A lawyer for a Kentucky nonprofit group, Stewart has spent the last two months holding workshops in bars, churches and libraries, explaining the state's health exchange and even helping people sign up. Some of them cried when they qualified for insurance. Most were skeptical that it would really work out. But no one left without some way to get covered.
"In Kentucky, everybody has an option," said Stewart, a fellow at the Kentucky Equal Justice Center. "Unless you're undocumented or in jail, there's something for you."
For Jeff Nelson, things haven't run so smoothly. Nelson is a social worker for The Right Place in Anniston, which has a contract to help people sign up on the federal health care website. Nelson had to put meetings with clients on hold last week to make sure the site was truly fixed. And some people find they're too poor for federal subsidies, but still not eligible for Medicaid.
"They go away with nothing," he said.
To health policy experts, Alabama and Kentucky look like near twins — Southern states with some of the highest rates of poverty, and some of the worst health outcomes, in the nation. But their approaches to the Affordable Care Act, also known as Obamacare, couldn't be more different.
In Kentucky, where Democratic Gov. Steve Beshear has embraced health care reform, the state health care exchange has been praised as a model of how health care reform should work.
By early November, about 50,000 applications for insurance had been filed through the program, one of the best compliance rates in the nation, according to federal numbers. Kentucky is now reporting 60,000 people signed up for either Medicaid or private insurance, though it's not clear how those numbers compare to early December numbers states with a federal exchange.
In Alabama, Republican Gov. Robert Bentley and other state officials have rejected both the Medicaid expansion and the option of creating a state health insurance exchange. Policy cancellations and higher rates from the state's biggest insurer have dominated the headlines. Only about 10,000 applications for insurance through the program were filed by early November — and only 642 people had bought insurance through the plan.
Many Alabama residents — 308,000 of them, by the most widely-used estimate — are expected to fall into a gap, too poor for subsidies but not covered by an expanded Medicaid program.
“I don’t know how we can help them,” Bentley told The Star. “I can tell you how they can be helped. If the federal government can repeal this law and start all over again, that’s how they can be helped.”
The difference in outcomes really is as stark as it looks, said Douglas Scutchfield, a professor of health services research at the University of Kentucky.
Scutchfield, who taught in Alabama for years, said that in demographic terms, the states really are strikingly similar. Politically, both are deeply conservative, and both are home to wide expanses of rural poverty.
"The only real difference is that most of your uninsured folks are black, and most of our uninsured folks are white," he said. "We have the Appalachians, you have the Black Belt."
Eighteen percent of Kentuckians live below the poverty line, compared to 14 percent of people nationwide according to census numbers. In Alabama, it's 17.6 percent.
Both states rank near the bottom on many key indicators of public health, such as obesity and diabetes.
And both states are usually reliable Republican territory. In Alabama, Republicans control both houses of the Legislature and all statewide offices. Kentucky sent Mitch McConnell and Rand Paul, two of the most vocal critics of President Barack Obama, to the Senate.
But Kentucky did one thing that was a little different. The Commonwealth elected Steve Beshear, a Democrat, as governor. While most Southern governors rejected Obamacare in every way possible, Beshear accepted it as a challenge.
"He has made this his legacy," Scutchfield said.
Pitching the program
Kentucky set up its own state-based health care exchange, known as Kynect. A state call center was set up to address questions about the program. To make sure people knew how to use the system, Kentucky officials fanned out across the state to spread the word.
"They went to county fairs, baseball games, state fairs and other places where they could reach people," said Jill Midkiff, a spokeswoman for Kentucky's Cabinet for Health and Family Services. "It's worked really well."
The right people seem to be signing up, as well. One key assumption of the Affordable Care Act was that insurance rates could be held in check if young, healthy people get insurance. Forty-one percent of the new enrollees in Kentucky were 35 years old or younger.
"It's been a huge surprise, really," said Susan Dunlap, a spokeswoman for the Kentucky Health Cooperative, a nonprofit insurance company that was set up to offer insurance on the Kentucky state health exchange.
The cooperative is one of several companies that offer health insurance on the exchange, where a family of three living at $33,000 per year — Anniston's median household income — could get coverage prices that range from around $300 per month to nearly $700, with the possibility of a federal subsidy to offset the cost.
Still, most of Kentucky’s new enrollees so far are on Medicaid. In many Southern states, the only young adults eligible for Medicaid are people on disability or parents with an income below the poverty line. Under the Affordable Care Act, the federal government offered to pick up most of the tab if states expand the program to people up to 138 percent of the poverty line.
Medicaid enrollees sign up as soon as they discover they're eligible, Midkiff said. She expects a surge of private insurance enrollees as the enrollment deadline approaches.
"We have a large group of people who are eligible for a subsidy, but they're still shopping for the right plan," she said.
Paying for the program
While state officials in Kentucky were out spreading the word about their health care exchange, Alabama leaders were defending their decision not to create one — and their decision not to expand Medicaid.
Bentley supported the idea of state health exchanges during his 2010 campaign for governor. But by 2012 he had changed his mind, citing the potential cost of running a state exchange. The state went with the federal health exchange instead.
Reports from Bentley's now-defunct Alabama Health Insurance Exchange Study Commission suggest that an exchange would have cost between $34 million and $50 million per year, and could have been paid for with a tax on all health plans in Alabama.
Asked last week if Alabama could have had Kentucky-style success by setting up an exchange, Bentley said "no."
"And the reason I don’t think that is because basically we have one major insurance company already in Alabama, and that's Blue Cross Blue Shield," he said.
When the Affordable Care Act was drafted, state health care exchanges were expected to bring prices down, in part, by opening markets to multiple insurers. But in Alabama, Blue Cross/Blue Shield owned 86 percent of the market before the health reform rollout, according to reports by the Health Exchange Study Commission. Blue Cross is now the only option for people on the health exchange in most Alabama counties.
A Blue Cross/Blue Shield spokeswoman said the company isn't responsible for driving up prices.
"Among 34 states using the federal exchange, Alabama has the second-lowest average premiums for individuals age 27 in each of the Bronze, Silver and Gold metal levels, according to an analysis of plan offerings in the October 2013 edition of the AIS Report," Koko Mackin wrote in an email to The Star.
Scutchfield, the health policy analyst, said competition is usually going to lower prices. And Alabama could have had more competition if the state had set up a nonprofit health care cooperative, he said.
"That was an option under the Affordable Care Act," he said. "Kentucky did it before the deadline, and I guess you didn't."
Dunlap, the spokeswoman at the Kentucky Health Cooperative, said cooperatives typically are set up by medical or hospital groups. But the idea was little-discussed in Alabama.
The Alabama Hospital Association had something else on its mind — Medicaid.
"Our focus was really on working with the governor to make sure we could find a more efficient way to deliver Medicaid," said Rosemary Blackmon, vice president of the Alabama Hospital Association.
With a $615 million annual price tag, the state's Medicaid program was struggling to come to terms with the new enrollees the program had absorbed since the recession began.
Bentley cited that struggle when he announced he wouldn't expand Medicaid. The program needed to be reformed, with cost-cutting in mind before it could be expanded, the governor said.
Democrats panned the governor's choice, saying that it hurts poor and black Alabamians in the name of politics.
The Alabama Hospital Association is worried, too. Federal payments to hospitals — known in bureaucratic jargon as “disproportionate share, hospital,” or DSH — are expected to go down in coming years. That’s based on the assumption that Medicaid will be expanded and fewer people will use the emergency room as their doctor.
“The decline in DSH will cost (Alabama) hospitals $16 million this fiscal year, and twice as much in 2015,” she said.
Meanwhile, a growing number of studies are questioning the governor’s assertion that the state can’t afford to expand Medicaid. A study released last week by the Commonwealth Fund concluded that the state could gain $2 billion per year in federal money from the expansion by 2022, twice as much as Alabama would get annually in federal highway funding in the same period. A study funded by the University of Alabama’s Center for Business and Economic Research projected that expansion could create more than 30,000 jobs. An earlier UAB study projected the state could generate as much as $1.7 billion in state and local tax revenue by 2020 if it expanded.
“It comes down to an investment decision, one that the state needs to make,” said UAB professor Michael Morrisey, one of the authors of that study.
Bentley says the Affordable Care Act itself has dampened the economy, creating uncertainty among employers and making them reluctant to hire new employees.
“Confusion causes companies to not want to hire,” he said. “If the Affordable Care Act had not been passed, our economy would have turned around a long time ago.”
The Republican-controlled U.S. House of representatives has voted more than 40 times to repeal the Affordable Care Act, though those efforts have never made it past the Democratic-run Senate.
Health care advocates in Kentucky say many of the flaws of health care reform could have been fixed already, if Congress weren’t so polarized.
“If the people in Congress were inclined to work collaboratively, they would have fixed the holes,” said Susan Zepeda, president of the Foundation for a Healthy Kentucky.
Even Kentucky has had glitches, according to those who work with the system. The Kentucky system has refused to recognize some enrollees because they don’t have a credit history, health care advocates say. Stewart, the Kentucky Equal Justice Center worker, said she’s run into difficulty working with people who already have employer-provided insurance, but want to switch to the exchanges to cover family members.
When Stewart complains about those problems to colleagues in other Southern states, though, there’s not much sympathy. Most report problems that are far worse, Stewart said.
“I’m losing my peer group,” she joked.
Capitol & statewide reporter Tim Lockette: 256-294-4193. On Twitter @TLockette_Star.