By John Cheves

After many years without health insurance, Cathy Ingram recently got a subsidized policy through the state-run Kynect exchange. Her first stop was the dentist, who pulled some rotten teeth infecting her gums.

"For a long time, my teeth were giving me so much trouble that I would get a migraine," said Ingram, 37, who does cleaning and laundry work around Lexington. "It felt like my eardrums were going to burst. But now that they've got my teeth out, I feel fine."

Ingram can visit her dentist because Gov. Steve Beshear decided in his second term to fully embrace the federal Patient Protection and Affordable Care Act of 2010, which many call Obamacare.

Voters going to the polls Nov. 3 to choose Beshear's successor will decide the Affordable Care Act's future in Kentucky.

By executive order, Beshear, a Democrat, bypassed the politically divided General Assembly to create Kynect, an online marketplace of insurance policies, with public subsidies available to help many people buy a private plan. Beshear also expanded the state's Medicaid program to include people in households with incomes up to 138 percent of the poverty line -- $33,465 for a family of four.

The state spent millions publicizing Kynect and sending agents, known as "Kynectors," into communities to sign up people like Ingram. Federal funding and a 1 percent assessment on insurance plans paid for nearly all of this.

The results were dramatic. In 2011, 14.4 percent of Kentuckians were uninsured. That figure plunged to 8.5 percent by 2014. No state saw a bigger drop. More than 400,000 people got coverage -- mostly through Medicaid -- letting them visit doctors, order prescription drugs, undergo preventive disease screening and enroll in psychiatric and addiction treatment.

However, the next governor can dismantle what Beshear built. Otherwise, he might have to find $923 million over the next four years to pay the state's share of Medicaid spending on newly eligible Kentuckians and those who already were eligible but didn't know until a Kynector told them.

Of the three men running for governor this fall, Democrat Jack Conway and independent Drew Curtis say they support Kynect, although they worry about looming Medicaid expenses. Conway has praised Beshear for "doing it the Kentucky way" -- letting the state run its own exchange rather than relying on the federal exchange, HealthCare.gov, which had a disastrous launch two years ago. States that did not embrace the Affordable Care Act as Kentucky did have seen comparatively little change in health coverage for their residents.

Republican Matt Bevin is staunchly opposed to Kynect. Bevin has said he would shut down the state exchange and tell Kentuckians to buy their plans instead through the federal exchange. As for the Medicaid expansion that covers several hundred thousand people, Bevin has said he would repeal it.

"Absolutely. No question about it. I would reverse that immediately," Bevin told reporters in February. "The fact that we have one out of four people in this state on Medicaid is unsustainable, it's unaffordable, and we need to create jobs in this state, not more government programs to cover people."

Once Conway started criticizing Bevin for being "callous," Bevin denied that he ever called for repealing the Medicaid expansion, and he modified his stance. Bevin now says he would narrow the eligibility for Medicaid and request a federal waiver to set new conditions for recipients, as Indiana does, such as charging premiums and deductibles that "require skin in the game."

"What Matt has said since, to add further context, is that we cannot offer Medicaid as it exists today to working-age, able-boded adults at 138 percent of the federal poverty line. We simply cannot afford it," Bevin spokeswoman Jessica Ditto said last week.

Health care advocates say this is the defining issue of the gubernatorial race.

"If you throw a few hundred thousand of your colleagues and neighbors off health insurance, then they would be back to using the hospital emergency rooms to seek medical care," said Susan Zepeda, president of the nonprofit Foundation For A Healthy Kentucky. "I think that would not only carry humanitarian implications, it would bring with it serious economic consequences for the state as well."

'A wonderful blessing'

By many measures, the Affordable Care Act worked as intended in Kentucky.

The law requires Americans to get health insurance or pay a penalty. Before it passed, one in five Kentuckians were uninsured. Now that figure is about one in 12.

It also mandates that insurance companies cover people with pre-existing medical conditions; let children stay on their parents' plans through age 26; and provide 10 "essential health benefits," including mental-health and substance-abuse treatment, prescription drugs and maternity and newborn care.

"This has been a huge deal. We now have people who can get their psycho pharmaceutical medications who could not get it before because they had no prescription coverage. It's a wonderful blessing to tell our people, 'You can have your medicine now, you're going to feel better,'" said Ginny Ramsey, who helps Lexington's homeless at the Catholic Action Center on East Fifth Street.

On the other hand, evan as insurance has become more accessible, it's not more affordable for people who pay for their coverage.

In 2015, monthly premiums for workplace insurance plans in the United States rose by an average of 4 percent, close to the average 5 percent annual growth over the previous decade, according to the Kaiser Family Foundation. Deductibles also keep rising, forcing people with workplace plans to pay more out of their own pockets.

And many Kentuckians aren't paying for their coverage, creating another problem.

Most of those who enroll through Kynect are signing up for Medicaid, a federal-state entitlement program traditionally meant for the poor and the disabled. Fewer than one-third of the Kentuckians who qualified for even a subsidized private insurance policy bought one.

The Beshear administration initially estimated that 147,000 Kentuckians would enroll in Medicaid during fiscal year 2014, rising to 187,000 by 2017 and then staying there. The actual numbers so far have been more than twice that, and as a result, Kentucky taxpayers will have to dig deeper into their pockets than expected.

The federal government paid 100 percent of Kentucky's expanded Medicaid costs for the first three years. That drops in the next fiscal year to 95 percent, and it keeps dropping until it reaches 90 percent in 2020. Kentucky's bill for 2017, once projected at $64 million, now could be $109 million. In four years, it could be $409 million, making it one of the single biggest expenses in the state's General Fund.

'We can't afford it'

This is the concern that Bevin raises on the campaign trail, that Kentucky is promising free medical care to masses of people with no idea how to pay for it. Kentucky struggled with its Medicaid expenses even before the Affordable Care Act, Bevin says.

"It's financially untenable," Bevin told voters in Elizabethtown during last spring's Republican primary. "The fact is, we can't afford it. We are already broke. We are already fast on the road to insolvency as a state."

Bevin says he would "transition" those currently using Kynect to the federal health exchange and seek waivers from the federal government that would let Kentucky impose new rules on Medicaid recipients. In Indiana, for example, which Bevin has cited as a model, Medicaid enrollees pay a monthly premium and some co-pays. They also can be temporarily locked out of coverage if they miss a payment and don't make it up within 60 days.

Health care advocates say the federal exchange charges higher assessments on insurance plans than Kentucky's does to pay for itself. Also, they say, the federal exchange doesn't provide the aggressive patient outreach in communities that Kentucky's Kynectors offer.

As for Medicaid program waivers, health care advocates say, every cost or restriction imposed on coverage makes it less likely that families will get the treatment they need. In Indiana, 11.9 percent of the population was uninsured in 2014, compared to Kentucky's 8.5 percent.

"That seems to be part of the purpose of these waiver programs, to reduce enrollment and cut costs," said William Wagner, executive director of Family Health Centers in Louisville, a chain of clinics that treats many patients using Kynect.

"Politicians talk about wanting Medicaid patients to 'have skin in the game' by making them pay something toward the cost of their medical care," Wagner said. "But my experience is, these are just administrative remedies intended to lower enrollment. I don't think we should want to lower enrollment. We're paying for these people one way or the other -- either up front through expanded Medicaid, where we're investing in a healthy work force for the future, or through uncompensated or indigent medical care when they finally come into the hospital emergency rooms, terribly sick."

Beshear insists that, in the long run, Kynect will pay for itself. Officials in his administration say some of the state's health costs, such as care for inmates and foster care children, are shifting to the federal government; health care jobs are being created as more people can afford to seek care, meaning more tax revenue for Frankfort; and a population that gets to see a doctor will be healthier and more productive.

"By suggesting a repeal of the expansion of Medicaid and choosing other 'plans' or waivers, Mr. Bevin should identify who among our newly insured Kentuckians he believes should lose health care coverage. Which hospitals, physicians and other providers does he think should bear the brunt of a return to increased uncompensated care?" Beshear said in a written statement last month. "This is a short-sighted view for the future of our commonwealth, which is the 47th-sickest state in the country."

Of course, Beshear leaves office in two months. Paying for the swollen Medicaid rolls will fall to his successor.

Conway publicly defends Kynect, but he hasn't explained where he would find hundreds of millions of dollars for Medicaid, on top of the billions owed to the state's public pension systems. Conway sides with Beshear in arguing that Kynect ultimately will pay for itself. It's also the right thing to do, Conway says.

"As governor, I'll continue to monitor this program and make the tough decisions about what we can and can't afford," Conway said. "If we need to scale it back in the future, we can. But I do not support kicking the hundreds of thousands of Kentuckians who have benefited from the Medicaid expansion off their health insurance right now because of something that may or may not happen in six years."

(c)2015 the Lexington Herald-Leader (Lexington, Ky.)