Trump Won Big in Kentucky. Medicaid Cuts Could Hit It Hard.

Over a decade ago, Keith Farah was homeless in Louisville, Kentucky, struggling with addiction and beginning recovery when he tested positive for hepatitis C after experiencing fatigue and weight loss. The disease, often spread through shared needles, requires a 12-week antiviral treatment that can cost up to $94,000.

Farah was on Medicaid, which he credits for enabling him to get tested and ultimately treated. Still, getting approval for the medication was difficult, a process he described as “a subtle negotiation of my humanity.” Medicaid eventually covered his treatment, and today, Farah is the regional director of operations at Pinnacle Treatment Centers.
 

Join our email list to get the stories that mainstream news is overlooking.
Sign up for Capital & Main’s newsletter.

 
Farah emphasizes that even with insurance, accessing care — especially for the vulnerable populations he now serves — is already a major challenge.

But if the Senate passes the “One, Big, Beautiful Bill Act” to make permanent trillions of dollars in tax cuts, health care may become further out of reach for the millions of people who rely on Medicaid, including as many as 345,000 people in Kentucky who could lose coverage. In late May, the House passed its version of the bill, which would add co-pays, work reporting requirements and other obstacles to getting and keeping Medicaid coverage. Those cuts are expected to reduce Medicaid spending for the state by $1.7 billion and threaten the strides Kentucky has made since it expanded Medicaid in 2014.

President Trump won Kentucky in the 2024 election by more than 30 percentage points, with especially wide margins in the rural areas where Medicaid cuts would hit hardest.

While Rep. Thomas Massie of Kentucky was one of just two House Republicans to vote against the bill, his opposition stemmed from his concern that the legislation would add trillions of dollars to the national debt, not the health impact of Medicaid cuts. Sen. Rand Paul of Kentucky opposes the bill, which contains massive tax cuts that would disproportionately benefit the wealthiest households, for similar reasons. He said on Face the Nation that he would not vote to increase the debt ceiling and that his fellow Republicans are “asking for too much money.” Advocates in Kentucky are more concerned with the price of losing Medicaid, as more than 30% of state residents are enrolled in the program. 

If enacted, the bill “would devastate Kentucky,” said Emily Beauregard, executive director at advocacy group Kentucky Voices for Health. The coverage losses and the corresponding rise in uncompensated care “would essentially destroy our health care system,” she said. 

New program rules would primarily affect the adults without children living with them who benefited from 2014’s Medicaid expansion.

“Medicaid expansion was a game changer for Kentucky,” said Dustin Pugel, policy director at the Kentucky Center for Economic Policy. Indeed, in 2013, 14.4% of Kentucky residents were uninsured — by 2016, that number had dropped to 6.1%, the biggest decline in the uninsured population in any state in the country. The state’s residents began seeking preventative care they had put off as well as treatment for illnesses like substance use disorder, asthma and cancer. Medicaid is the largest source of funding for substance use disorder treatment in Kentucky, where overdose deaths have declined for three consecutive years. Last year, overdose deaths decreased by more than 30% as compared to 2023.

But the benefits Medicaid expansion brought to the state weren’t merely related to health.  

As  previously uninsured adults made increasing use of the state’s health care system, more jobs were created in rural hospitals and clinics. That economic activity proved critical in the coalfields of Eastern Kentucky, where jobs were disappearing as the industry contracted.

Today, Medicaid accounts for 13.5% of GDP in Eastern Kentucky — where more than 40% of residents rely on the program — and nearly 9% of the state GDP.

*   *   *

Across the Appalachian Mountains in Louisville, the nonprofit Family Health Centers serves roughly 40,000 patients each year at several health clinics in and around the Central Kentucky city. More than half of these patients receive health care through Medicaid, said Melissa Mather, the centers’ chief communications officer.

Before Kentucky expanded Medicaid in 2014, Mather remembers overhearing patients in the lobby discussing having to choose between medication and groceries. Since Medicaid has expanded, that’s not the case. And the centers — which offer patients the option to pay on a sliding scale — will serve anyone who needs health care, including the uninsured.

As a result, margins are “always razor thin,” said Mather. Over the past few years, the nonprofit has actually lost money.

But if the budget bill cutting Medicaid passes, the organization’s finances will get worse.

Even a small decline in the share of Medicaid patients Family Health Centers serves would lead to significant financial losses, Mather said, adding that cutting Medicaid “will shrink our ability to provide access.”

The cuts will reverberate across the entire state, disrupting “an economy that is rooted in health care,” Mather said. According to a March analysis by the Commonwealth Fund, the proposed cuts would lead to the loss of 13,500 jobs in the health sector and 11,500 in other industries. 

Plus, losing health care will disrupt the lives of those who will be forced to forgo necessary treatment.

Farah said that after he received treatment for hepatitis C, “Within two weeks my life was remarkably better,” adding that he “had more energy, more motivation [and] was more productive at work.”

Now he wonders how he will help his clients if they lose health insurance due to the proposed cuts — and where he would be now without the program.

“What would that have looked like if I had not had Medicaid?”

Copyright 2025 Capital & Main