Despite Kentucky’s uninsured rate dropping from 14.5 percent in 2013 to 5.6 percent in 2023 following the adoption of the Affordable Care Act’s Medicaid expansion and subsidized marketplaces, Kentucky ranks in the bottom half of states for overall health system performance. Impending Medicaid cuts, work requirements, and marketplace changes imposed by H.R. 1, along with looming expiration of the enhanced premium subsidies, will assuredly worsen Kentuckians’ health care access and outcomes.
We interviewed 73 insured Kentuckians — with Medicaid, Medicare, marketplace, and employer-based coverage — to understand the factors contributing to the state’s poor health outcomes despite having one of the lowest uninsured rates in the country. Full findings from this study are available from the Asclepius Initiative, a nonprofit organization working to improve the health and economic stability of Kentuckians. Some common themes emerged, including:
Real and Anticipated Costs Deter Patients
The barrier to care most often mentioned was cost. These included:
- direct costs, like high insurance premiums, copayments, deductibles, and care not covered by insurance
- indirect costs, in terms of transportation or lost wages
- anticipated or feared costs, that is, patients’ assumptions that prescribed medical care will be expensive.
One participant reported that the copayments on her employer-provided insurance were so high she must choose between health care and groceries; another opted not to get a medically necessary test because the hospital required a $3,000 payment up front.
Some patients avoid care out of fear of costs, even when the service is free. One Medicaid beneficiary skipped a mammogram, wrongly assuming that she’d be billed. Another woman, diagnosed with a rare cancer at 28, said financial concerns “probably stressed me out more than anything else.”
Provider Shortages Delay Care
Insured patients, especially those outside urban areas, described a shortage of health care providers, both for primary care and specialist treatment. This feedback is reflective of data seen in health policy maps, which show that 107 of Kentucky’s 120 counties are designated Health Professional Shortage Areas.
Participants said they often wait months — or even a year — for care. They travel long distances, sometimes out of state, to reach providers. During patient–provider interactions, many feel rushed or dismissed. Some sensed biases tied to race, gender, Medicaid coverage, or conditions like obesity. These experiences — particularly in places where the culture values toughness or where there is a general distrust of doctors — leave patients reluctant to seek care.
The study also revealed a hidden crisis: there are not enough dentists to meet the needs of Kentuckians, particularly for those with Medicaid coverage. Kentucky ranks near the bottom of the Commonwealth Fund’s 2025 Scorecard on State Health System Performance in the share of working-age adults who have lost six or more teeth. Tooth loss is common — and accepted as a normal situation — in many communities. Participants also noted the lack of fluoride in some water sources, such as private wells.
Provider shortages worsen health and disability. One participant described enduring pain and multiple infections as he waited about a year for a dentist to remove his wisdom teeth; another recalled ongoing pain and increasing difficulty walking before being able to get spinal surgery.
Transportation Gaps Keep Care Out of Reach
When people can find providers and make appointments, many still report transportation-related complications that prevent them from making or keeping medical appointments, including a lack of personal transport and poor public transit. Even for people with their own transportation, distances can be lengthy, making the trips expensive and difficult. Interviewees reported that they missed work time and lost wages as a result.
Although they are an important benefit, subsidized transportation amenities often failed to deliver. According to the study, in several cases, the service sent vehicles that were not appropriate (for example, a person could not get in to the vehicle), causing patients to miss appointments. Other participants described a failure of arrangements, causing them to have to walk home or find alternative transportation.
Administrative Tasks Add Uncertainty, Delays, and Stress
Those who do reach care described another hurdle: difficult and time-consuming insurance requirements and paperwork, especially around prior authorization for treatments and procedures. One participant explained, “I might have to be on the phone every day with two different entities for two weeks to make sure that my MS [multiple sclerosis] medication is approved.”
Navigating the insurance process isn’t just frustrating, it’s also stressful and delays care. Many participants noted that they had to go for prolonged periods without needed medication while awaiting insurance company approval.
Insurance-related demands also reinforce the impression among some patients that, as one put it, “doctors don’t work for their patients, they work for the insurance company.”
The Bottom Line: Health Care Requires More Than Coverage
The Affordable Care Act and Medicaid expansion were major steps forward for the health of Kentuckians. But significant hurdles remain. Health care is too costly for many, there are not enough of the right kinds of providers in the right places, patients experience long waits and lack of transportation, and many find the system confusing and hard to trust.
The challenges faced by Kentuckians in affording and accessing care are not unique to the state. The Medicaid cuts and marketplace changes created by H.R. 1 are projected to result in the loss of coverage for 16 million Americans, including 200,000 to 350,000 Kentuckians. In addition to those who lose their coverage altogether, costs will escalate for millions more who remain insured, as premiums skyrocket and out-of-pocket expenses rise in response to healthier people dropping out of the coverage pool.
Coverage is necessary for people to gain access to the health system, but alone it isn’t sufficient to ensure better health. Real progress will require maintaining and expanding upon coverage gains, eliminating identified barriers to care, fixing infrastructure, and rebuilding trust to make health care accessible, equitable, and affordable.
