In east Kentucky, the town of Pikeville anchors an Appalachian county with vanishing coal jobs, a plummeting uninsured rate and more than 7,000 people who have gained Medicaid coverage that could end under Gov.-elect Matt Bevin. (Jahi Chikwendiu/The Washington Post)

Amid the coal fields of eastern Kentucky, a small clinic that is part of the Big Sandy Health Care network furnishes daily proof of this state’s full embrace of the Affordable Care Act.

It was here that Mindy Fleming handed a wad of tissues to Tiffany Coleman when she arrived, sleepless and frantic, with no health insurance and a daughter suffering a 103-degree fever and mysterious pain. “It will be all right,” Fleming assured her, and it was. An hour later, Coleman had a WellCare card that paid for hospital tests, which found that 4-year-old Alexsis had an unusual bladder problem.

Such one-by-one life changes are the ground-level stakes ushered in by the election last week of businessman Matt Bevin as Kentucky’s next governor. The second Republican elected to the office in 48 years, he wrapped his campaign around a pledge to dismantle Kynect, the state’s response to the federal health-care law. If he follows through, the Bluegrass State would go from being perhaps the nation’s premier ACA success story to the first to undo the law’s results, razing a state insurance exchange and reversing its considerable expansion of Medicaid.

During his first news conference since his unexpected victory, Bevin named abolishing Kynect as a top priority, again contending that the state can’t afford it. He said change would come in “a thoughtful way” and made it clear that he intends for people on Medicaid to pay more for their care — but left other details of his intentions blurry.

Gary Ryan is checked by Fadi Al Akhrass, an infectious disease specialist at the Pikeville Medical Center. Ryan, 64, was a coal miner for 10 years in Pike County, Ky., who moved to Virginia to find work, then moved home for health insurance. (Jahi Chikwendiu/The Washington Post)

Still, the broad contours of his condemnation of the ACA are creating a quandary here in remote Pike County, where 55 percent of voters supported Bevin even though the county benefits greatly from the health-care changes he plans to rescind.

Dennis Blackburn has this splintered self-interest. The 56-year-old mechanic hasn’t worked in 18 months, since he lost his job at a tire company that supplies a diminishing number of local coal mines. “The old guy had to go home,” Blackburn says of his layoff.

He has a hereditary liver disorder, numbness in his hands and legs, back pain from folding his 6-foot-1-inch frame into 29-inch mine shafts as a young man, plus an abnormal heart rhythm — the likely vestige of having been struck by lightning 15 years ago in his tin-roofed farmhouse.

Blackburn was making small payments on an MRI he’d gotten at Pikeville Medical Center, the only hospital in a 150-mile radius, when he heard about Big Sandy’s Shelby Valley Clinic. There he met Fleming, who helped him sign up for one of the managed-care Medicaid plans available in Kentucky.

On Election Day, Blackburn voted for Bevin because he is tired of career politicians and thought a businessman would be more apt to create the jobs that Pike County so needs. Yet when it comes to the state’s expansion of health insurance, “it doesn’t look to me as if he understands,” Blackburn said. “Without this little bit of help these people are giving me, I could probably die. . . . It’s not right to not understand something but want to stamp it out.”

Largest drop in uninsured

Kentucky is the only state in the South that wholeheartedly placed in motion all the ideas for spreading access to health care envisioned by the ACA’s authors. During the fall of 2013, when the federal HealthCare.gov enrollment system began as a software mess, Kynect was orderly, signing up people for private health plans and Medicaid.

Mindy Fleming sits in her office at the Shelby Valley Clinic, where she is one of the foot soldiers known as “Kynectors” trained to enroll people in insurance through the Affordable Care Act. She has signed up more than 1,000 individuals and families. (Jahi Chikwendiu/The Washington Post)

When 2014 arrived, President Obama invited Gov. Steve Beshear (D) to sit in the first lady’s box for the State of the Union address and lauded him as “a man possessed when it comes to covering his commonwealth’s families.”

By the end of that year, census figures show, no other state had as large a one-year decrease in uninsured residents. In a state of 4.4 million people, 500,000 gained coverage because of Kynect — 4 in 5 through Medicaid.

The effects were particularly dramatic in this Appalachian county, where many coal jobs have vanished and the poverty rate is 23 percent. From 2013 to 2014, the proportion of residents lacking health coverage plummeted by half — from 13 percent to 6.6 percent.

The main driver of that achievement: the whopping 7,500 people who joined Medicaid as the state widened eligibility under the health-care law.

Fleming has single-handedly enrolled more than 1,000 individuals and families. As a “Kynector” — one of the foot soldiers trained to help people sign up for ACA insurance — she has stood with fliers in front of the local Wal-Mart and at Pikeville’s Hillbilly Days Festival, at churches and food banks, at the county seat’s two small colleges and at drug treatment centers.

Many enrollees are now sending referrals to her, people such as Coleman.

Coleman works a couple of days a month as a secretary for Appalachian Title Research off Main Street in Pikeville. She was a media specialist in a nearby school district until budget cuts ended her job and she decided to stay home with her toddler. Not long after, her husband, Jeremy, switched to a truck-driving job with Coca-Cola that paid $17 an hour and offered health insurance.

His new insurance card had arrived in the mail just before Alexsis got sick. But when Coleman took her to Pikeville Medical Center, she was astounded to learn that the coverage had not begun.

Even now, Kentucky rules allow her to keep WellCare, a Medicaid managed-care plan, as a backup. Coleman is near the end of a high-risk pregnancy that requires her to get frequent shots. WellCare picks up all but a few dollars of the $200 monthly co-pay that her husband’s work insurance requires for the shots. And WellCare helps cover the cost of a pediatric urologist at a Lexington hospital whom Alexsis sees every three months.

Visits to the doctor cost $3, medicine $1 per prescription — amounts that Coleman can manage even if she can’t always pay the electric bill on time.

Waiting for change

On Route 23 in Pike County, a billboard for Kynect touts “Happy teeth. Healthy bodies.” If Bevin carries out his intentions, the billboard will be gone. So will Fleming and the other Kynectors.

Beshear, the outgoing governor, created Kynect and broadened Medicaid by executive order. A new governor, however, cannot undo them on his own.

Under federal rules, a state must give a year’s notice before closing a state-run ACA insurance marketplace and switching to the federal one, something no state has attempted. And despite early vows to abolish the Medicaid expansion, Bevin has sounded more nuanced lately. His transition spokeswoman said last week that the expansion would remain intact while he drafts a plan for a different Medicaid permutation and tries to win federal approval.

Republican Matt Bevin was elected Kentucky's next governor after fiercely campaigning against the state's Medicaid expansion under the Affordable Care Act. (AP)

Big questions loom. Bevin has said repeatedly that Kentucky cannot afford the current expansion, which includes people with incomes up to 138 percent of the federal poverty line. He has not said whether he will try to lower the income threshold — something federal rules may not allow — or keep the income ceiling but require people to pay more for care.

Even the latter “would be a mess,” said Ancil Lewis, chief executive of Big Sandy Health Care, a nonprofit that traces its origins to President Lyndon B. Johnson’s War on Poverty. Before Kynect, 30 percent of Big Sandy’s patients had no help paying their bills. Now, it’s half that many. As Medicaid has taken up the slack, about $2 million more has flowed into the clinics, allowing Big Sandy to hire more nurses, buy new computers and plan to replace an aging clinic.

If Kentucky charges Medicaid patients a lot more, “it would certainly be a barrier for them seeking care,” Lewis said.

“It would probably be a life-threatening thing,” said Gary Ryan, 64, who was at Pikeville Medical Center two days after he voted for Bevin’s Democratic opponent. Ryan worked in the mines when he was young, but decent-paying work became so scarce that he took a job in Danville, Va., 270 miles to the east, and spent 13 years as a cookie mixer for Nestle Toll House. He moved back in 2013 to be with his sick wife and because he’d heard that good health insurance was available.

He sat on an exam table as a doctor, Fadi Al Akhrass, told him he was scheduling a liver biopsy because Ryan still had an active hepatitis C infection. They’d then talk about what treatment he should get.

“It’s a plan,” Ryan said. Medicaid will pay.