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In Jackson County, Reliance on Medicaid and Support For Matt Bevin

McKEE — Angel Strong is among more than 400,000 Kentuckians who have gained health insurance through the state’s expansion of Medicaid under the Affordable Care Act.

She also voted for Matt Bevin, who made rolling back the state's health care expansion a central part of his platform. In his first news conference as governor-elect, Bevin said scaling back the Medicaid expansion would be a top priority for his administration.

But Strong takes issue with the notion that she voted against her interests. She said she voted on issues such as abortion and same-sex marriage.

“My religious beliefs outweigh whether or not I have insurance,” she said.

Strong lives in Jackson County, Ky., about 65 miles southeast of Lexington. Earlier this month, 83 percent of the county's voters supported the Republican Bevin.

The overwhelming support for the Obamacare opponent may take outsiders by surprise: Jackson County, population 13,289, has one of the highest Medicaid enrollment rates in Kentucky. At last tally, 50 percent of the county is enrolled in the program, according to state data. And Strong is one of 2,000 in the county to gain access through the expansion.

Kentucky’s state-run health insurance exchange — Kynect — and its expansion of Medicaid led to about half a million people gaining health insurance. Some were insured for the first time.

The state had the sharpest decrease in uninsured residents nationwide, an achievement attributed to outgoing Democratic Gov. Steve Beshear’s embrace of the Affordable Care Act. It's an achievement that may be largely undone by his successor.

There’s been a mad dash to explain why so many Kentuckians voted for a candidate who repeatedly vowed to roll back health care programs many of the state's residents recently began to rely upon. For their part, Jackson County residents like Strong offer a mix of explanations.

Going into the statewide election earlier this month, there were expectations that Democrats — who still outnumber Republicans in the state’s voter rolls — would leap to the defense of these programs. But that’s not what happened.

Instead, Bevin ran against those efforts and won by 9 percentage points.

What Happened?

There are a couple theories about why — or whether — the working poor vote for candidates who openly oppose programs that benefit them.

ProPublica's Alec MacGillis, writing recently in The New York Times, argued low-income people aren’t voting against their interests; they are largely not voting at all.

It's a widespread belief, including in Jackson County. Stephanie Wilson, who owns a hair salon here, said that's what she thinks happened in Kentucky this year.

“Typically those people are still at home,” Wilson said. “They are not leaving the house to go vote.”

But that’s not the whole story. Ask Angel Strong, whose hair Wilson was cutting as she talked about this year’s gubernatorial results.

Strong said she’s hoping to change her line of work. In the meantime, she needed health insurance, and so she signed up through the state's Medicaid expansion.

“I had never had Medicaid because I had insurance at my job,” Strong said. “I was a nurse, you know. But now I am out of a job and I am looking for another job, but in the meantime I had no income."

Still, she stands by her support of Bevin.

Shane Gabbard, the county’s newly elected Republican judge-executive and a local pastor, said Medicaid was largely absent from political discussions around town.

“I don’t think that people was really worried about the health care swing of it because it wasn’t a hot topic here, you know,” he said.

Dale Emmons, a Democratic political operative in nearby Richmond, said he’s not surprised to hear that a county heavily reliant on government health insurance would not vote to protect that program.

“People vote for different reasons,” Emmons said. “They don’t always necessarily vote for their material interests. I think there is an automatic assumption that they do that. But that’s not always the case. And this election proves that.”

Emmons argues the election — in which Democrats lost important races down the ballot as well as the governor's office — shouldn’t be seen as a “referendum” on the state’s health care policies. In fact, he said this isn’t about health care at all.

“Elections sometimes have contradictions in them,” he said.

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Poverty and Isolation

Jackson County is insular and struggles with poverty.

According to recent Census figures, 99 percent of the population is white. About 34 percent of residents live below the poverty line. That's compared with less than 19 percent of the population statewide.

It's also isolated. People who do work have a long commute into cities such as Berea, London and Richmond.

Gabbard, who ran for office for the first time in his life this year, said he sees larger issues at play in McKee, a town nestled in the Daniel Boone National Forest and Jackson's county seat.

He said generational poverty and decades without industry nearby are what people are dealing with the most around here.

“We don’t have a movie theater,” he explained. “We don’t have a skating rink. We don’t have a bowling alley. We don’t have nothing. We got one red light in the whole county. It’s about as small town as you can get.”

Gabbard calls McKee “a small town with a big heart.” Even though there aren't a lot of material incentives to keep people around, most stay because they love their neighbors. Just about everyone in town will quickly tell you Jackson County is full of the friendliest people you will ever meet.

At a nearby barbershop, Chad Tankersaley, 35, said the people in McKee are what keep him there. He’s worried, though, because there’s not enough opportunity.

“There are no jobs here,” he said. “There’s no money coming in.”

It’s always been that way. That was Tankersaley's reason for not voting in this election.

“I don’t know,” he said. “I just didn’t. I just got tired of voting. Because it don’t matter. It doesn’t seem like who got in there or who it was or who you vote for — I don’t know, it always ends up with the same result.”

Back at the hair salon next door, stylist Wilson said people in struggling rural communities feel like they don’t matter.

“I feel like … and I know this is going to sound terrible, but it’s not going to matter what we think,” she said. “Our vote doesn’t really count at all.”

The Turnout Problem

Wilson was one of only 2,771 people in Jackson County who actually voted in the 2015 gubernatorial election.

Just more than a quarter of the registered voters here cast ballots in this year’s gubernatorial election. According to the state Board of Elections, there are 9,846 registered voters in the county; 83 percent are Republicans and 13 percent are Democrats.

Many political observers say Kentucky Democrats lost this year largely because voters in Democrat-heavy counties didn’t turn out on Election Day. Statewide turnout was 30 percent, and that included Republican-dominated counties such as Jackson.

In other words, it's not just those living in poverty, or those on Medicaid, or those with insurance through their jobs: Not many people are voting at all.

Emmons said it’s hard to say what people are voting for when so many are opting out of the process entirely. He also said there is a rise in low-information voting recently that may be driving new trends. A large percentage of people are voting straight-ticket, down party lines.

According to the Jackson County Clerk of Courts office, about 1,400 people voted straight ticket. That’s half the people who voted at all.

Medicaid Ramifications

Regardless of the motivations of voters and non-voters, some in Kentucky are hunkering down for the results of this election.

Doug Justice is a "kynector" employed by the Kentucky River Foothills Development Council. He helps residents of Jackson County enroll in health care programs through Kynect. Every Monday and Wednesday, Justice can be found at the Jackson County Public Library waiting for people to come in for assistance.

He said a majority of the people he helps qualify for Medicaid.

“A lot of those people cannot afford the $200 or $300 [per month for private insurance],” he said. “Some of it is extremely expensive ... and they simply can’t afford that. They're either not working or they are working and their income level — they just can’t afford it. It’s that simple."

Justice, who’s been a kynector since the first Kynect open enrollment period in 2013, said there are a few who are enrolled in qualified health plans and receive federal subsidies to help afford their premiums. But for the most part, he said, the people in his hometown have benefited from Kynect.

Under Bevin, the program may no longer exist in the way they’ve come to know it these last two years. He has said the state’s health insurance exchange is redundant because Kentuckians can get the same benefits via the federal exchange. As for Medicaid expansion, Bevin may apply for a federal waiver from the Centers for Medicare and Medicaid Services to give the state more flexibility in how it operates Medicaid.

Bevin has yet to offer details on what his scaled-back Medicaid expansion may look like, other than to suggest recipients contribute financially in some way. That could mean a program similar to Indiana's, where Medicaid enrollees pay some portion of a monthly premium. Experts say it will be at least a year before changes are approved and finalized.

Still, Justice said some Jackson County residents are wondering what it may mean for them and their health insurance.

“I have had people ask me about that, and I tell them like everybody else, I know there is a new government coming in that’s going to make changes,” he said. “That’s all the information I have about that."

With the economic challenges in Jackson County, people try to take life one day at time, Justice said. That doesn’t always include concerns about what the state’s next governor plans to do about health care.

“They’re not getting into the details of that either, because they don’t understand the ramifications of that should it happen, or they’re just going to deal with it when it takes place,” Justice said.

Still, Justice said he has helped many people who were in dire need of health care.

“I had a lady come to me who had cancer and lost her job," he said. "When she lost her job, she lost her insurance. Things just kind of snowballed. We were able to get her insurance to get her treatment. And that’s just one example, and I’ve had others as well."

Justice said people may have varying opinions on Obamacare, but he believes it’s done some good.

“If you ask me on a scale of one to 10, the people that it has helped, did it help?" he said. "On a scale of one to 10 — seven or eight, or better. It’s helped them. Yep. It sure has."

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