Alan Shafer should be a walking advertisement for Barack Obama's Affordable Care Act, the landmark U.S. legislation that takes aim at the country's uninsured.

He's from Kentucky, a poverty-stricken state that has the most to gain from Obamacare. A former steakhouse chef, he can't work because of stomach pain and numbness in his feet. He's uninsured and the act should, in theory, help him access doctors and testing.

Like many in Bluegrass country, however, Mr. Shafer doesn't want Obamacare, a crucial election platform plank for the President and his party.

Story continues below advertisement

One of the law's key provisions will make Mr. Shafer buy a health-care plan and he just doesn't have the money.

"How can I take insurance if I can't pay for it?" said the 50-year-old in the waiting room of the Mission Free Clinic, a faith-based facility that sits alone among disused buildings on a former mental-health hospital's grounds in suburban Lexington.

Affordable Care is meant to make sure nearly all Americans have health-care coverage, using a mix of government programs and private insurance companies.

The act, the ill-begotten child of numerous congressional compromises, is the single largest domestic achievement of Mr. Obama's term – and a tough piece of legislation to explain to voters. He won't have to worry about Kentucky. It's firmly in the Republican win column nationally. But even with the program's strengths, selling it in swing states like neighbouring Ohio, for instance, will prove difficult.

Steve Christensen, a software consultant and Obamacare supporter, sums up the problem outside a Lexington hospital with his wife, who is recuperating from pancreatitis. "People who are against it spout out, 'Oh, Obama will force everyone to buy insurance.' They exaggerate that but they don't know anything about the good points," he said. "They miss the big picture."

THE MOST NEEDY STATE IS THE MOST RELUCTANT

The numbers back him up. The Urban Institute, a Washington-based think tank, estimates that Kentucky would save money under Obamacare: The law defers some health-care costs to the federal government. The new rules also allow people to write off insurance costs on their taxes.

Story continues below advertisement

A recent report from The Kaiser Family Foundation shows that one of the act's key provisions – expanding government-run Medicaid – would provide the greatest benefit to GOP-leaning states such as Mississippi, West Virginia and Alabama, states that will almost certainly vote against Mr. Obama's re-election bid. The state with the most to gain would be Kentucky, whose proportion of uninsured adults would drop by 57 per cent.

About 15 per cent of the population doesn't have insurance.

Kentuckians struggle with above-average rates of heart disease, diabetes and lung cancer, according to the Kentucky Institute of Medicine. Many of the health problems are due to poor lifestyle choices such as smoking and diet. Almost half of the population lives in rural counties and does not receive enough preventative or primary care due to the lack of doctors.

Yet the state's Democratic governor, Steve Beshear, is mulling whether to opt out of Medicaid, and sympathetic swing voters are raising similar concerns.

Dr. M.A. Winchester, a retired physician who volunteers at free clinics for the uninsured, says he's inclined to support some sort of single-tier system, but he thinks the Affordable Care Act is so complicated it will drive up costs. The genial 79-year-old with a small pair of spectacles perched on his nose and socks adorned with a stethoscope pattern, voted for Mr. Obama four years ago. He's still weighing his decision this time around.

"I don't think we can afford it, that's the problem," he said. "Everything that's good about it adds to someone's expense. We'll have to have a tax increase."

Story continues below advertisement

Affordable Care is supposed to be a magic pill for the country's uninsured, but its numerous provisions resemble a complex cocktail of drugs. There are rules that force insurance companies to cover more people; provisions that expand Medicaid, a joint federal-state program that provides free care to the poor and disabled; and a new law called the "individual mandate" that forces everyone to buy insurance or get slapped with a fine.

And, like Mr. Shafer, many say they can't afford it.

THOSE WHO NEED IT MOST SAY THEY CAN'T AFFORD IT

The average health-care plan costs a little under $200 a month, money Dale Fryman doesn't have. A 53-year-old electrician, he has had trouble finding work since the recession and is already paying to put one of his children through university. Plus, he owes about $600 for an operation on his wife.

"I'll either be taxed to death or thrown in jail," he said, standing in the blistering late afternoon sun outside Saint Joseph, a hilltop hospital.

His friend, Bob Dixon, a paraplegic undergoing a fistula operation – part of his digestive system was poking against his skin – uses Medicaid to pay part of his bills, but also uses a private insurance company to supplement his coverage. When the new law come down, he said, his insurer will pass on the added cost by doubling his premiums.

Story continues below advertisement

"My insurance rates are going up now," said the 59-year-old embalmer, lying on a wheel bed.

It isn't just individual patients who are double-checking their wallets. Some legislators argue a larger Medicaid program would add hundreds of millions to the budget in a state that cut program spending by 8.5 per cent this year to balance its books.

And on the ground, Mr. Obama's opponents are proposing health-care laws of their own.

OTHER PRESCRIPTIONS

Members of Kentucky's powerful Tea Party, for instance, advocate removing existing restrictions on the insurance market, such as laws that prevent residents of one state from buying insurance from a company in a different one.

"We understand health care needs help, needs reforms. If we had a competitive market, it would drive costs down," said Tea Party activist Mica Sims, sitting in a pub tucked into a mall of big-box stores near the outskirts of town.

Story continues below advertisement

The only simple thing, perhaps, is the demand for change. And nowhere is this more evident than at free clinics like the Mission, where thousands of Kentuckians depend on the kindness of volunteer doctors and the donations of churches to secure medical treatment.

Across town, on a side street in the working-class neighbourhood of Davis Bottoms, Nathaniel United Methodist Mission handles about 2,400 patient visits every year for medical and dental care. Since the economic downturn, the place has seen an uptick in new patients, Rev. David MacFarland says. Many of them have jobs but, with minimum wage translating into roughly $15,000 a year, they can't afford the $2,000 or so for insurance.

Even with the new laws, Mr. MacFarland says, there may still be people who fall through the cracks. Some of those who will gain insurance, for instance, may only have "catastrophic coverage" – a plan that covers worst-case scenarios, like a car crash or cancer diagnosis – but won't have anywhere to go for routine ailments. The clinic, he says, will likely keep going.

"The Christian response is to go to the margins. I feel there will always be margins somewhere," he says.

The question is how big those margins will be.