LOUISVILLE, Ky. — The Affordable Care Act allowed Robin Evans, an eBay warehouse packer earning $9 an hour, to sign up for Medicaid this year. She is being treated for high blood pressure and Graves’ disease, an autoimmune disorder, after years of going uninsured and rarely seeing doctors.
“I’m tickled to death with it,” Ms. Evans, 49, said of her new coverage as she walked around the Kentucky State Fair recently with her daughter, who also qualified for Medicaid under the law. “It’s helped me out a bunch.”
But Ms. Evans scowled at the mention of President Obama — “Nobody don’t care for nobody no more, and I think he’s got a lot to do with that,” she explained — and said she would vote this fall for Senator Mitch McConnell, the Kentucky Republican and minority leader, who is fond of saying the health care law should be “pulled out root and branch.”
Ms. Evans said she did not want the law repealed but had too many overall reservations about Democrats to switch her vote. “Born and raised Republican,” she said of herself. “I ain’t planning on changing now.”
Kentucky is arguably one of the health law’s biggest early success stories, with about 10 percent of the population getting coverage through the state’s online insurance marketplace — albeit mostly through Medicaid, not private plans — and none of the technology failures that plagued other enrollment websites. The uninsured rate here has fallen to 11.9 percent from 20.4 percent, according to a recent Gallup poll that found only Arkansas experienced a steeper decline.
But there is little evidence that the expansion of health coverage will help Kentucky Democrats in this fall’s midterm elections. Republicans hold all of the state’s Congressional seats except for one, in a district centered in Louisville, and none are considered vulnerable this year. Republicans, who already control the State Senate, have a chance of taking the State House of Representatives, where Democrats hold an eight-seat majority. And several recent polls have put Mr. McConnell ahead of his Democratic opponent, Alison Lundergan Grimes, even though his approval ratings are tepid.
Mr. McConnell and other Republicans here, while more focused on other issues, like protecting Kentucky’s coal industry, continue to attack the health law as a symbol of government overreach and Democratic bungling. And far from flaunting Kentucky’s strong enrollment numbers, Democratic candidates — most notably Ms. Grimes — have remained reticent about the law, even its successes.
In many ways, the role that the law is playing in Kentucky politics reflects what is going on nationally as the midterm elections approach. The law remains deeply unpopular among Republicans and independents, and Republican candidates still use it to flog their Democratic opponents, although not as single-mindedly as before. That is partly because voters are more focused on other issues: A recentGeorge Washington University Battleground Poll found that among likely voters who think the country is on the wrong track, only 5 percent blamed “issues with Obamacare.” More pointed to concerns about the economy, foreign policy, President Obama and Congress.
Why would people like Ms. Evans who are benefiting from the law vote for candidates who would dismantle it? Gov. Steven L. Beshear, one of the few Democrats forcefully promoting the law here, said many were driven by a dislike of Mr. Obama. A recentCNN poll found that only 33 percent of likely voters here approved of his job performance, and that 63 percent disapproved.
“The campaign by the Affordable Care Act’s critics against it has been very effective in demonizing the phrase Obamacare and anything to do with the president,” said Mr. Beshear, who cannot seek re-election next year because of term limits. “So I think you find a reluctance on the part of people, even though the law is benefiting them, to publicly acknowledge it.”
Interest groups and candidates — including Mr. McConnell — have run more than 10,000 broadcast television spots here since January 2013 that mention the law in a negative way, according to Kantar Media’s Campaign Media Analysis Group. Kantar found only one positive television ad, from Elisabeth Jensen, the Democrat challenging Representative Andy Barr in the state’s Sixth Congressional District. The ad refers to Mr. Barr’s votes to repeal the law, warning that he “would restrict our access to affordable health care.” Ms. Jensen, who is running in a swing district, also ran a radio adpraising the law last spring.
At the state fair’s annual ham breakfast, Mr. Beshear tried to humanize the law, describing how several farmers in attendance had signed up for the new coverage and how one had used it to check out a spot that turned out to be skin cancer.
“It’s not about the president,” he told the crowd of 1,600, who did not applaud once during the six minutes he spent discussing the law. “It’s about you. It’s about your families. It’s about your children.”
That message has not persuaded people like Billy Bishop of Lexington, who is retired and gets health insurance through his former employer. He said his out-of-pocket costs had risen sharply while his coverage had gotten worse. He blames the Affordable Care Act — particularly its expansion of Medicaid to many more low-income Americans.
“I haven’t heard anything good about it, to be honest,” said Mr. Bishop, who has diabetes and heart stents. “I’ve heard with this, you can’t get doctors’ appointments and people get put on wait lists for surgery.”
Nonetheless, at the state fair, Mr. Bishop, 57, and his wife, Cindy, 56, stopped by an information booth run by Kynect, the state’s health insurance marketplace. Mrs. Bishop was curious about whether she could get less expensive coverage through Kynect, even though her husband refused to consider it for himself.
She took some brochures but said that regardless of what she learned about the cost, she and her husband would vote for Mr. McConnell. Mrs. Bishop said Ms. Grimes was “with Obama on everything,” and she called the president “the worst we’ve ever had.”
At the teeming fairgrounds in late August, the Kynect booth handed out 26,000 reusable shopping bags stamped with its logo and toll-free number, and more fairgoers were clutching them than corn dogs or cotton candy. Crowds also gathered around information booths sponsored by the managed-care companies providing Medicaid coverage for the newly insured, one of which had a star University of Louisville basketball player greeting passers-by one day.
All the marketing did not sway Teri Eisenmenger of Louisville, who said she was against the health care law even though it had allowed her adult daughter to get Medicaid coverage.
“I don’t like that people are being forced to buy insurance,” Ms. Eisenmenger, 58, said, referring to the law’s requirement that most Americans get health coverage starting this year or face a tax penalty. She is insured through her husband’s job at a car dealership, but the premiums are high, she said — $1,000 a month for the two of them — and they might join a Christian health care sharing ministry instead. Members of these ministries pay monthly fees that help members with medical bills, and they are exempt from the penalty for not having insurance.
“Most people are going to see things through their partisan default position,” said Representative John Yarmuth, Kentucky’s lone Democrat in Congress. “They separate the personal impact of policies from their perception of what is good for the country.”
Despite his unyielding attacks on the law, Mr. McConnell also takes positions that suggest he knows it would be difficult to dismantle. He has hedged on whether he would take away Medicaid from new enrollees and suggested — without explaining how — that the Kynect marketplace could survive even if the law was repealed.
Yet he frequently calls the law a “job killer” that is driving up premiums and deductibles for consumers — charges that resonate with the many Kentuckians who are not directly benefiting from the law. He has spoken about the law at about 70 hospitals around the state since its passage in 2010, telling doctors, nurses and administrators that the law is “a trillion-dollar hit on those of you who provide health care to the rest of us.”
At one such gathering last month, at Paul B. Hall Regional Medical Center in Paintsville, in eastern Kentucky, Dana Keaton Collett, the hospital’s director of rehabilitation services, told Mr. McConnell that her insurance rates were rising so sharply that it was not worth keeping her coverage.
“This is the consequence of this awful law,” Mr. McConnell replied, adding, “I’m going to take you on the road with me.”
(Experts say that although insurance costs are indeed going up, they have been doing so for years, and a slowdown in the rate of health-cost growth since 2009 has moderated the increase in premiums for most people.)
Ms. Grimes typically avoids talking about the health care law but, when pressed, says she wants to improve it. At acandidate forum here last month, during which Mr. McConnell called the law catastrophic, Ms. Grimes said, “We have to work to streamline the Affordable Care Act to make sure there aren’t overburdensome regulations on our businesses.” She also called for letting more people keep their old insurance policies, a point of contention that emerged last fall when several million people’s plans were canceled because they did not comply with the law’s coverage requirements.
Some party activists and political analysts say Ms. Grimes is missing an opportunity to excite the Democratic base — and perhaps siphon votes from Mr. McConnell in places like southern and eastern Kentucky, where the drop in the uninsured rate has been especially steep — by not vigorously defending the law. “It may be her last, best chance,” said Al Cross, a longtime Kentucky political reporter.
For now, Ms. Grimes is focusing on painting Mr. McConnell as a creature of Washington who will perpetuate partisan battles and gridlock.
“I think she realizes, as does the McConnell camp, that this is not going to be an issue that’s going to sway people that much one way or the other,” Mr. Beshear said. “So she is concentrating her efforts on where they should be, reminding people of the last 30 years of Senator McConnell and the fact that he is part of the problem in Washington, and not part of the solution.”
Some Kentucky voters seem receptive to that message.
Karen Ekstrom, 60, who described herself as an independent voter, said she and her husband were deeply disappointed with the private insurance he got through Kynect. With the cost at $439 a month, “I really feel we are being ripped off,” she said.
Ms. Ekstrom, who works for a medical marketing company in Lexington, is ambivalent about Mr. Obama. But she said she planned to vote for Ms. Grimes, mostly because she sees Mr. McConnell as spending too much time trying to block Mr. Obama on the health care law and other initiatives.
“I’m tired of that,” she said. “It’s a law. Let it go, move on and get some stuff done.”