NEWS

Trump brings health care debate back to Kentucky

Chris Kenning
@ckenning_cj

Along with nearly three-quarters of voters living among Floyd County's Appalachian mountains, Melinda Watson voted for President Donald Trump – drawn to his vows to stop illegal immigration, bring back coal jobs and banish political correctness.

But now she's worried about cutbacks in the Medicaid coverage that she's come to rely on as Trump and congressional Republicans push a replacement for former President Obama's Affordable Care Act. The Congressional Budget Office said recently the replacement plan could increase the uninsured by 24 million over 10 years.

"It definitely scares me," she said.

Watson's sentiments reflect uncertainty and concern among some Kentucky supporters of President Donald Trump as he prepares to visit Louisville on Monday for a political rally – expected to bring out supporters and protesters – to build support for a replacement to Obamacare, which he and other Republicans have dubbed a "disaster."

Kentucky is on the front lines of the health care debate in part because its rollout of the ACA was hailed as a national success story under former Gov. Steve Beshear, one of the only Southern governors to expand Medicaid – a move that brought coverage to 439,044 people. The state exchange also helped about 81,000 people buy commercial health insurance plans. All told, the law brought about $3 billion in additional federal funds to the state.

As a result, the uninsured rate in Kentucky dropped from more than 20 percent to 7.5 percent, a reduction lauded by health advocates in one of the nation's unhealthiest states.

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But Republican Gov. Matt Bevin, arguing the state couldn't afford the expansion and that the state-run exchange was unnecessary, shuttered the state exchange and is seeking a Medicaid waiver that would apply new conditions and costs for some receiving the coverage. In Kentucky, more than 1.2 million are on Medicaid – more than a quarter of the population.

With the replacement American Health Care Act drawing opposition from Democrats, who say it will roll back health care gains, and even some Republicans – including Sen. Rand Paul of Kentucky – who say it's too close to Obamacare, Vice President Mike Pence was also dispatched to Louisville earlier this month to argue the ACA had "failed the people of Kentucky" and to build support for the new proposal.

On Friday, media outlets reported that the Republican bill might be reworked slightly to include changes to appease critics, such as making tax credits more generous for older Americans.

Emily Beauregard, head of Kentucky Voices for Health, said the Republican plan "will cover far fewer people" and "is not going to be good for the health of Kentucky."

For many Trump voters, hashing out the replacement plan's impact on them personally isn't easy given the complexities of both systems. But in Kentucky, the biggest concerns center around changes in the Medicaid program.

The Republican proposal calls for eliminating the expansion’s boost in federal funding, and would limit federal Medicaid funding through a per capita cap. States could be offered increased flexibility that may lead some to seek cuts in eligibility, benefits and provider reimbursement, according to the Kaiser Family Foundation.

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Nina Sulzer, 55, who lives in Louisville's Portland neighborhood, a working-class area whose voters were split on Trump in the 2016 election, went on Medicaid in 2013 when she lost insurance following her husband's death.

Now, she lives on $550 a month, has applied for disability and is battling health conditions including back ailments and Crohn's disease, she said. She is worried about the cutbacks as well as a state Medicaid waiver that would add premium payments, disenroll people who don't pay and require able-bodied adults to be working, seeking work, training for a job or volunteering or serving as a caregiver.

"Without my (Medicaid), I wouldn't have nothing," said Sulzer, who supported Trump early on but didn't vote in the election because she ultimately didn't favor either major candidate. "I had to let my sons who are grown move in and help pay bills so I didn't lose my house."

The Republican plan also would no longer require Americans to buy health insurance, would replace direct federal subsidies with tax credits to help low-income people buy insurance and allow insurance companies to charge older Americans more for their coverage. Set tax credits would replace income-based premium support.

The Congressional Budget Office said the bill is expected to raise the average premiums that Americans would have to pay before 2020, and then lower them after that. By 2026, average premiums would be roughly 10 percent lower than under the existing Affordable Care Act. But the number of uninsured Americans would rise dramatically during that same period, it found, as more opt out of coverage or fall from Medicaid rolls.

In Floyd County, for example, where Watson lives, tax credits by 2020 under the Republican proposal would be higher than the current ACA for some younger people making $30,000 a year, but it would be lower for those aged 60 making the same among, a Kaiser analysis found.

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Watson said she understands the impulse behind trimming Medicaid. In her region, she said, some "are abusing the system." But she works 40 hours a week at a rehab center but still doesn't make enough to pay for private health insurance.

"I don’t think that (Trump is) going to (push off Medicaid) people like me that work 40 hours and still can’t afford it," she said  "I don’t think so. But I could be wrong."

Mark Wilson, who lives in south Louisville, sells insurance and supported Trump in the election. He said Obamacare was cumbersome and left some of the subsidized individual plans on the exchanges still unaffordable. He's not sure how the replacement plan would eventually shake out but said finding a solution is important.

"No matter what happens, something has to be done," he said.

Jeff Klusmeier, who helped campaign for Trump in Louisville, said he hopes they "take their time." After years of criticizing Obamacare, Republicans are under pressure to make a change.

"Unless it’s a national emergency, take your time and deliberate," he said. "I’m in no hurry to see it repealed and replaced, but right now there's so much political pressure and demagoguery" on both sides, he said.

In Kentucky’s 3rd Congressional District, which covers Louisville, the ACA helped reduce the uninsured rate from 13.3 percent uninsured in 2012 to 5.3 percent in 2015, according to the Kentucky Center for Economic Policy, a liberal-leaning policy and research group.That's mainly from expanded Medicaid, from which more than 69,000 people have coverage, the group said.

Such patients have beat a path to the Family Health Center in Louisville's Portland neighborhood, where Sulzer lives.

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Family Health Center facilities now serve about 40,000 patients a year, 12,000 more than before Obamacare took hold thanks mainly to Medicaid, said Bill Wagner, executive director of the clinics.

They've been able to expand staff and programs such as a substance abuse programs and dental clinics, he said, and it has helped people get important screenings for cancer, join diabetes programs and diagnose long-neglected illnesses. He said the ultimate payoff from improved health may take a long time to emerge.

Ultimately, Wagner said, the debate over the ACA and its proposed replacement reflects a larger and unresolved ideological debate in the U.S. over the extent to which "health care is a right or a privilege."

Reporter Chris Kenning can be reached at ckenning2@gmail.com or 502-306-3361.

Melinda Watson of Floyd County, Ky. voted for President Donald Trump but now worries about changes to the Affordable Care Act.