One of the first issues Matt Bevin will confront as the new governor of Kentucky is how far to take his pledge to roll back parts of the state's Medicaid expansion under the Affordable Care Act.
The effects could be particularly dramatic in places such as Jackson County, one of the poorest counties in Kentucky. Half of the population of 13,000 is on Medicaid, the state and national program that provides health care insurance to low-income Americans. According to Census figures, 34 percent of Jackson County's residents live below the poverty line, compared to almost 19 percent of the population statewide.
But even as many in the county depend on government help to access health care, residents overwhelmingly voted for Bevin, a Republican who called the state's expansion of Medicaid under the Affordable Care Act, "unsustainable" and "unaffordable" and has vowed to dismantle Kentucky's health insurance exchange.
Among those on Medicaid in Jackson County is Angel Strong, an unemployed nurse in McKee, Ky. — one of roughly half a million Kentuckians who received health insurance after outgoing Gov. Steve Beshear, a Democrat, embraced the Affordable Care Act's Medicaid expansion. Kentucky saw one of the sharpest declines in the rate of uninsured adults.
"I had never had Medicaid, because I had insurance at my job," said Strong. "Now I am out of a job and I am looking for another job, but in the meantime I had no income."
Religious beliefs "outweigh" having health insurance
Bevin's lack of support for expanded Medicaid didn't faze Strong, who voted for Bevin because she supported his socially conservative stands against gay marriage and abortion.
"My religious beliefs outweigh whether or not I have insurance," Strong said.
Most Jackson County residents are in Strong's shoes and need some kind of financial help to get health insurance coverage, said Doug Justice, who helps locals sign up for insurance.
"I do have some who are subsidized," he explained. "They get some help there but the majority of [my cases are] Medicaid. A lot of it is. And it's helped a lot of people."
Justice said many in Jackson County did not have the future of Medicaid in their state in mind when they went into the voting booth last month.
"They are not getting into the details of that either," Justice said. "Maybe because they don't understand the ramifications of that should it happen, or they're just thinking, 'I'll deal with it when it takes place.'"
Shane Gabbard, a county administrator and a local pastor, was also not surprised that Medicaid didn't play a bigger role in this year's election.
"I don't think that people were really worried about the health care swing of it because it wasn't a hot topic here," Gabbard said.
In Jackson County, the lack jobs and other day-to-day issues related to poverty loom larger than health care, Gabbard said.
"Unfortunately we don't have a lot of factories here right now. We are working on that — trying to get some industry going," said Gabbard. "We don't have a movie theater. We don't have a skating rink. We don't have a bowling alley. We don't have nothing."
If Bevin does try to reduce Kentucky's Medicaid rolls, he'll get plenty of support from Strong, who said tough love might be good for some people in Jackson County as she was getting a haircut around the corner from the public library where Justice was signing up people for health insurance.
Strong, and her hair stylist, Stephanie Wilson, both voted for Bevin because they believe too many people in Jackson County rely on the government.
"They want everything they can get for free," Strong said.
"They think somebody owes it to them — just because," chimed in Wilson. "Nobody owes you anything. You earn what you get."
With a nursing background, Strong said she plans on finding a new job soon so that she can leave Medicaid. Both women are optimistic Bevin, a former businessman, will improve the economy in their corner of the state — which has yet to catch a break.
DAVID GREENE, HOST:
They are preparing for an inauguration in the state of Kentucky. Matt Bevin is being sworn in as the governor of that state. He won election while promising to roll back an expansion of Medicaid under the Affordable Care Act. Ashley Lopez from member station WFPL has been spending time in a county where many people depend on Medicaid.
STEPHANIE WILSON: I haven't - I'm not done.
ASHLEY LOPEZ, BYLINE: Stephanie Wilson is cutting Angel Strong's hair at a salon in McKee, Ky.
WILSON: All right, you want it shorter?
ANGEL STRONG: I want some poof back there.
LOPEZ: McKee is a tiny town nestled in the middle of the Daniel Boone National Forest in Eastern Kentucky. The town is in Jackson County, where the population barely breaks 13,000. And half of the people who live here are on Medicaid. Strong, the woman who's getting her hair cut, is one of them.
STRONG: I had never had Medicaid 'cause I had insurance at my job. I was a nurse, you know? But I just - now I'm out of a job. And I'm looking for another job. But in the meantime, I had no income.
LOPEZ: Strong got Medicaid recently because the outgoing governor embraced Obamacare. But the incoming governor, Matt Bevin, isn't a fan of expanded Medicaid. Strong says Bevin's position didn't affect her vote. She cares more about stopping gay marriage and abortion.
STRONG: My religious beliefs outweigh whether or not I have insurance.
SHANE GABBARD: I don't think that people was really worried about the health care swing of it 'cause it's not a hot topic here, you know.
LOPEZ: That's Shane Gabbard. He's a county administrator and a local pastor. He says people worry about how there's nothing to do here, and there are no jobs.
GABBARD: Unfortunately, we don't have a lot of factories here right now. We're working on that, trying to get some - get some industry going. And so we have a lot of people who have commuted out of the county to work.
LOPEZ: While Kentucky's cities and suburbs have recovered from the recession, rural Kentucky is still struggling. Thirty-four percent of Jackson County's residents live below the poverty line, compared to almost 19 percent of the population statewide. Doug Justice helps people in Jackson County sign up for health insurance. He says most people here need some kind of financial help to get covered.
DOUG JUSTICE: I do have some who are subsidized, you know. They get some help there. But the majority of mine's Medicaid. A lot of it is. And it's helped a lot of people.
LOPEZ: Even though the future of Medicaid in Kentucky is cloudy, Justice says people don't seem worried about it.
JUSTICE: They're not getting into the details. That either may be because they don't understand the ramifications of that should it happen, or they're just - they just say, well, I'll deal with it when it takes place.
LOPEZ: Back at the hair salon in McKee, stylist Stephanie Wilson and her client, Angel Strong, say tough love might be good for some people around here. Both women say they voted for Matt Bevin because they say too many people in Jackson County rely on the government.
STRONG: They want everything they can get for free.
WILSON: And they think somebody owes it to them just because. Nobody knows you anything. You earn what you get.
LOPEZ: Strong says she's optimistic Bevin will boost the economy, which will make it easier for her to find another job soon. Then she'll no longer need Medicaid. For NPR News, I'm Ashley Lopez in McKee, Ky. Transcript provided by NPR, Copyright NPR.