If there's one thing certain about the future of expanded Medicaid and qualified health plans in Kentucky, it's that nothing is certain. 

 

The line between who's for and who's against repealing former President Barack Obama's landmark health care overhaul is more divisive than just politics; it drives to the heart of a question over what role government will play, or even can play, in ensuring health and wellness. 

 

Millions of Americans say there's little to no place for government in delivering care -- especially as they watch their insurance deductibles and co-pays skyrocket year after year. Meanwhile, millions of others rely on government-subsidized care to survive and care for their children. 

 

Yet still, as Republicans in Washington hurtle toward real decisions that will impact people on either side of that debate, one question seems left tucked neatly behind any conversation about insurance coverage next year and beyond: What's next? 

 

Joel Thompson wants everyone to remember that health insurance wasn't exactly easy before major provisions of the Affordable Care Act went into effect in 2014. 

 

"It was unsustainable the way it was," he said. "Something had to give." 

 

An insurance agent in West Virginia near the border with Kentucky and Ohio, Thompson said he watched for decades the region's health degenerate while prices continued to rise. 

 

It's a part of America at the center of today's health care debate, where conservative principles run deep, but the effects of affordable care are undeniable. More people in eastern Kentucky could stand to lose insurance or Medicaid coverage if the ACA were repealed than almost any other place in the country, according to the Kentucky Center for Economic Policy. 

 

When the legislation was passed in 2010, Thompson said it built a complicated framework of mandates, standards and regulations that relied on everyone's participation -- something like a massive game of Jenga, where each wooden block represented different interests in American health. Remove the wrong block and the whole thing falls apart, he said. 

 

Now, he added, Republicans in Congress and President Donald Trump have promised an entirely new plan built with those same wooden blocks. 

 

"This unforeseen replacement of the Affordable Care Act is supposed to lower costs for consumers, decrease government participation and increase availability of care," he said. "You can't do all three, and if you do one, it's at the cost of the other two." 

 

Left untouched, Thompson said the ACA is the best of both worlds. It represents a compromise between single-payer and multipayer health care delivery. 

 

Western Kentucky isn't that far behind its eastern counterpart in ACA access to care. More than 200,000 people on this side of the state found an affordable connection to care through Medicaid or subsidized insurance. The Medicaid expansion accounted for at least 10 percent of that population, according to KCEP. 

 

About one in three Daviess County residents have purchased either "Obamacare" insurance on an exchange or qualify for Medicaid, recent figures show. Because of Owensboro's growing population, the county earned about $60 million in federal expansion dollars, second only to Bowling Green on this side of the commonwealth. 

 

Still, 2nd District U.S. Rep. Brett Guthrie, of Bowling Green, said he and fellow Republicans in Congress will undo the legislation -- and fast. 

 

"Obamacare is not working," he said. "It's as simple as that. Out-of-pocket costs are skyrocketing and states are losing millions of dollars in these failed Obamacare co-ops."

 

Guthrie serves as vice chairman of the House Subcommittee on Health, putting him in a position to help design a replacement for what he calls the failed law. But the congressman says those discussions are premature, because insurance plans for 2017 are already in place. His party's focus remains on dismantling provisions of the existing law now so they cannot impact future enrollment periods. 

 

But he did promise that the replacement legislation will be designed to work for everyone -- all Americans -- and that it won't return the country to how insurance was handled before the ACA was passed. 

 

"It's not a choice of going back to the way it was," he said. "That's not an option." 

 

For individuals with pre-existing conditions, Guthrie proposed high-risk pools, which group individuals into separate miniature healthmarkets if they can't qualify for normal plans because of their health. But Kentucky Voices For Health Executive Director Emily Beauregard said 35 states have already tried those plans before the ACA banned insurers from denying individuals with pre-existing conditions. High-risk pools charged people about twice as much as typical premiums, and most had lifetime maximums on how much they would pay for people's care.
 

Guthrie said associated health plans would allow small businesses to afford health insurance collectively, and he reputed individual and business mandates in the existing ACA. 

 

"There's been no final decision on how we deal with Medicaid at this point," he said. "But we have to make it sustainable in states that can't afford it, like Kentucky." 

 

The congressman said he supports Kentucky Gov. Matt Bevin's 1115 waiver to "make individuals more accountable for their health." That plan does propose major cuts to dental and vision benefits among expansion enrollees. 

 

Lacey Hamilton, 27 of Utica, said she's tired of her family paying for other people's insurance. She's an office manager for a pediatric dentist, and her husband, Blake, is a farmer. The couple had a baby late last year, which has only further complicated their insurance woes. Hamilton and her husband have to purchase health insurance off the federal marketplace, and Hamilton said she's watched deductibles and co-pays rise, while options disappear. 

 

"It's comical that we call this affordable care," she said. "We pay $750 a month, which is more than we paid last year, for worse insurance." 

 

Anthem Blue Cross Blue Shield is the only insurer offering qualified health plans on the marketplace in all 120 Kentucky counties. Daviess County is among the dozens that only offer one Health Maintenance Organization plan -- a limited option that restricts users to a set number of providers. 

 

The pediatric physician the family chose to care for their newborn in Owensboro is not yet accepting HMO coverage. 

 

"We just got $800 worth of shots, and I don't know if insurance is going to cover this," Hamilton said. 

 

No matter what Republicans come up with to replace Obamacare in Congress, she said, the law has to go. She said she knows there are a lot of people who qualify for expanded Medicaid who need coverage, but there are plenty of Medicaid recipients who shouldn't qualify, too. 

 

A short drive south in Hartford, Alex Macke, 30, a single mother with two young children said she has the ACA to thank for her life. 

 

Macke, a bartender in Owensboro, said she only qualified for Medicaid under the expansion, which pushed the minimum threshold to within 138 percent of the federal poverty line. She has pre-existing conditions and underwent major surgery last year that she says she couldn't have afforded without insurance. 

 

"When people talk about public assistance, I think they have this vision of a welfare queen in their minds," she said. "They think people are cheating the system. But this is terrifying for me. I'm 30 years old, and my mom had lung cancer at 38. That's eight years away. If I lose my insurance, and I get diagnosed with cancer, how will I pay for surgery? How will I pay for chemo? How will I survive?" 

 

Her 6-year-old son was diagnosed with mid-to-high functioning autism near birth, and Medicaid services have paid for therapy Macke said he has needed to learn how to communicate and grow as a person. She said she worries about threats to the insurance status quo every day, because it feels as if she just earned a desperately needed gift that will soon be snatched away. 

 

"This anxiety I feel is real," she said. "I don't think anybody thought we would be close to repealing this thing so quickly." 

 

But the threat is real, says Beauregard. Up to 500,000 Kentuckians could lose coverage next year if the ACA were repealed. That could mean a loss of $259 million in federal marketplace spending, and 1.9 million people with pre-existing conditions whose insurance would either skyrocket or disappear entirely. 

 

Pending the loss of subsidies, elimination of the requirement to buy insurance, and the requirement on insurers to sell to all purchasers, prices would rise and the healthiest people would drop coverage, she said. Nationwide, 4.3 million people would lose insurance right away, rising to 7.3 million by 2019. 

 

"This is real," she said. "This is happening right now. If we don't rein in insurance companies' ability to make enormous profits off of us, we will not make a difference." 

 

At Owensboro Health Regional Hospital, the area's largest employer and dominant provider, charity care, which accounts for how much the hospital had to cover the costs for individuals who couldn't afford treatment, has dropped significantly over the years that the ACA has been effective. Between 2012-13, charity care amounted to an average of almost 10 percent of total patient care. Last year, it was just 2 percent. 

 

It's a trend, says Steve Johnson, Owensboro Health's vice president of Government and Community Affairs, that health providers have witnessed nationwide. But at the same time, bad debt as a percent of net patient revenue has only slightly declined, illustrating the added burden that the ACA has put on doctors and their staff. 

 

Johnson said he does not believe that repeal efforts will completely strip the ACA of its power. It's likely, he said, that Republicans will introduce a bill that reimagines portions of Obama's vision from a local government perspective. 

 

"The ACA insured more people," he said. "There's no denying it. But what it didn't do is incentivize health literacy. That's the next step." 

 

But if the Medicaid expansion population disappeared and thousands of subsidized plans were no longer available, Mike Rust, president of the Kentucky Hospital Association, said there would be millions of dollars to be lost in the health care industry. Premiums, any many cases, he said, went down under the law, but co-pays and deductibles went up; so was the case for Hamilton and her family. Rust said it's what has contributed to bad debt increases in many hospitals across the commonwealth. 

 

The solutions aren't obvious, and he said they're likely to take cooperation from both sides of the aisle, but he said he remains confident that a solution exists. 

 

"Hopefully we'll find it soon," he laughed. "Kentucky's not exactly the healthiest state around."