In the South, the Obamacare debate continues, even as law insures thousands

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FRANKFORT, Ky.—In one of the poorest areas of Appalachia, about 2500 people have signed up to get health insurance over the last six months – a number that represents more than a tenth of Clay County’s residents.

One hundred and twenty miles way, the county’s state senator, Robert Stivers, is laying out his plans to gradually gut the Affordable Care Act in Kentucky, which provided his constituents with insurance. The soft-spoken 52-year-old Republican is hardly a fiery Tea Party type: he first joined the state legislature back in 1997 and slowly rose through the ranks to become the state Senate president. In a mid-March interview in a small room just off the floor of the Senate in Kentucky’s Capitol building, Stivers acknowledged that Kentucky Gov. Steve Beshear had handled the rollout of Obama’s health-care law smoothly in this state and that some people in his district now have health insurance for the first time.

Stivers, though, is unmoved. The Affordable Care Act, he says, is “unsustainable” in the long run. If Republicans can gain more seats in the state legislature here over the next year, he said, they will look to peel back Kentucky’s participation in the health-care law by limiting  the expansion of Medicaid in the state.

And he backs scrapping the entire law, too, at the federal level. “I do think it should be repealed,” Stivers said emphatically at the end of the interview.

Kentucky’s implementation of the Affordable Care Act has been successful, with a well-functioning state website from Day 1 of open enrollment and a major push that’s led to more than 300,000 signing up for the exchanges or Medicaid. Indeed, the rollout in this red state has been so successful that President Obama invited Beshear, a Democrat, to attend the State of the Union address in January and praised him by name during the speech.

Far from being seen as a success story, though, in Kentucky, the health-care law and Beshear’s strong embrace of it remain deeply controversial. A recent poll here showed a plurality of Kentuckians continue to favor repealing the law. Other than Beshear, many of the state’s leading Democrats, aware of the lingering tensions around the ACA, avoid speaking about it publicly, wary of being seen as too supportive of “Obamacare.”

And Kentucky Republicans are acting just like those in Washington and states around the country: GOP state legislators in the Democratic-controlled Kentucky House this month pushed unsuccessfully for a provision to repeal the state’s Medicaid expansion under the ACA and suspend its health-care exchange.

“The politics have really not changed,” said Regan Hunt, executive director of Kentucky Voices for Health, a non-profit group that supports the health-care law. She noted that while it’s easy to find Republicans in the state’s legislature who will publicly blast the law, “I don’t know if we have true Democratic champions” besides Beshear.

The lingering opposition isn’t surprising. Kentucky didn’t become the poster child for Obamacare because of a broad consensus in the state, but because of the actions of one man: Beshear.

Like the rest of the South, the state, once dominated by Democrats, has moved decidedly right over the last 15 years. Bill Clinton won here in 1992 and 1996, but President Obama was defeated by 23 points in 2012. Kentucky’s U.S. senators, Mitch McConnell and Rand Paul, are ardent conservatives.

At the same time, five of Kentucky’s six statewide, non-federal officers are Democrats, including Beshear, and the party has maintained a majority in the state House of Representatives. That’s because state Democrats distance themselves from the national party whenever possible. Beshear, first elected in 2007, won again in 2011 by blasting Obama as an enemy of the state’s coal industry.

Through his first five years in office, the governor had high approval ratings, but that was largely because he hewed close to the political center.

Then came Obamacare. Freed from political considerations because term limits prevent him from running again, Beshear over the last two years has stunned Republicans and even Democrats here with his forceful advocacy of the ACA. He unilaterally decided to create a health-care exchange and expand Medicaid, ignoring complaints from Republicans in the state’s legislature who either opposed those moves outright or wanted to reach some sort of compromise.

Kentucky is the only state in the South with expanded Medicaid and an exchange website built locally.

“Our statistics are horrible, our health statistics are among the worst in the country,” Beshear said in an interview in his office on the first floor of the Capitol, two floors below where Stivers and the legislators were meeting. He was referring to Kentucky’s high percentages of people who smoke, are obese or have dental problems.

“When the Affordable Care Act came along, it was a gift from heaven in the sense it gave us a tool to change the history of this commonwealth when it came to the health of our people,” Beshear said.

In the months before the October 2013 start of the new insurance options under the health-care law, Beshear and his aides prepared extensively. Their strategy was to try to reach Kentuckians everywhere, with enrollment events at state fairs and bourbon festivals, but also to name their insurance website “kynect” (combining the words “Kentucky” and “connect”) and de-emphasize the link between kynect and the national health-care law.

That approach worked. Even Republicans here say that some Kentuckians will criticize “Obamacare,” but in the next breadth emphasize how well “kynect” works, as if they are not part of the same law. Kentucky’s health-insurance website has also had few of the technical problems that have dogged healthcare.gov.

Beshear, to the consternation of Kentucky conservatives, has not only implemented the law without any input from them, but spent the last several months on something of a victory tour, penning an op-ed in the New York Times telling Obamacare opponents to “get over it,” making regular appearances on MSNBC highlighting Kentucky’s success and sitting in the First Lady’s box when Obama singled him out for praise.

The Republicans were initially caught flat-footed, particularly as enrollments surged in many of the state’s most conservative areas, which are also high in poverty. And some Republicans privately concede it will be difficult to roll back expansion of health insurance to so many.