Kentucky Republican Governor-elect Matt Bevin addresses his supporters during his victory speech. | AP Photo Kentucky health law repeal: Not so fast Governor-elect Bevin is already easing back from his promise to abolish Obamacare in the state.

Matt Bevin won the Kentucky governorship on a vow to dismantle Obamacare, but the obstacles he faces rolling back a law that covers nearly one in 10 Kentuckians offers a preview of the struggles that a Republican president would face living up to a “repeal and replace” pledge in 2017.

Even before the votes were cast, Bevin had started hedging his repeal bet, saying he would not take coverage away from people who have it. He can give the health law in his state a more conservative veneer. But he can’t scrap it completely.


“Vowing to repeal the Affordable Care Act in some cases has been used as an effective political strategy, but it’s not a terribly effective governing strategy,” White House press secretary Josh Earnest said Wednesday.

And that’s the reality facing the GOP contenders for the White House in 2016. A new president can undermine Obamacare by halting outreach and advocacy, rewriting the rules and starving it of funds. But that’s still a far cry from yanking the whole law up by its roots.

“Throwing 10 million people out of the marketplace and however many millions of people off of Medicaid is not going to be very easy politically,” said Tim Jost, an expert on the Affordable Care Act and a consumer advocate. “Somebody is going to have to answer for everybody who would lose coverage. I haven’t seen any Republican proposal that would come close to replacing the ACA in terms of the number of people it would cover.”

That doesn’t mean foes of Obamacare aren’t buoyed by Bevin’s win over Democratic Attorney General Jack Conway in a race that previewed themes of the 2016 presidential campaign.

"The lesson for Republicans is to be bold," Americans for Prosperity President Tim Phillips said after Bevin's win. “The lesson for any Democrat running is that if they embrace Obamacare, they do so at their own political peril,” he added, noting that Kentucky voters punctured the myth of their state’s Obamacare success.

Kentucky has been a beacon of Obamacare in the South because of its embrace of the president’s signature domestic achievement under outgoing Gov. Steve Beshear, a Democrat. About half a million people are covered through Kentucky's state-run health insurance exchange and its Medicaid expansion. The state has seen an unparalleled drop in its uninsured rate.

Even Bevin, a Tea Party favorite, acknowledged the difficulty of undoing Obamacare in the state.

“It’s like going to war,” Bevin said at a forum during the campaign. “You don’t just come home on Tuesday.”

At first, though, Bevin made bold promises. In his "Blueprint for a Better Kentucky" he said that undoing the Medicaid expansion that has brought coverage to more than 400,000 low-income adults “would be financially prudent and give Kentucky more control over how medical financial assistance is administered.”

Beshear set up Obamacare in Kentucky through executive orders, and Bevin could use his own executive orders to reverse course on both the marketplace and Medicaid expansion.

“He was the person who ran saying he was beholden to nobody,” said Judy Solomon, vice president for health policy at the Center on Budget and Policy Priorities, a left-leaning think tank that supports the Affordable Care Act.

But Bevin shifted to say he would look at how other red states have molded the low-income health care program along more conservative lines. He’s mentioned Indiana, where some people on Medicaid now have to pay modest premiums for coverage.

And if he tries to scale back Medicaid too much, he could crash into another complication: an obscure 1966 state law that requires the state to draw on all the federal dollars available for Medicaid. Advocates say any move to leave federal dollars untapped would likely lead to a lawsuit. The federal government is fully funding expansion through 2016, and will pay at least 90 percent in future years.

Nor can Bevin completely do away with health insurance exchanges, the online marketplaces that let people shop for subsidized health plans. A governor just can’t unilaterally toss out a federal law. He could scrap the state-run marketplace, called Kynect. But people would then switch to HealthCare.gov, the portal to the federal marketplace.

Bevin could also trim efforts to get people to sign up — and given how much public confusion persists about Obamacare insurance, cutting back on outreach might dampen enrollment, although various advocacy groups would try to fill the gap.

“There will be a difference between having a state-based exchange and potentially going to the federal exchange,” said Emily Beauregard, executive director of Kentucky Voices for Health, a consumer advocacy group. “There will be changes that could make access to health coverage more difficult.”

The election results gave a hint of consumer confusion that could increase. Audrey Haynes, secretary of Kentucky’s Cabinet for Health and Family Services, said Kynect was already getting some calls from people worried about keeping their insurance and asking if they should re-enroll for next year. The help line changed its script to reassure callers that they were covered — and should go ahead and sign up for next year.

Al Cross, director of the Institute for Rural Journalism and Community Issues at the University of Kentucky, also pointed out that not all the decisions are up to the governor-elect.

“A key thing to remember at this point is the Republican president of the Senate, Robert Stivers, made clear in July that the Legislature was going to decide the future of the Medicaid expansion,” Cross said.

He recalled that just one day later, Bevin stopped talking about killing expansion and started talking instead about changing it.

Cross wonders whether Bevin might have similar second thoughts about scrapping Kynect, given that it’s had far fewer glitches than many of the marketplaces — and that the Beshear administration has estimated that scrapping it would cost $23 million.

“It may be a test of Bevin’s pragmatic streak,” Cross said. “He’s a businessman; he’s been in the military. You’ve got to do what works. He might be persuaded Kynect isn’t worth killing.”

The failure of Kentucky Health Cooperative less than a month before Election Day was also a wild card in the race. Roughly 50,000 Kentuckians enrolled in plans sold by the nonprofit startup, established with $146 million in ACA loan dollars. They now face the prospect of scrambling to find new coverage during the current open enrollment period, which began Sunday and lasts three months.

Bevin seized on the collapse of the co-op plan — one of a dozen such failures nationwide — as evidence that Kentucky’s Obamacare infrastructure was crumbling.

“Everybody wanted to portray it as this great thing,” Stivers said of the Obamacare efforts. “But you don’t see a whole lot of people who are satisfied with it. … I think that was loud and clear last night.”

Ron Pollack of Families USA sees a gap between the political rhetoric and the coverage reality — and he doesn’t see the health law disappearing. “The ultimate lesson here,” he said, “is that because so many people have gained coverage already through the Affordable Care Act that legislation is a whole lot more resilient than the rhetoric you hear from its opponents.”

