What Happens If the ACA Is Repealed?: A Look at Kentucky

Bluegrass Triage
What could happen to HIV/AIDS patients in Kentucky without Obamacare
by Larry Buhl

In January, the Republican-led U.S. Congress set into motion the full repeal of the Affordable Care Act, also known as Obamacare. There have been a few trial balloons offered by Republicans as possible replacements, but nothing concrete. Which means many people with HIV, HCV and other infectious diseases who have benefitted from the ACA have no idea what kind of care they’ll be able to afford next year.

In the first part of a series on the possible effects of ACA repeal, I wanted to find out what would happen to those who work with at-risk populations with HIV/AIDS in Kentucky, which was touted as a model for ACA implementation with its state exchange known as Kynect.

I spoke with Alice Thornton, MD, the Chief of Infectious Diseases at the University of Kentucky Medical Center, and Robert Parrish, a Medical Case Manager at Kentucky’s Bluegrass Care Clinic, which serves primarily lower-income patients.

They told me that some benefits patients enjoyed have already been eroded since their new governor, Republican Matt Bevin, ended Kynect in 2015.

Larry Buhl: What is the current state of accessing healthcare?
Robert Parrish: Because we don’t have our own state-run [ACA] exchange anymore, patients now go through healthcare.gov, and it’s very confusing. We went from an efficient system where anyone could sign up without much help, to one that’s been broken up into two different websites that don’t communicate with each other well. Under Kynect, we could have someone enrolled in Medicaid in thirty minutes. Now it takes weeks to resolve issues. And they need our help much more often to advocate and to navigate Medicaid enrollment. That’s time I could be spending on actual case management instead of dealing with those issues.

What was it like before the Affordable Care Act went into effect?
Alice Thornton: When the state exchange, Kynect, was implemented, many of our patients were crying out of happiness because had insurance for the first time. They knew their lives would not be destroyed if they had a huge bill.
RP: You had Medicaid, Medicare, employer-based plans, or nothing. And forty-two percent of our population had nothing. They were totally reliant on Ryan White funding for medications and all HIV care. But there are gaps that can’t be covered by Ryan White. If you have to go to ER, or be in hospital or ride in ambulance, now these patients can be covered. And it doesn’t cover in-patient care.
AT: In 2013, before Kynect, forty-two percent or our patients were uninsured. That decreased to twelve percent in 2014 and 2015 it went down to seven percent uninsured. For 2016, though we don’t have the full numbers, we think the uninsured percent will be even lower.

What surprised you about the ACA?
AT: Back then a lot of our patients were diagnosed by the health department. Then suddenly with the ACA, we got people coming from different sources. We got referrals from urgent care clinics and from primary care doctors who were testing them for HIV. I never thought that was one of the outcomes we would see. That goes to preventative care. Folks could get screenings that they would normally not be screened for.

Assuming ACA is repealed without replacement, do you worry that more people will not be getting preventative care? Or drop out of the continuum of care?
AT: I do. And fewer people will be getting diagnosed. And medications could be a problem. We have ADAP, and right now there’s no waiting list, but if we put those forty-two percent back on no insurance, there’s going to be a waiting list like there was before ACA. I mean, we had a system [under Kynect] that really worked.

What are some other concerns about repeal of the ACA without replacement?
AT: We’re hearing a lot of fear about what will happen with insurance and not knowing what’s going to happen. We’ve had an increase in patients wanting to see our mental health counselors about the anxiety over that. One scary thing for HIV patients is the pre-existing clauses, which might come back.
RP: That would be one portion of repeal that would be devastating for our patients, who are generally low-income. And that means people with hepatitis, with diabetes. It will affect almost everyone, not just those with HIV.
AT: Many of our patients do work and have access to insurance, but you can imagine that premium may go from a low amount to $800 or $1,000. These are often young people, maybe still going to school, working in food service. It’s not like they’re staying at home being lazy. They happen to have HIV and need to make a living. They might not be able to keep working if something disastrous happens. It can be a vicious cycle.

Larry Buhl is a radio news reporter, screenwriter, and novelist living in Los Angeles. Follow him on Twitter @LarryBuhl.


  1. The Republicans will pay for this in November 2018. They (and Trump) promised over and over that they would cover everyone and blah blah blah. Instead they are taking away coverage for tens of millions directly, and allowing governors like Bevin to choose whether or not to cover things like birth control and maternity costs and all of the other “essential health benefits”. Obamacare was funded in large part by a Medicare tax on people with incomes above $200,000. That money is now given back to the rich in the form of a tax cut, and the coverage it used to pay for is gone. Republicans just screwed all of you non-rich Trump voters over. How does it feel?

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