How to Run Against Obamacare in a State that Depends on Obamacare

As Republicans look to take the governor's mansion in Kentucky, they'll have to contend with the law's success in connecting residents with insurance.

Republicans love running against Obamacare, and in the half-decade since the law passed, they've ridden that strategy to a host of congressional and gubernatorial victories. They've been particularly successful in leveraging the law to oust moderate Democrats from purple states. In that regard, as Kentucky Republicans hope to retake the Governor's Mansion this November, the anti-Obamacare campaign strategy appears ideal. But in Kentucky, it's not so simple, because in Kentucky, the law has had tremendous success in getting state residents insured.

More than half a million Kentuckians signed up for private insurance or Medicaid through the state's Obamacare exchange. Since the exchange—known as "Kynect"—launched in 2013, the state has cut its uninsured rate by more than 40 percent. And because Kentucky, unlike many red and purple states, set up its own exchange, the state's aspiring insurance buyers were spared the early failures of In exit polling from the 2014 Senate race, 50 percent of voters said Kynect was functioning "well" or "very well," compared with 37 percent who assessed the exchange negatively.

The exchange's popularity, however, didn't stop Republican Sen. Mitch McConnell from attacking Obamacare en route to a massive victory last year over Democrat Alison Lundergan Grimes. McConnell, who has pushed relentlessly for repeal of the law, as the top Republican in the Senate, added a Kentucky twist for his state race: He attacked Obamacare as a whole, but said Kynect could survive even if the federal law came off the books. (The claim was challenged by Democrats, who noted that the exchange depends in part on Obamacare subsidies and mandates.)

It's unclear, however, whether a Republican gubernatorial candidate will apply the same strategy, or if that rhetorical line will survive the party's competitive four-way primary. Both the overall law and Kynect are unpopular among Republican voters, and the race's two underdogs have already pledged to scrap the exchange entirely. And therein lies the difficulty for the two favorites. If they coddle Kynect in the primary, they risk losing the base and watching the general election from the couch. But if they pledge to do away with the exchange, they risk drifting too far to the right of the state's swing voters—and handing a health care advance to the state's Democratic candidate, Attorney General Jack Conway.

So far, the two GOP front-runners—state Agriculture Commissioner James Comer and former Louisville Metro Council member Hal Heiner—have been tight-lipped over what they would do with Kynect.

Heiner's campaign was reluctant to offer much by way of comment on the topic. Spokesman Doug Alexander would say only this: "Hal Heiner opposed Obamacare from its inception, and supports efforts by Senators McConnell and [Rand] Paul to repeal the law." Alexander wouldn't respond to additional questions on whether Heiner agreed with McConnell's statement that Kynect could persist even absent Obamacare.

In a statement provided to National Journal, Comer described Kynect as "just a tool to expand Medicaid." Indeed, 80 percent of people who got insurance through Kynect did so by enrolling in Medicaid. (Kentucky's exchange is one of the few in which the insurance exchange's only portal can also be used to connect with Medicaid.) But instead of repealing the program, Comer says he would call for reforms, including a proposal "that Kentucky requires Medicaid participants to reenroll in Medicaid every two years like everyone with private health insurance plans have to do."

Former Kentucky Supreme Court Justice Will Scott and McConnell's 2014 primary challenger, Matt Bevin, meanwhile, have been unequivocal. Bevin and Scott are calling for an end to the Kynect exchange and the transfer of the program's private insurance enrollees to the federal exchange. Scott's logic is this: "The only thing we are getting out of a state-run Obamacare exchange is the privilege of paying for it. When we shut ours down, the feds will come in and pay for the whole thing."

According to a spokesperson at the Kentucky Cabinet for Health and Family Services, Kynect currently costs the state roughly $28 million a year to administer. States were given federal funds to set up their exchanges, but they are now responsible for the costs of administering them.

Notably, no Republican in the race has yet called for a repeal of Medicaid expansion, symbolizing the limits of running against a law that's become increasingly ingrained. "If we start following the law, we're stuck following the law. The apt analogy is a roach motel—you can check in, but you can't check out," David Adams, Scott's campaign manager, said of the difficulties of taking back Medicaid expansion.

The question of Kynect's future is unlikely to go away before November. In the primary, it is one of the few issues that divides the GOP field, giving Scott and Bevin an incentive to accentuate it as they try to make up ground. And, in the general, it promises to be a key issue: Questions about McConnell's view on Kynect were largely hypothetical—senators don't get a say over their state's exchanges—but after the November election, the fate of the state's exchange will rest largely in the new governor's hands.