Kentucky is one of the states most affected by former President Barack Obama's health care law, new data from the U.S. Census Bureau shows.
Yet it's also a state that has elected some of the law's biggest opponents.
In 2013, 14.3 percent of Kentucky's population had no health insurance. By 2016, just 5.1 percent of the population lacked coverage. That's a 64 percent decline, the largest of any state in the country according to data from the American Community Survey released this week. It's similar to data from other national polls, including the Gallup-Healthways Survey.
Nearly all of that decrease is because Kentucky was one of 31 states that expanded their Medicaid programs under the federal Affordable Care Act, allowing more than 461,000 people to get health coverage.
Since then, Kentucky voters have elected a wave of Republican leaders who campaigned on repealing the law. Republican Gov. Matt Bevin wants to move people off Medicaid and onto private insurance plans. He has asked the federal government for permission to charge some Medicaid recipients monthly premiums and require some of them to work or volunteer in order to keep their benefits.
If approved, Bevin estimates Kentucky's Medicaid enrollment would decline by 95,000 people in five years.
"All those things really jeopardize the kind of gains we've made lately," said Dustin Pugel, a research and policy associate for the Kentucky Center for Economic Policy. "It takes a while for health to improve, and coverage is the first step to that. If you don't have coverage, you don't get care."
Bevin says not all of those people would lose coverage. The system is designed to reward people who get jobs and serve in their communities. Most of them, Bevin hopes, will graduate to private insurance plans either by purchasing one or obtaining coverage through their employer.
Eastern Kentucky, part of the Appalachian region, has had the largest proportionate increase among the state's Medicaid population. And while the health of eastern Kentuckians has improved since 1990, they have fallen behind the rest of the country in most major health indicators, according to a recent study by the Appalachian Regional Commission, the Foundation for a Healthy Kentucky and the Robert Wood Johnson Foundation.
"What we have seen is unsustainable growth of 68 percent in the state's Medicaid program," Bevin spokesman Woody Maglinger said. "One in three Kentuckians are obese, we have the second highest smoking rate in the nation and we rank first for cancer deaths. We owe it to our citizens to do more than simply enroll people in social welfare programs."
The census data also showed the number of young people 19 and under with health insurance increased to 96.7 percent from 93.6 percent in 2013. But Terry Brooks, executive director of Kentucky Youth Advocates, said that gain could be in jeopardy because of Bevin's Medicaid proposal, since it could mean fewer adults will have health insurance. He said research shows the biggest factor in whether a child has insurance is whether their parents have insurance.
"If fewer parents are covered under (Bevin's Medicaid proposal), fewer kids will be covered," he said. "That's just a fact of life."
"It may be a fact of life in Terry Brooks' alternate universe, but it is not a fact in Kentucky," Maglinger said, noting Bevin's plan would not change Medicaid eligibility requirements for children.