employment in a “timely” manner. They will be without coverage for six months unless they complete a financial or health literacy course.154

The Trump administration approved the Kentucky HEALTH waiver one day after announcing that they would allow states to impose work requirements on Medicaid. Kentucky became the first state in the country to enact this policy.155 The provisions of this waiver are all clearly designed to decrease Medicaid enrollment. Bevin wants to reduce costs by lessening the number of people with consistent coverage. He said in his waiver application that he believed the

Medicaid expansion would cost the state of Kentucky $1.2 billion from 2017 to 2021.156 But this doesn’t take into account the overwhelming positive effect Medicaid expansion has had and will continue to have on Kentucky’s economy. In the first year, more than 12,000 jobs in the healthcare sector were created in Kentucky. Kentucky health providers received $1.6 billion in

29 revenue from Medicaid. And the expansion was predicted to have a $30 billion positive impact on Kentucky’s economy from 2014 to 2022.157 This would more than make up for the $1.2 billion that Matt Bevin felt was too expensive.

When Bevin first announced the Kentucky HEALTH waiver, many Kentuckians responded with fear. Freida Lockaby, a 56-year-old woman from Clay County, Kentucky (a part of coal country), said in November 2016 that she was “worried to death about it [Bevin’s waiver].”158 60% of Clay County is covered by Medicaid, and many of these people became eligible after the expansion. The uninsured rate in Clay County for non-elderly adults has fallen from 29% to 10%.159 As a place that benefitted immensely from the Medicaid expansion, many community members are terrified of losing the access to care they now have. A Kentucky Health

Issues Poll (KHIP) conducted in late 2017 found that 24% of Kentuckians were concerned that they may lose their health coverage in the next twelve months.160 It is likely that this very high number is a result of the uncertainty produced by Matt Bevin’s waiver, in conjunction with the

ACA “repeal and replace” efforts on the national level.

There is also an additional factor making the Medicaid situation in Kentucky even more precarious. After the Kentucky HEALTH waiver was approved, Matt Bevin issued an Executive

Order to revoke the Medicaid expansion implemented in 2012 if any portion of his waiver is struck down in court.161 Woody Maglinger, a spokesman for Bevin said, when informing the public, “Governor Bevin has consistently said…that these [the waiver’s provisions] are the terms under which Kentucky will maintain expanded Medicaid.”162 Many people felt that this threat from Bevin was extremely manipulative and callous. Leonardo Cuello, Director of Health Policy for the National Health Law Program, asked, “Is the Governor of Kentucky saying that if he is caught doing something illegal, he will take health care away from hundreds of thousands of

30 Kentuckians who have done nothing wrong?”163 Democratic Congressman from Kentucky, John

Yarmuth, also spoke out against Bevin’s ultimatum, saying it allows no room for correcting errors.164

Implementation of the Kentucky HEALTH waiver began in April and the provisions are meant to be active starting July 2018.165 The work requirement will be phased in a few counties at a time, starting with this summer.166 One of Bevin’s aides revealed that that the waiver is expected to decrease Medicaid enrollment by 95,000 people over the next five years.167 The waiver application predicted Medicaid enrollment to have 238,310 less member months in the first year of implementation, and 1,140,032 less member months in the fifth year of implementation, which is equivalent to the 95,000-person estimate put forth by Bevin’s aide.168 Overall, it is clear that Bevin’s waiver is meant to discourage Medicaid enrollment in

Kentucky. Though we will not know the effects until the waiver is implemented, we are likely to see an increase in the amount of Kentuckians with inconsistent access to insurance. Through repealing kynect, introducing Benefind, and filing Kentucky HEALTH, Matt Bevin has accomplished his goals of turning back “Obamacare” in Kentucky to the greatest extent that he can.

There are still some people who want to push back. Just a few days after the Kentucky

HEALTH waiver was approved and Bevin issued his threatening executive order, fifteen

Kentuckians chose to risk losing the expansion and filed a lawsuit in the United States District

Court for the District of Columbia against the Trump administration’s approval of Bevin’s

Section 1115 waiver. The plaintiffs are represented by the National Health Law Program, the

Kentucky Equal Justice Center, and the Southern Poverty Law Center.169 An attorney for the

Kentucky Equal Justice Center has said, “The purpose of Medicaid is to provide medical

31 insurance to people who cannot afford it, not to create barriers to coverage. Demonstration waivers are supposed to make access to health care easier. This approval does the opposite. It is not only in violation of Medicaid law but is immoral.”170 And with regard to Bevin’s Executive

Order allowing him to revoke the previous Medicaid expansion if any part of Kentucky

HEALTH is struck down in court, the Deputy Legal Director of the Southern Poverty Law

Center said, “The governor’s threat – to punish the [more than] 400,000 residents who have received Medicaid under the expansion if a court rules against the Kentucky HEALTH project – is shameless. We will not be intimidated. We will defend the rights of individuals to enroll in

Kentucky’s Medicaid program.”171 It may be a long and dangerous fight, but people are willing to stand up against Bevin and the numerous ways he has tried to take away Kentucky’s health coverage.

Conclusion: Kentucky Elects Bevin at Great Cost to Their Health

Kentuckians overwhelmingly did not support changing the reforms put in place by

Governor Beshear. Even 43% of those who voted for Bevin were in favor of keeping the

Medicaid expansion.172 So why was a man with no prior Government experience able to sweep in so easily and quickly and turn back the reforms Kentucky had made to health policy? The answer is: a combination of partisan politics and a lack of knowledge about the issues. When people voted for Matt Bevin, many of them didn’t look at his policies; they looked at the letter

‘R’ next to his name. Obama was so unpopular in Kentucky that Bevin could win simply by tying his opponent to the President. More people than ever are voting based on party ideology as opposed to individual issues, and this allowed Matt Bevin to rise to power in Kentucky. The reforms put in place under Governor Beshear—kynect and the Medicaid expansion—were undeniably successful and popular. But they came from “Obamacare,” which was reviled by

32 Kentuckians, and this made those reforms especially vulnerable when an anti-establishment

Republican was elected Governor. The dismantling of kynect and the creation of the Kentucky

HEALTH waiver were less about decreasing costs and more about erasing the effects of Obama- era policies in Kentucky and getting the government out of the health care business. Matt Bevin planned all along to decrease the amount of people enrolled in public health insurance, and it seems likely that his waiver will accomplish this over the next five years. Kentuckians still mourn the loss of kynect, but it remains to be seen whether they will demonstrate their grief during the 2019 election. Four more years of Matt Bevin could mean the death of Democratic health reforms in Kentucky for good.

1 Beshear, Steve. "Executive Order 2012-587." Sos.ky.gov. July 17, 2102. 2 "Gov. Beshear Launches Kynect: Kentucky's Healthcare Connection." Kentucky.gov. May 15, 2013. 3 State Journal Staff Report. "Gov. Beshear Touts Kynect Success." The State Journal. April 23, 2014. 4 Musgrave, Beth, and Jack Brammer. "Beshear Says Kentucky Will Join Obamacare Plan to Expand Medicaid." Kentucky.com. May 09, 2013. 5 Artiga, Samantha, Jennifer Tolbert, and Robin Rudowitz. "Implementation of the ACA in Kentucky: Lessons Learned to Date and the Potential Effects of Future Changes - Issue Brief." The Henry J. Kaiser Family Foundation. April 20, 2016. 6 Stolberg, Sheryl Gay, and Alan Blinder. "Matt Bevin, Republican, Wins Governor's Race in Kentucky." The New York Times. November 04, 2015. 7 Wieczner, Jen. "One Health Exchange Success Story." Fortune. November 22, 2013. 8 Tavernise, Sabrina, and Allison Kopicki. "Southerners Don't Like Obamacare. They Also Don't Want to Repeal It." The New York Times. April 23, 2014. 9 Cillizza, Chris. "Matt Bevin Is the next Governor of Kentucky. He Has President Obama to Thank." The Washington Post. November 03, 2015. 10 Stolberg, Sheryl Gay, and Alan Blinder. "Matt Bevin, Republican, Wins Governor's Race in Kentucky." The New York Times. November 04, 2015. 11 "Feds Give OK to Disconnect Kynect." WHAS11. October 04, 2016. 12 Cheves, John. "Kynect Was Not Sustainable, Kentucky Officials Say." Lexington Herald Leader. February 16, 2016. 13 Sonka, Joe. "Former Gov. Steve Beshear Launches Organization to Fight Rollback of Health Care Reforms." Insider Louisville. February 11, 2016. 14 Hamel, Liz, Mira Norton, and Mollyann Brodie. "Survey of Kentucky Residents on State Health Policy." The Henry J. Kaiser Family Foundation. April 11, 2016. 15 "Proposed Changes to Medicaid Expansion in Kentucky." KFF.org. August 04, 2017. 16 Abramson, Alana. "Kentucky Is First State to Adopt Medicaid Work Requirement." Time. January 13, 2018. 17 Musumeci, MaryBeth, Robin Rudowitz, and Elizabeth Hinton. "Approved Changes to Medicaid in Kentucky." The Henry J. Kaiser Family Foundation. January 17, 2018. 18 Ibid. 19 Yetter, Deborah. "Bevin Issues Ultimatum: If Courts Block Medicaid Plan, Half Million Kentuckians Will Lose Care." The Courier Journal. January 17, 2018.

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20 Sonka, Joe. "Kentuckians File Federal Lawsuit against Trump Administration for Approving Bevin's Medicaid Waiver Plan." Insider Louisville. January 24, 2018. 21 Yetter, Deborah. "Bevin Issues Ultimatum: If Courts Block Medicaid Plan, Half Million Kentuckians Will Lose Care." The Courier Journal. January 17, 2018. 22 Ibid. 23 Desrochers, Daniel. "Here's How Kentucky's Congressmen Voted on the Republican Health Care Bill." Lexington Herald Leader. May 04, 2017. 24 Kessler, Glenn. "Mitch McConnell's Puzzling Claims on Insurance in Kentucky, Post-Obamacare." The Washington Post. October 16, 2014. 25 "PPACA Sec. 1311 - Health Reform Navigator." Google Sites. 26 Brill, Steven. Americas Bitter Pill: Money, Politics, Backroom Deals, and the Fight to Fix Our Broken Healthcare System. New York: Random House, 2015. p.208. 27"Stakeholder Perspectives on Health Benefit Exchanges." Healthcarereform.ky.gov. June 2012. 28 Ibid. 29 Giovannelli, Justin, and Kevin Lucia. "The Experiences of State-Run Marketplaces That Use HealthCare.gov." The Commonwealth Fund. September 17, 2015. 30 "Kentucky General Assembly." Ballotpedia. 31 Young, Matt. "Beshear Reauthorizes Health Care Exchange, Again Sidestepping State Lawmakers." Lexington Herald Leader. July 02, 2014. 32 "PPACA Sec. 1311 - Health Reform Navigator." Google Sites. 33 "2014 Kentucky Health Issues Poll: ACA Understanding, Support Rise; Most Felt No Impact." Foundation for a Healthy Kentucky. , 2015. 34 Beshear, Steve. "Executive Order 2012-587." Sos.ky.gov. July 17, 2102. 35 "Gov. Beshear Launches Kynect: Kentucky's Healthcare Connection." Kentucky.gov. May 15, 2013. 36 Beshear, Steve. "Executive Order 2012-587." Sos.ky.gov. July 17, 2102. 37 Galewitz, Phil. "State Obamacare Exchanges 'Sustainable' Without Federal Aid, Official Tells Congress." Kaiser Health News. December 09, 2015. 38 Patrick, Melissa. "Kynectors Tell Why They're Important to Keeping Kentuckians Signed up for Coverage; Stivers Says They're Making Assumptions." Kentucky Health News. February 25, 2016. 39 Cherkis, Jason. "Kentucky's Obamacare Website Works, But Word Of Mouth Is What Sells It." Huffington Post. November 05, 2013. 40 "2013 Kentucky Health Issues Poll: Awareness High about State's Insurance Marketplace." Foundation for a Healthy Kentucky. January 2014. 41 "Nearly 11,000 complete application for coverage." WYMT RSS. October 04, 2014. 42 State Journal Staff Report. "Gov. Beshear Touts Kynect Success." The State Journal. April 23, 2014. 43 Artiga, Samantha, Jennifer Tolbert, and Robin Rudowitz. "Implementation of the ACA in Kentucky: Lessons Learned to Date and the Potential Effects of Future Changes - Issue Brief." The Henry J. Kaiser Family Foundation. April 20, 2016. 44 Ibid. 45 Tavernise, Sabrina, and Allison Kopicki. "Southerners Don't Like Obamacare. They Also Don't Want to Repeal It." The New York Times. April 23, 2014. 46 "Kentucky Is Ahead in Health Insurance Enrollment." The New York Times. November 04, 2013. 47 Wieczner, Jen. "One Health Exchange Success Story." Fortune. November 22, 2013. 48 Kessler, Glenn. "Mitch McConnell's Puzzling Claims on Insurance in Kentucky, Post-Obamacare." The Washington Post. October 16, 2014. 49 "Gov. Beshear Expands Medicaid in KY." FOX19. May 09, 2013. 50 Musgrave, Beth, and Jack Brammer. "Beshear Says Kentucky Will Join Obamacare Plan to Expand Medicaid." Kentucky.com. May 09, 2013. 51 "Total Monthly Medicaid and CHIP Enrollment." The Henry J. Kaiser Family Foundation. March 08, 2018. 52 Sommers, Benjamin D., Robert J. Blendon, E. John Orav, and Arnold M. Epstein. "Changes in Utilization and Health Among Low-Income Adults After Medicaid Expansion or Expanded Private Insurance." JAMA Internal Medicine 176, no. 10 (October 2016): 1501-509. 53 Aron-Dine, Aviva. "ACA's Medicaid Expansion a Huge Success in Kentucky." Center on Budget and Policy Priorities. October 11, 2017.

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54 Beshear, Steve. "Medicaid Expansion: Kentucky Governor Explains His State's Success." Richmond Times- Dispatch. August 18, 2015. 55 "America's Health Rankings: 2012 Edition." United Health Foundation. 2012. 56 Beshear, Steve. "Medicaid Expansion: Kentucky Governor Explains His State's Success." Richmond Times- Dispatch. August 18, 2015. 57 Ibid. 58 Ibid. 59 Ibid. 60 "2013 Kentucky Health Issues Poll: Large Majority Supports State's Medicaid Expansion." Foundation for a Healthy Kentucky. January 2014. 61 Ibid. 62 Strom, Stephanie. "Election Results 2010: Kentucky." The New York Times. 2010. 63 Gregory, John. "Profile: Republican Gubernatorial Candidate Matt Bevin." Insider Louisville. October 30, 2015. 64 Blake, Aaron. "Businessman Set to Enter Primary against McConnell." The Washington Post. July 22, 2013. 65 Lega, Stephen. "Incumbent Faces Four Challengers in Senate Primary." The Lebanon Enterprise. April 30, 2014. 66 "Kentucky Primary Results." The New York Times. 2014. 67 "Ky Gubernatorial Candidates on the Issues." The Courier Journal. May 19, 2015. 68 Ibid. 69 Ibid. 70 Jensen, Tom. "Kentucky Republican Primary Remains Toss-Up." Public Policy Polling. May 08, 2015. 71 "SurveyUSA Poll." Bluegrass Poll. May 2015. 72 "Kentucky Gubernatorial and Lieutenant Gubernatorial Election, 2015." Ballotpedia. 2015. 73 Ibid. 74 Berman, Russell. "A Kentucky Election That's Too Close to Call?" The Atlantic. May 20, 2015. 75 Barton, Ryland. "Bevin, Conway Clash Over Kynect, Education at Kentucky Chamber Debate." WFPL News Louisville. July 28, 2015. 76 Ibid. 77 "Full Video: Kentucky Gubernatorial Debate." WKYT. October 25, 2015. 78 Ibid. 79 Ibid. 80 "Guidance to States On Exchanges." Centers for Medicare & Medicaid Services. May 09, 2013. 81 Pulliam, Baylee. "Beshear: 'Facts Show' Kentucky Can Afford Kynect, Medicaid Expansion." Louisville Business First. November 13, 2015. 82 Barton, Ryland. "Bevin, Conway Clash Over Kynect, Education at Kentucky Chamber Debate." WFPL News Louisville. July 28, 2015. 83 Artiga, Samantha, Jennifer Tolbert, and Robin Rudowitz. "Implementation of the ACA in Kentucky: Lessons Learned to Date and the Potential Effects of Future Changes - Issue Brief." The Henry J. Kaiser Family Foundation. April 20, 2016. 84 Beshear, Steve. "Medicaid Expansion: Kentucky Governor Explains His State's Success." Richmond Times- Dispatch. August 18, 2015. 85 Galewitz, Phil. "State Obamacare Exchanges 'Sustainable' Without Federal Aid, Official Tells Congress." Kaiser Health News. December 09, 2015. 86 Mann, David A. "Beshear: Report Shows Medicaid Expansion's Benefits." Louisville Business First. February 12, 2015. 87 Ibid. 88 "2015 Kentucky Health Issues Poll: What Kentucky Adults Think Should Be State's Top Priorities." Foundation for a Healthy Kentucky. October 2015. 89 Ibid. 90 "Ky Gubernatorial Candidates on the Issues." The Courier Journal. May 19, 2015. 91 Ibid. 92 Mann, David A. "Beshear: Report Shows Medicaid Expansion's Benefits." Louisville Business First. February 12, 2015. 93 "2015 Kentucky Health Issues Poll: What Kentucky Adults Think Should Be State's Top Priorities." Foundation for a Healthy Kentucky. October 2015. 94 "Full Video: Kentucky Gubernatorial Debate." WKYT. October 25, 2015.

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95 Bump, Philip. "Why Were the Polls so Wrong?, Kentucky Governor Edition." The Washington Post. November 04, 2015. 96 "SurveyUSA Election Poll #22541." Survey USA. October 28, 2015. 97 "Kentucky Gubernatorial and Lieutenant Gubernatorial Election, 2015." Ballotpedia. 2015. 98 Bump, Philip. "Why Were the Polls so Wrong?, Kentucky Governor Edition." The Washington Post. November 04, 2015. 99 Ibid. 100 Ehrenfreund, Max. "Why Matt Bevin's Win in Kentucky Could Be the Future of American Politics." The Washington Post. November 04, 2015. 101 Ibid. 102 Ibid. 103 Tavernise, Sabrina, and Allison Kopicki. "Southerners Don't Like Obamacare. They Also Don't Want to Repeal It." The New York Times. April 23, 2014. 104 Ehrenfreund, Max. "Why Matt Bevin's Win in Kentucky Could Be the Future of American Politics." The Washington Post. November 04, 2015. 105 Cillizza, Chris. "Matt Bevin Is the next Governor of Kentucky. He Has President Obama to Thank." The Washington Post. November 03, 2015. 106 Ibid. 107 Tavernise, Sabrina, and Allison Kopicki. "Southerners Don't Like Obamacare. They Also Don't Want to Repeal It." The New York Times. April 23, 2014. 108 "2013 Kentucky Health Issues Poll: Large Majority Supports State's Medicaid Expansion." Foundation for a Healthy Kentucky. January 2014. 109 Gillespie, Lisa. "Kynect No More: Bevins Move To Federal Exchange Approved." 89.3 WFPL News Louisville. October 04, 2016. 110 Sonka, Joe. "Gov. Bevin Revives Kynect through Executive Order, Operations to Continue until Transition to Federal Exchange Is Complete." Insider Louisville. July 12, 2016. 111 Sonka, Joe. "Federal Agency Informs Bevin Administration of Steps and Deadlines for Ending Kynect." Insider Louisville. February 08, 2016. 112 Ibid. 113 Bevin, Matthew G. "Executive Order 2017-269." Healthbenefitexchange.ky.gov. May 01, 2017. 114 Sonka, Joe. "Gov. Bevin Revives Kynect through Executive Order, Operations to Continue until Transition to Federal Exchange Is Complete." Insider Louisville. July 12, 2016. 115 Ibid. 116 Sonka, Joe. "Federal Agency Informs Bevin Administration of Steps and Deadlines for Ending Kynect." Insider Louisville. February 08, 2016. 117 Artiga, Samantha, Jennifer Tolbert, and Robin Rudowitz. "Implementation of the ACA in Kentucky: Lessons Learned to Date and the Potential Effects of Future Changes - Issue Brief." The Henry J. Kaiser Family Foundation. April 20, 2016. 118 "Feds Give OK to Disconnect Kynect." WHAS11. October 04, 2016. 119 Barton, Ryland. "Auditor: Staff, System Weren't Ready For Benefind Rollout." WFPL News Louisville. February 15, 2017. 120 Ibid. 121 Yetter, Deborah. "New Ky Benefits System Disrupting Aid for Many." The Courier Journal. March 25, 2016. 122 Ibid. 123 Ibid. 124 Ibid. 125 Ibid. 126 Barton, Ryland. "Auditor: Staff, System Weren't Ready For Benefind Rollout." WFPL News Louisville. February 15, 2017. 127 Ibid. 128 Barton, Ryland. "Bevin Administration Knew Of Benefind Problems Before Rollout." WFPL News Louisville. April 01, 2016. 129 Ibid. 130 Barton, Ryland. "Auditor: Staff, System Weren't Ready For Benefind Rollout." WFPL News Louisville. February 15, 2017.

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131 Yetter, Deborah. "Parents Are Losing Child Care Assistance Because of Flawed Benefind System, Advocates Say." The Courier Journal. February 19, 2018. 132 "Full Video: Kentucky Gubernatorial Debate." WKYT. October 25, 2015. 133 Johnson, Ja'Nel. "What May Happen If Obamacare Is Rolled Back In Kentucky." WFPL News Louisville. November 10, 2015. 134 Sonka, Joe. "Federal Agency Informs Bevin Administration of Steps and Deadlines for Ending Kynect." Insider Louisville. February 08, 2016. 135 Goodnough, Abby. "With Health Care Switch, Kentucky Ventures Into the Unknown." The New York Times. January 13, 2016. 136 Gillespie, Lisa. "Kynect No More: Bevins Move To Federal Exchange Approved." 89.3 WFPL News Louisville. October 04, 2016. 137 Radcliff, Holly. "Letter: Thanks, Bevin, for Dismantling Kynect." The Courier Journal. November 03, 2016. 138 Slavitt, Andrew M. "Letter to Matt Bevin from HHS." Centers for Medicare and Medicaid Services. October 04, 2016. 139 Eblen, Tom. "Gov. Matt Bevin Killed Kynect in Its Prime. Here's a Eulogy - and a Hope." Lexington Herald Leader. November 01, 2016. 140 Hamel, Liz, Mira Norton, and Mollyann Brodie. "Survey of Kentucky Residents on State Health Policy." The Henry J. Kaiser Family Foundation. April 11, 2016. 141 Ibid. 142 Cheves, John. "Kynect Was Not Sustainable, Kentucky Officials Say." Lexington Herald Leader. February 16, 2016. 143 "Proposed Changes to Medicaid Expansion in Kentucky." KFF.org. August 04, 2017. 144 Ibid. 145 Goldstein, Amy. "Kentucky Becomes the First State Allowed to Impose Medicaid Work Requirement." The Washington Post. January 12, 2018. 146 Musgrave, Beth, and Jack Brammer. "Beshear Says Kentucky Will Join Obamacare Plan to Expand Medicaid." Kentucky.com. May 09, 2013. 147 "Proposed Changes to Medicaid Expansion in Kentucky." KFF.org. August 04, 2017. 148 Ibid. 149 Ibid. 150 Ibid. 151 Abramson, Alana. "Kentucky Is First State to Adopt Medicaid Work Requirement." Time. January 13, 2018. 152 "Proposed Changes to Medicaid Expansion in Kentucky." KFF.org. August 04, 2017. 153 Abramson, Alana. "Kentucky Is First State to Adopt Medicaid Work Requirement." Time. January 13, 2018. 154 "Proposed Changes to Medicaid Expansion in Kentucky." KFF.org. August 04, 2017. 155 Goldstein, Amy. "Kentucky Becomes the First State Allowed to Impose Medicaid Work Requirement." The Washington Post. January 12, 2018. 156 Galewitz, Phil. "In Depressed Rural Kentucky, Worries Mount Over Medicaid Cutbacks." NPR. November 19, 2016. 157 Beshear, Steve. "Medicaid Expansion: Kentucky Governor Explains His State's Success." Richmond Times- Dispatch. August 18, 2015. 158 Galewitz, Phil. "In Depressed Rural Kentucky, Worries Mount Over Medicaid Cutbacks." NPR. November 19, 2016. 159 Ibid. 160 "2017 Kentucky Health Issues Poll: 1 in 4 Kentucky Adults 18-64 Concerned About Losing Their Health Insurance." Foundation for a Healthy Kentucky. February 2018. 161 Yetter, Deborah. "Bevin Issues Ultimatum: If Courts Block Medicaid Plan, Half Million Kentuckians Will Lose Care." The Courier Journal. January 17, 2018. 162 Ibid. 163 Ibid. 164 Ibid. 165 Musumeci, MaryBeth, Robin Rudowitz, and Elizabeth Hinton. "Approved Changes to Medicaid in Kentucky." The Henry J. Kaiser Family Foundation. January 17, 2018. 166 Carter, Darla. "Medicaid Work Requirement to Be Phased in Slowly." Insider Louisville. May 07, 2018.

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167 Goldstein, Amy. "Kentucky Becomes the First State Allowed to Impose Medicaid Work Requirement." The Washington Post. January 12, 2018. 168 "Proposed Changes to Medicaid Expansion in Kentucky." KFF.org. August 04, 2017. 169 Sonka, Joe. "Kentuckians File Federal Lawsuit against Trump Administration for Approving Bevin's Medicaid Waiver Plan." Insider Louisville. January 24, 2018. 170 Ibid. 171 Ibid. 172 Hamel, Liz, Mira Norton, and Mollyann Brodie. "Survey of Kentucky Residents on State Health Policy." The Henry J. Kaiser Family Foundation. April 11, 2016.

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