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Interview: former Gov. Steve Beshear explains how he sold deep-red Kentucky on Obamacare

"We wanted to get as far away from the word ‘Obamacare’ as we could."

Former Kentucky Gov. Steve Beshear speaks at the Fancy Farm picnic August 2, 2014<br>

Win McNamee/Getty Images

Democrats have selected former Kentucky Gov. Steve Beshear to deliver the party’s response to President Donald Trump’s congressional address on Tuesday.

Beshear bolstered his national reputation by implementing Obamacare in an especially conservative area. Under the health law, Kentucky’s uninsured rate has fallen from 20 percent to 7.5 percent — the largest drop in the country.

“In the first 18 months, we had, like, 400,000 to 500,000 Kentuckians involved in this program, most of them for the first time in their lives getting health care,” Beshear told us in an interview last November.

The selection of Beshear for this Trump rebuttal suggests that Democrats are keen to talk about the health care law and the success it had in lowering Kentucky’s uninsured rate.

In November, we had the chance to interview Gov. Beshear about the health law’s rollout in Kentucky. We talked about the strategic decisions he made to sell Obamacare in an area that was staunchly opposed to the law, and what he felt worked and what didn’t.

What follows is a transcript of that conversation, edited for clarity and length, that gives some insight into what Beshear thinks about health care policy and how he thinks it might move forward.

Sarah Kliff

You were serving as governor when the Affordable Care Act passed. You had to decide whether to expand Medicaid and whether to expand the state marketplace. I was hoping you could start off by telling us how you made those two decisions.

Steve Beshear

Well, to understand the decision we made about the ACA, you've got to understand the background of health in Kentucky. It's pretty simple: It's awful.

Our people are some of the most unhealthy people in the country. When you look at any health rankings, Kentucky is at the bottom or near the bottom. And we haven't been there just in the last year or two years. We've been there ever since they started keeping the rankings. It's such a big issue and our health is so bad that we needed a big solution.

Lo and behold, along came the ACA. I saw it as a solution that Kentucky had better grab hold of as our one chance of making a big difference in the future of health for our people. We started doing the planning as soon as the act was passed.

So we started doing the planning. And I had basically two decisions to make. One was do we have a state based exchange or do we use the federal exchange? That was a pretty easy decision to make because every provider in Kentucky, every advocacy group who was interested in this issue, all felt that we should devise our own state-based exchange because we knew better how to deliver care to Kentuckians than some cookie-cutter approach from Washington.

The second decision was a tougher decision to make. Do you expand Medicaid? I knew all along that morally it was the right thing to do, if we could afford it, but that was the real question: Can we afford it? So before I made that decision, I brought in PricewaterhouseCoopers and the University of Louisville Urban Studies Institute and asked them to take a hard look at this whole issue of expanding Medicaid and tell me what it was going to do to Kentucky.

They took about six months and came back, sat down, looked at me across the desk, and said, “Governor, you can't afford not to do this, because over the next eight years, it's going to infuse $15 billion into Kentucky's economy. You're gonna create about 17,000 new jobs. There's going to be a positive impact on your budget.”

So based on that study, I made the decision to expand Medicaid.

And as much as you work on these kinds of issues, it's sort of a shot in the dark as to whether they'll work or not. Come October 2013, we basically said a prayer, crossed our fingers, and threw the switch at midnight. And ours worked!

We had thousands of Kentuckians coming out of the woodwork trying to find out what this was and what might be available to them. We had a few little bugs, but we had a team that was ready, and we repaired those quickly.

By the end of the day, things were humming, and boy, they just ... they went crazy from there on.

Sarah Kliff

Can you tell us the name of your state marketplace and how you remember how you settled on it?

Steve Beshear

We called our state-based exchange Kynect, obviously a take on “Kentucky” and “connection.” It was to connect our people with the marketplace, to be able to get health insurance or to see if you qualified for Medicaid.

Many Kentuckians don't know they are benefiting from Obamacare, which is called "kynect." Byrd Pinkerton/Vox

We wanted a system and an advertising campaign that was simple. Folks that were going to use this for the most part were not college graduates, you know. Good golly. I've got two college degrees, and when I try to read about health care and understand the terms, I feel like I've got to go back to the first grade. It had to be simple.

Obviously another reason we named it Kynect is because we wanted to get as far away from the word “Obamacare” as we could.

The president [then President Obama] has about a 30 percent approval rating in Kentucky, so it's not popular politically to have the president front and center on any issue here. The term Obamacare had already been turned into a curse word by the critics of the program.

Polls at that time in Kentucky showed that Obamacare was disapproved of by maybe 60 percent of the people. Kynect was disapproved by only, like, 20 percent. Of course it was the same thing.

But I still remember, we had a big booth at the Kentucky State Fair. And lots of people were coming up and finding out what the program was.

I walked by one day, and one of our folks was explaining to this fellow in bib overalls what this was. And this guy, I heard him say, “Oh, man. This is great. This is a lot better than that Obamacare.”

After he left, I came back to the gal and said, “Did you tell him?”

And she said, “Well ... I hesitated. I thought I should. And then I just said, No. I'm just going to sign him up.”

So ... we signed up a whole lot of people. In the first 18 months, we had, like, 400,000 to 500,000 Kentuckians involved in this program, most of them for the first time in their lives getting health care.

That was just amazing.

Sarah Kliff

And do you think most of those people knew they were signing up for an Obamacare program, whether it was through marketplace or Medicaid expansion?

Steve Beshear

Obviously many did. I mean, I went around the state when I was selling this, and my message was, “Look, you don't have to like the president, and you don't have to like me, because this is not about him or me. It's about you. It's about your family. It's about your kids. So just do me a favor. It won't cost you a dime to go online and to take a look at what you might be able to get. I'll just guarantee you, you're gonna like what you find.”

People took me at my word. They went online, and you know what? Pretty soon they didn't care what it was called, because they liked what they found. They signed up in droves, and I'll tell you — our state is so much better off today than it was just two and a half years ago.

And some of the early studies are already showing some big positive changes in health outcomes.

Sarah Kliff

Can you talk a little bit about those? What has changed since the introduction of ACA in Kentucky? Which changes matter most?

Steve Beshear

We went from over 20 percent to 7.5 percent uninsured over the last two and a half years. Our uncompensated care rate with all of our providers went from something like 25 percent to less than 5 percent.

When you look at the early returns on our health care program here in Kentucky, what you see is, like, 150 to 200 percent increases in screenings. Things like diabetes, cancer, high blood pressure. People are taking advantage of those things because they can afford it for the first time.

It's going to teach them how to better manage their health conditions. It's going to catch a lot of these conditions while they're in their early stages so that they are better managed. And it's going to improve the quality of life for so many people.

It is also going to help us economically. It's going to make our workforce better. You're not going to have a productive workforce if you don't have a healthy workforce.

After a year of actual implementation, after a year of experience with expanded Medicaid and the exchange, I brought in Deloitte and the Urban Institute at the University of Louisville and I said, “I want you to take these actual numbers and, based on these actual numbers, make projections on what's happening and where we'll be in the next seven to eight years.”

Well, they did. They came back in and they said, “You've already got $2 billion or $3 billion infused into your economy just in the first year. You're going to have more like $30 billion over eight years.”

It works, not only from a personal standpoint, people and getting healthier. It works from an economic standpoint. The program is sustainable. It's affordable. And it just doesn't make sense not to continue on with it.

Now, obviously, there are some problems with it. You get any big program like this that is a sea change in an area like health care, and you're going to have issues. And you're gonna need to tweak it, and you need to change it.

There are small businesses that had some issues with the program. There's a small group of people but a group of people out here who are getting hit hard by increased premiums right now, and we ought to look at ways to address that.

We need to look at ways of doing that, but you know, that is doing what we've done with every major program we've instituted with health care. We did that with Social Security. It took a while to get that right. We did it with Medicare. It took two or three years and changes to get that to where it ought to be.

And that's what needs to happen with the ACA.

Sarah Kliff

Looking back, do you think it was the right move to distance Kynect from the ACA? Did it make Kentuckians less invested in saving Obamacare?

Steve Beshear

I think we did just the right think because the effect it had was at the beginning of implementation. We were able to get, I think, more people to look into the situation and find out what they were able to get by labeling it in a different way.

But it wasn't long before people realized, mostly, what they were getting and where it came from. And as I mentioned, now people don't care. You can mention Obamacare in Kentucky and they may not like the word, but they sure as heck like the program, and they don't want to see it go away.

Sarah Kliff

Your successor, Gov. Matt Bevin, ran for office and won on the promise of ending Kynect and possibly ending Medicaid expansion. Why do you think that message was appealing to Kentucky voters given how many of them rely on the ACA for coverage?

Steve Beshear

There are two reasons for that. One is that the Republicans have been very successful in demonizing the program.

Secondly, the Democrats have done a horrible job in explaining to people what this is all about and how good it is. Democrats, for several years now, under Republican attack, have kind of run from the program. They've shied away from campaigning on health care reform. We made a big mistake by doing that.

In the governor's race here in 2015, our candidate shied away from talking about it at all, because the polling indicated that Obamacare in and of itself still was a bad word.

Looking back, that was a mistake. I think you get out and you acquaint people with what's going on and what they're getting.

Sarah Kliff

How do you think about what will change for Kentucky under incoming President Trump? The consultant who worked on Gov. Bevin’s Medicaid proposal, Seema Verma, will now be running the Center for Medicare and Medicaid Services. How much change do you expect, and what do you think that will mean for the folks in your state?

Steve Beshear

I think it's much more likely that some type of waiver here in Kentucky will get approved. That will throw some people off the program, and that's what they're looking to do. They can discuss it in any way they want— making it more efficient or whatever — but all of that is just code words for, “We've got to get as many people off this program as we can.”

The Republicans in Washington will obviously make a run at totally dismantling Obamacare. The Democrats in the Senate will stop that by a filibuster if necessary. Hopefully that will bring people up there to the table to try to figure out a middle path forward.

There are so many things in this law that are great and that it's pretty hard to argue against. Insurance companies can no longer use preexisting conditions to deny you coverage. I think the vast majority of Americans think that is good and that ought to be part of the law. The fact that you can now be up to 26 years old and be on your parents’ policy, I think people really think that is a good thing.

I think they think it's good that insurance companies now can't charge women more than men for the same kind of coverage.

But the bottom line needs to be every American ought to have access to affordable health care. And the thought that has to be impressed on all of the Republicans now that are going to be in control in Washington is simply this:

There are 20 million Americans right now that are enjoying the fruits of the Affordable Care Act. Yes, some of their premiums are going up, and they're yelling. But everybody else likes it.

What are you going to do with 20 million people?