Kentucky election an ominous sign for Obamacare

Governor-elect Matt Bevin has promised undo Democratic healthcare reforms in Kentucky

By most accounts, Kentucky's implementation of President Barack Obama's 2010 healthcare reform was a success. Tuesday's elections in the state could mean big changes are coming, however - with ominous portents for the future of the president's signature legislative achievement.

The governor's race in Kentucky was supposed to be close. Although the state has been solidly Republican in federal elections - Mitt Romney beat Mr Obama 60% to 38% in 2012 presidential balloting, for instance - it had a popular outgoing Democratic governor in Steve Beshear and has only elected a Republican to the top office twice since World War 2.

In addition the Democrats thought they had a silver bullet in the popular state-run Kynect health-insurance marketplace, implemented under the auspices of Obamacare. While the federal government and states like Maryland and Oregon had struggled rolling out their public exchanges, where qualified individuals can choose among subsidised health insurance plans, Kentucky's system operated smoothly from the start.

Mr Beshear also accepted federal funds to expand Medicaid healthcare to the poor, resulting in coverage for more than half a million additional Kentuckians and a 9% drop in the uninsured rate - the largest of any state.

"This is a winner for our people, and because it's a winner for our people, it's going to be a winner politically," Mr Beshear promised.

Outgoing Kentucky Governor Steve Beshear predicted healthcare reform would be a winning issue for Democrats

Republican candidate Matt Bevin, a grass-roots Tea Party-backed businessman who has never held public office, pledged to undo both these moves, however, turning operation of the Kynect exchange over to the federal government. Over the course of the campaign he was relentlessly attacked on the issue by Democratic opponent Jack Conway.

In the end, however, the Kentucky voters sided with Mr Bevin - or were more concerned about other issues. Despite recent polls showing a dead heat - and a majority support for Kynect's healthcare expansion - Mr Bevin handily beat Mr Conway 53% to 44%.

The win gives Republicans control of 33 governorships, a net gain of 12 since Mr Obama took office in 2008. It also sets up a high-stakes showdown over the future of state-level healthcare reform implementation and highlights the fragility of even successful set-ups in the face of continued conservative opposition.

A successful Kynect health-insurance programme fails to boost Democrat Jack Conway's campaign for governor

Because Mr Beshear implemented the programmes through executive action, bypassing a deadlocked Kentucky legislature, Mr Bevin likely will be able to change course unilaterally. Although Greg Stumbo, leader of a state House of Representatives still controlled by Democrats, has promised to battle the governor-elect, the election results have his party on its heels.

There have been plenty of fights in states across the US over whether or not to fully support national healthcare reform efforts. Of the 50 states, only 14 initially agreed to set up their own exchange system. Medicaid expansion has been slightly more successful, with the 30th state, Montana, recently signing on. (Republican wins in Virginia's legislature on Tuesday likely mean Democratic Governor Terry McAuliffe won't make his state #31 anytime soon.)

Kentucky marks the start of a different kind of battle, however, where a formerly supportive state - one held up as a shining example of reform - tries to walk it all back. If Mr Bevin is successful in fulfilling his campaign promises, while maintaining public support, it could not only serve as a guide to like-minded governors, but also to Republicans on the national level.

A winning Republican presidential candidate in 2016 could find himself in a similar situation as the newly elected Kentucky governor, having campaigned on the promise of killing healthcare reform and then presented with the opportunity to do so.

If Mr Bevin signs the death warrant for Mr Obama's reforms in his state, a Republican in the White House may find the political courage to do likewise.