Rebecca Esparza is a 41-year-old single mother of three from Lawrence who works part-time at the local homeless shelter and studies social work at Kansas University. And she doesn't have health insurance.
She thought the Affordable Care Act, the 2010 law often called Obamacare, would change that. But when she went to a local clinic to enroll, she found out she didn't make enough money to qualify for tax subsidies to help obtain private insurance. On the other hand, her income put her above the eligibility threshold for KanCare, the state's Medicaid program.
If Esparza lived in another state whose name starts with a K, one, like Kansas, that voted overwhelmingly against President Barack Obama in the last two elections and whose flagship university is famous for its basketball prowess, she would have health insurance.
Kentucky fully participates in the Affordable Care Act, having eased the eligibility requirements for Medicaid and created its own health insurance marketplace, while Kansas does not. In turn, Kentucky has reduced its uninsured population by, according to some estimates, two-thirds, while Kansas has barely made a dent in its number of residents who lack health coverage. The states started out with similar uninsured rates (12 percent in Kansas versus 14 percent in Kentucky).
So how did Kentucky do it?
The answer, largely, resides in the governor's mansion. Democrat Steve Beshear, without the support of his state legislature, expanded Medicaid and set up a state-based marketplace through executive orders. He later called covering the state's uninsured population "a moral issue."
"Over 400,000 people in Kentucky have voted with their feet or pocketbooks in obtaining private insurance and Medicaid," said Susan Zepeda, president and CEO of the Foundation for a Healthy Kentucky. "It's clear the state has embraced this opportunity to get insurance among families who previously didn't have access."
She said expanding health coverage was imperative in a state whose poor population has abnormally high rates of preventable chronic diseases.
Medicaid expansion drives numbers
Kansas and Kentucky had a similar percentage of their populations enroll in private insurance through the Affordable Care Act — Kansas residents just had to go to HealthCare.gov, which is operated by the federal government, while Kentuckians used Kynect, which is run by the state. Where Kentucky drastically reduced its uninsured rate was through its Medicaid expansion, which has provided coverage to more than 350,000 people in the state so far.
Kansas Rep. Dave Crum, R-Augusta, who chairs the House Health and Human Services Committee, said the state shouldn't consider expanding Medicaid until the federal government gets the growth of its entitlement spending under control and Kansas works out the kinks in its KanCare program. Under KanCare, three private managed-care organizations last year began operating the state's Medicaid program in the hopes of cutting costs and improving quality of care.
Supporters of Obamacare's Medicaid expansion often point out that the federal government is covering the entirety of the costs for the first three years, then 90 percent after that, and that the state is leaving billions of dollars of federal aid on the table over the next several years. But Crum notes that money has to come from somewhere.
"There's a feeling that when the federal government pays for something it's free," he said. "That thought process is part of the reason our federal government has a $17 trillion debt. Until states are willing to acknowledge the fact that our federal government is in debt and we're borrowing money to fund the Medicaid expansion, there's no way we're going to get the situation in Washington fixed."
Politics not completely similar
Even though Kansas and Kentucky have in recent years voted overwhelmingly for Republicans in national elections, their politics are by no means identical. The Kentucky governor's office and House of Representatives are both run by Democrats, while in Kansas the legislative and executive branches both are controlled by the GOP. In Kentucky all the statewide officeholders but one are Democrats, while in Kansas they're all Republicans.
While the majority of Kentuckians might agree with the Republican party on social issues, they are often more in step with Democrats on economic matters, said Stephen Voss, a political science professor at the University of Kentucky.
"We have a jargon term for it: dual partisanship," said Voss, asserting that Kentuckians are to a considerable degree economic populists. "People can literally identify with one party at the national level and another one at the state and national levels."
He added that this is largely a phenomenon of the South, which supported the Democratic party until the civil rights movement of the mid-20th century.
Not everyone in Kentucky thinks health care reform has been a success. David Adams, a tea party activist from Nicholasville, Ky., believes it will eventually come crashing down, either because a court overrules the governor's decisions, which Adams claims were illegal, or under the weight of its financial obligations.
"Unfortunately, the governor has insisted on running this without legal authority," said Adams, who has filed lawsuits challenging the legality of the state's Medicaid expansion and insurance marketplace. "He's too busy speaking to left-wing groups in Washington, D.C., and accepting congratulations on his 'massive success' without bothering to follow the law back here."
Adams also pointed out that Kentucky hospitals have recently reported an influx of newly insured Medicaid patients showing up in their emergency rooms because of the Affordable Care Act.
A lot left unsettled
Time will ultimately tell how successful health care reform is in Kentucky. While its implementation has been almost entirely funded by the federal government, the law gradually requires states to cover a greater share of the costs of their marketplaces and Medicaid expansions.
The state will start paying for Kynect next year using funds from a now-defunct high risk insurance pool, said Gwenda Bond, spokeswoman for the Kentucky Cabinet for Health and Family Services. Meanwhile, the federal government covers 100 percent of the Medicaid expansion through 2016.
In Kentucky, people continue to sign up for Medicaid under the state's eased eligibility requirements. But that's cold comfort for Esparza, the Lawrence single mother, who believes she's being penalized by the government for working. If she quit her job, she says, she would likely qualify for KanCare and even disability insurance.
And while she freely admits she hasn't always been a health-conscious person, she says that in recent years she has quit smoking and started exercising more. But she still often puts off needed care because of her lack of coverage.
"I could either completely mooch off the government and they'll cover my health issues, or I could go to work and do the best I can and continue to be sick," she said. "I'm not asking for a handout; I'm asking for a hand up."