Big-Change or No-Change in Post-Election Kentucky Healthcare?

I have been out of the country these last two weeks and am trying to catch up. Perhaps the biggest news item while I was away happened just as I left town – the election of Matt Bevin as our next Governor.  I had only just learned of this fact when I was contacted by an out-of-state reporter who asked whether people in Kentucky who gained coverage through Medicaid expansion or through our KYNECT state insurance exchange should be concerned.  If so, why would people who only so recently obtained healthcare coverage vote for Mr. Bevin – as they obviously must have in winning fashion?

Of course they should be concerned!
I responded that based on Mr. Bevin’s campaign promises and comments alone, as reported by our local press, current KYNECT and Medicaid expansion recipients have every reason to worry about their future coverage and access to healthcare.  I would certainly worry if I were in their shoes and not the satisfied Medicare beneficiary that I am.  In the heat of the campaign, and to appeal to virulent anti-Obama haters, Tea-Partiers, and other conservative voters; Mr. Bevin unequivocally promised to undo as much as possible of the Affordable Care Act (ACA) implemented in Kentucky by Governor Steve Beshear.  At least that is what I heard.

Real promises or campaign maybes?
Campaign promises included unwinding Kentucky’s successful KYNECT insurance plan, or switching it from a state-run plan to a federal plan.  It also seemed clear to me that Mr. Bevin promised to end or roll back the Medicaid expansions that have numerically provided the most coverage to previously uninsured Kentuckians. (Mr. Bevin later apparently hedged his promise to something short of a full roll-back.)  Much was made during the campaign of Mr. Bevin’s possible confusion of Medicare and Medicaid, and statements about whether beneficiaries of publicly-financed healthcare should be required to submit urine tests for illegal drugs.  I took some of this to be red-meat stuff thrown Trump-style by both parties to their admiring crowds.  I would rather see Governor-elect Bevin improve what we have rather than walk away from it solely to satisfy his political base.

Are campaign promises immaterial?
Shouldn’t we be able to take the promises of political candidates at their word?   Are candidates for public office free to say whatever they feel will get them elected without any intention to follow through?  I hope not. Mr. Bevin ran on his promises, and he won.  Nonetheless, I am thinking of the story about the dog that chases the car.  What does he do when he catches it?  Now that he has won the election, Mr. Bevin is going to have to clarify and reconcile all the campaign promises he made and to turn them into discrete legislative and policy initiatives.

I do not know why Mr. Bevin thinks a federal exchange would be better or less expensive for Kentuckians than KYNECT – he will have to explain why.  In terms of dumping current beneficiaries from Medicaid or not adding any new ones, Mr. Bevin will have to defend why this would be a humane thing to do.  When Mr. Bevin is able to catch his post-election breath and explain what he said, I predict there will be much gnashing of teeth on both sides over promises made and promises kept.  Surely many of the people who voted for him are currently benefiting from the Obama/Accountable Care Act. The nation is very interested in what is happening in Kentucky.

Who gets to decide what is in my best interest?
Over a half-million individuals so far gained healthcare insurance as a result of Kentucky’s embrace of the ACA.  Less than a million people voted for Governor earlier in the month when Mr Bevin won over Mr. Conway by some 85,000 votes.  A Transylvania political scientist, Andrea Malji, is reported to have found a strong correlation between the numbers of Medicaid beneficiaries in a given Kentucky count and the percentage of votes for Mr. Bevin. That is to say, counties with the most Medicaid enrollees voted most strongly for Mr. Bevin.  Of course, it is probably true that many Medicaid patients don’t vote, but there were enough of these to hand Mr. Bevin the Governorship. Is it fair to say that these voters voted against their best interests?

Voting against one’s overall best interest is a phenomena discussed by better political scientists than I, but the thing I remember best from my introduction-to-government course in college is that American voters are rather magnificently uninformed about who is representing them and how.  In my opinion, what we have just seen in this election is in large measure a consequence of narrow- or single-interest politics. So long as I get to carry my gun where I want, or get to decide what laws I choose to follow based on my religious preferences, or can keep other women from using contraception or having an abortion, or can thwart the initiatives of a black president, or can prevent loving people of the same sex from marrying, or [insert other identity-defining issue here] –  I am willing to be diverted from the reality that I may be cutting off my nose to spite my face.

When President Obama pointed out early in his terms of office that people can be easily convinced to vote against their best interests, he drew so much criticism that, as I recall, he backtracked from that argument.  Who is it that gets to define what is in any other person’s best interest?   Of course, it is a matter of settled fact that people can be convinced to drink even the fatal Kool-Aid.

I do not think it will happen.
I do not believe it is incorrect when it is said that most folks who hate Obama (and therefore his Care) like the new opportunities and coverage they have gained through the Affordable Care Act!  It will be interesting to see if and how their voices get heard.  I am reminded of the 1989 image of U.S. Representative Dan Rostenkowski of Chicago (Chairman of the committee that spearheaded a new law raising premiums for Medicare beneficiaries) as he fled his car to escape from a band of unhappy but not impotent elderly voters. The Law was repealed.  Medicare is not called a “third rail” of legislation for nothing.

Medicaid beneficiaries, by virtue of their socioeconomic status, do not have the political clout of Medicare voters.  It remains to be seen if those who gained access to healthcare only to lose it will have any such recourse.  Certainly the healthcare industry of Kentucky recognizes the benefits to Kentucky of the Affordable Care Act and is already telling the Governor-elect he would be making a bad mistake to follow through on his promises to undo its most important implementations in Kentucky.  Mr. Bevin has won – now he must govern.  How he reconciles his promises with the reality already on the ground will define the tenure of our new Governor.

Peter Hasselbacher, MD
President, KHPI
Emeritus Professor of Medicine, UofL
18 November 2015