The Affordable Care Act (ACA) presents states with an opportunity to tailor the implementation of key health policy approaches intended to increase health insurance coverage and access to timely, high-quality care in a way that fits their populations best.

Kentucky may well be one of the most interesting cases to watch and learn from as we seek to understand how the ACA can make us healthier while controlling costs and improving quality of care.  The Foundation for a Healthy Kentucky has been tracking the impact of the ACA on coverage, access, costs, quality of care, and health outcomes through a multiyear contract with the State Health Access Data Assistance Center (SHADAC), a health policy research institute at the University of Minnesota, to study how Kentucky’s implementation of the ACA is impacting state residents.

This multiyear study involves both quantitative and qualitative research methods to provide a richer and more complete picture of Kentuckians’ experience in the early implementation period of the ACA—researchers are using claims data, telephone surveys, and national surveys, as well as focus groups and interviews.  In addition to quarterly “snapshots,” the researchers develop baseline, semiannual, and annual reports. The study was launched in March 2015, with the first annual report released in March 2016, with many highlights worth sharing.

Before delving into the report highlights, I will provide a little background on Kentucky and the ACA. Kentucky was the sole southern state to both expand Medicaid and establish a state-based exchange, kynect (the state initiated both in 2013).  It is important to note that these policy actions were taken as a result of former Gov. Steve Beshear (D) issuing an executive authority. Kentucky gained national recognition for achieving one of the two largest drops in the percentage of uninsured people in the country—with more than half a million Kentuckians gaining coverage through Medicaid expansion and through private insurance available through kynect. Kynect was hailed as a success among health insurance marketplaces for its broad and effective outreach and enrollment efforts.

In November 2015, the state of Kentucky elected Republican Matt Bevin as its new governor.  Bevin campaigned on the promise of dismantling kynect and discontinuing Medicaid expansion, but he later changed his stance to reforming Medicaid expansion through an 1115 waiver that would guarantee low-income Kentuckians would have more “skin in the game.”  Flash forward to March 2016, and Bevin has been making good on his campaign promises.

As the Foundation for a Healthy Kentucky released the findings of this first annual report for the Study of the Impact of the ACA Implementation in Kentucky, kynect is in the process of being dismantled, and a team led by former Cabinet of Health and Human Services Secretary Mark Birdwhistell (who served under former Gov. Ernie Fletcher [R]) is at work developing a proposal for an 1115 waiver to reform Kentucky’s Medicaid expansion.

As the policy landscape continues to change in Kentucky, it is more important than ever to have reliable data and research findings to guide evolving health policy decisions.  With this background in mind, here are some of the highlights from the first annual report (released in March 2016).

Health Insurance Coverage

  1. Kentucky’s overall rate of uninsurance fell to 8.7 percent in 2014—a 4.9 percentage-point drop from 2012. Kentucky’s uninsurance rate of 8.7 percent is statistically significantly lower than the overall US uninsurance rate of 11.6 percent; it is also significantly lower than the uninsurance rate of a number of neighboring or comparable states, including Arkansas, Illinois, Indiana, Missouri, Tennessee, and Virginia.
  2. People with lower incomes saw the greatest declines in uninsurance. Those with incomes below 138 percent of the federal poverty level (the Medicaid expansion group) experienced the largest decline with an 11.2 percentage-point drop in uninsurance from 2012 to 2014.
  3. Some disparities in insurance coverage persist: the uninsurance rate for the Hispanic/Latino population (28.9 percent) is more than triple the state’s overall uninsurance rate.


  1. There was a statistically significant increase in the share of the population reporting having a usual source of care from 2012 to 2013.
  2. The percentage of Kentuckians reporting emergency department (ED) visits in general in the past year dropped from 30.4 percent in 2012 to 24.9 percent in 2013, a statistically significant decrease.

It will be important to track these measures as the state moves forward to see how they are affected by increased access to coverage through the ACA.


  1. In 2013, Kentucky had a statistically significant higher percentage of people with trouble paying medical bills compared with the United States as a whole (Kentucky: 42.8 percent, United States: 30.2 percent).
  2. Kentucky’s rate of people with trouble paying medical bills in 2013 was also significantly higher than several neighboring states, including Illinois, Missouri, Ohio, and Virginia.

Quality of Care

  1. Among all neighboring states, Kentucky was the only state that had a statistically significant increase in the percentage of respondents who reported having a colorectal cancer screening from 2012 (62.4 percent) to 2014 (66.4 percent). The ACA is likely not the only reason for this increase—Kentucky has programs promoting colorectal cancer screening.
  2. Racial disparities continue in incidence of low birth-weight: Non-Hispanic blacks continued to have the highest rate of low birth-weight in 2014.

Health Outcomes

  1. An opportunity for improvement: Kentucky’s adult obesity rate remained stable from 2012 to 2014, with an obesity rate of 31.6 percent in 2014.
  2. Chronic disease prevalence: 29.1 percent of adults in Kentucky reported having one or more chronic conditions in 2014, a statistically significant increase from 26.8 percent in 2012. It’s important to note that increases in reported chronic disease prevalence can be expected with increases in coverage and access to care.

This first-year look at the impact of the ACA implementation in Kentucky indicates that kynect and Medicaid expansion not only substantially increased the proportion of Kentuckians with health insurance coverage, but the ACA also improved access to care.

Importantly, the first-year findings show an increase in preventive care and a decrease in ED use; these findings are an important move as we work to have not just more care, but the right care at the right time and place.

The Foundation for a Healthy Kentucky will continue to share findings from this important study with policy makers, providers, payers, users of health care (all of us!), and advocates.  As the health policy realm remains in flux, we will continue to shine a light on decision making through reliable data and research findings and through elevating Kentuckians’ voices through our annual poll and through our partnerships with grantees and others committed to improving the health of all Kentuckians.