No state serves as a better test case than Kentucky for the impact of state-level leadership on the success of the Patient Protection and Affordable Care Act (ACA; Pub L No. 111-148, 124 Stat. 855 [March 2010]) coverage expansions. During his State of the Union speech in 2014, President Barack Obama celebrated Kentucky’s work to implement the Medicaid expansion and build a health insurance exchange. President Obama singled out Governor Steve Beshear and called the state an example for the rest of the nation.
Two years later, I interviewed Governor Beshear for a book I was finishing on health insurance exchanges.1 He was immensely proud of his success but worried about sustainability. He had just been term-limited from office and replaced by Matt Bevin, a Republican who campaigned on ending the state’s cooperation with the ACA. Bevin has since followed through with giving up control of the state’s exchange and has been approved to add a work requirement to Medicaid.
The key statistic Beshear and I discussed in 2016 was that Kentucky experienced the greatest improvement in coverage in the nation, with uninsured rates dropping from 14.4% in 2013 to 6.1% in 2015.2 The study by Blewett et al. (p. 24) highlights another side of Kentucky’s success and tells us more about what was at stake in the transition from Beshear to Bevin.
RACIAL DISPARITIES IN COVERAGE
Blewett et al. present two provocative findings about what happened in Kentucky as the ACA went into effect. First, the Black–White gap in coverage disappeared between 2013 and 2015. This is true in the sense both that the uninsured rates of each population are statistically comparable and that each population’s share of the total number without insurance matched that group’s share of the state population. The elimination of this statewide racial gap is a stunning and underappreciated aspect of the ACA’s implementation.
The second finding of Blewett et al. highlights the limits of the ACA’s initial success in Kentucky. Their disparity analysis shows that gaps persisted and even got worse for some racial/ethnic groups. Although the percentage of the Hispanic/Latino population without insurance decreased from 34.5% to 24.2% between 2013 and 2015, this group became overrepresented relative to their share of the state’s population. The numbers are not quite as large for the state’s Asian population, but the trend is the same.
IMPLICATIONS FOR TODAY
These findings are in only one state and are from a different era, but they have several relevant implications for the current national debate. First, the history of health reform over the last 100 years teaches us that the fight over what comes next is largely shaped by how opposing sides define the past and the present.3 This study gives us a fuller understanding of the accomplishments and shortcomings of the ACA’s coverage expansions at a crucial moment in time and in a place where state and federal leaders were aligned in supporting the law. This is a snapshot of what was possible across the country had the ACA been fully implemented as intended.
Second, this study shows that racial gaps can be mitigated or even eliminated. As Blewett et al. put it, they demonstrate that “disparities are not necessarily intractable and that public policy can be an effective tool in mitigating them.”(p928) This finding is both encouraging and frustrating: I worry that when more recent data are available showing the effects of Governor Bevin’s retrenchment we will see the reemergence of the Black–White gap.
Third, these findings are consistent with research showing historic gains in coverage for the Hispanic/Latino population resulting from the ACA4 and showing that these improvements might not be on par with those that other populations have experienced. Collins et al. show that even as the national uninsured rate decreases for the Hispanic/Latino population, the improvements are relatively modest compared with other populations. Disparities are actually worse than before, as the proportion of uninsured people in the United States who are Hispanic/Latino increased from 29% to 40% between 2013 and 2016.5
The findings of Blewett et al. in Kentucky show that even in the best of circumstances it is very hard to eliminate the Hispanic/Latino disparity in coverage. This is particularly alarming considering the growing evidence that President Donald Trump’s rhetoric on immigration is having a chilling effect on Hispanic/Latino people, including US residents and legal immigrants, seeking health services.6 Rather than build on the already challenging baseline Blewett et al. found in Kentucky in 2015, we will likely spend many years trying to regain this population’s trust enough to get back to this point.
STATE LEADERSHIP ON ENROLLMENT
Kentucky may seem like an odd choice for an examination of racial disparities considering that the state is relatively homogenous: only 7.7% of the population is Black, for example. But Kentucky is a fantastic example of what is possible when state leadership works in conjunction with a supportive federal government to carry out the ACA.
These findings reinforce the importance of devoting resources to enrollment. The dramatic gains in coverage in Kentucky did not happen on their own. The Beshear Administration took a strong leadership role in carrying out aggressive and targeted outreach. States that abdicated control of their exchange—as Kentucky has under Governor Matt Bevin—are limited in their ability to maximize enrollment. Blewett et al. do not provide definitive evidence, but I suspect that the Black–White gap was not eliminated in states relying on the federal exchange (also known as states with a Federally Facilitated Marketplace).
This gap between state and federal exchanges existed during the Obama Administration but has since grown. The Trump Administration systematically worked to undermine the ACA during open enrollment by shutting down Healthcare.gov every weekend during prime hours, producing videos of people complaining about the law’s effects, and cutting the outreach budget by 90%. The result was a 10.5% decline in enrollment in Federally Facilitated Marketplace states. Meanwhile, states running their own exchange saw a 1.5% increase in enrollment.7 This is likely modest compared with what would have happened in the absence of federal sabotage, but it helps put the study by Blewett et al. in a broader context, showing just how much state leadership matters.
Footnotes
See also Blewett et al., p. 924.
REFERENCES
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