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HAZARD, Kentucky — Until she qualified for Medicaid, Frances Trice avoided seeing a doctor.

Already thousands of dollars in medical debt and unable to afford health insurance, she skipped her annual physical and relied on home remedies to treat viral infections. When she broke her foot, she reused the orthopedic boot she had from a prior fracture.

"The only time I would go to the emergency room was if I thought I was dying," said Trice, a resident of Adairville, Kentucky, a rural town of fewer than 900 people.

In 2019, Trice was diagnosed with heart failure. By then, Kentucky had expanded access to Medicaid.

Jointly funded the federal government and the states, the Medicaid expansion program provides health insurance coverage to eligible adults, pregnant women and people with disabilities who meet the income requirements. The program also helps self-employed people, small business owners, farmers, seasonal workers and older adults who don't yet qualify for Medicare.

The expansion program is credited with a substantial reduction in the rate of uninsured adults ages 18 to 64 in rural areas. In 2019, among states that expanded Medicaid coverage, government figures show that 11.8% of those adults were uninsured, compared with 21.5% in states that didn't adopt the expansion.

Because she had health insurance through Medicaid, Trice was able to focus on her recovery without worrying about how she could afford her lengthy hospital stays and prescription medications. She said they the medicines alone would have cost hundreds of dollars per month.

"The expansion of Medicaid has helped a lot of people around here, including myself," she said. "There would have been absolutely no way I could have afforded everything I had to have done."

The Affordable Care Act, enacted in 2010, expanded Medicaid eligibility to adults under age 65 whose earnings total up to 138% of the federal poverty level. In most states with the expanded program, in 2024 that translates to an income up to about $20,780 for an individual, or about $35,630 for a family of three.

By law, the federal government pays 90% of the costs associated with expanding Medicaid coverage. To date, 40 states and Washington, D.C., have adopted the expansion.

Hoping and waiting in Kansas

Derby, Kansas, resident Melissa Dodge prays that her state takes advantage of Medicaid expansion. Her children are covered by Medicaid, but for the most part her income has been too high to qualify, landing her in the so-called coverage gap.

Dodge's adolescent daughter has several health issues, including a congenital heart defect that requires her to see a cardiologist several times a year.

For her own care, Dodge has set aside her income tax refund to pay for an annual physical and routine dental care, and she has also dipped into her savings and used credit cards to pay for unexpected medical expenses.

In 2022, she experienced severe abdominal pain and made the difficult decision to seek treatment at the emergency room despite her lack of insurance. Doctors determined that Dodge had an unviable pregnancy causing a medical emergency, which required them to remove her fallopian tubes and a liter of blood from her abdomen.

In addition to the grief of losing a child, Dodge felt overwhelmed by thousands of dollars in medical bills that steadily trickled in. She was relieved to learn that Kansas has different income requirements for pregnant women and applied for the program. Ultimately, the state agreed to grant the pregnancy benefits retroactively.

"If I can sit in front of a therapist and cry, I'm going to be a better employee at work, a better mother to my children and a better friend and neighbor," she said, adding that it was "a huge weight off my shoulders."

Kansas' governor, Laura Kelly, has pursued Medicaid expansion in budget and legislative proposals since shortly after she took office in 2019. But the measures have not won the state Legislature's approval.

Determined to push such legislation forward, Dodge has shared her story with local representatives and spoken in front of the state's Senate Committee on Public Health and Welfare. "To be able to stand in front of the committee and share my story, to kind of plead with them, was really impactful," she said. "I believe (Medicaid expansion) is what's right, and I'm forever hopeful."

Helping health care facilities

By ensuring that more patients can pay for their medical care, Medicaid expansion has also helped sustain rural health care facilities. One recent study found median rates of uncompensated care in 2019 were just 2.88% for rural hospitals in Medicaid expansion states, compared with 6.31% for rural hospitals in non-expansion states.

Medicaid expansion has buoyed the University of Kentucky North Fork Valley Community Health Center, said its medical director, Dr. Key Douthitt. The health center in Hazard, a town of about 5,300 people, treats all patients regardless of their ability to pay.

Prior to Medicaid's expansion in Kentucky, the facility was facing rising debt. "We were providing services to people who couldn't pay for them," Douthitt said.

Since the state expanded Medicaid, far more of the center's patients are covered by insurance. As a result, the facility has been considering expanding the services it offers. In the past, they anguished over which services to cut. "It completely changed the landscape for us," Douthitt said.

Most importantly, he said, "We know it's improved our patients' lives." Research shows that groups without access to affordable health care have higher infant mortality rates, more chronic illness and greater risk of dying from illnesses such as heart disease and stroke, compared with people who can access affordable care.

After having open-heart surgery to implant a device that helps her heart pump blood, Frances Trice qualified for Social Security Disability Insurance and enrolled in Medicare with Medicaid serving as the secondary insurer.

She sometimes wonders whether having health coverage earlier would have changed the course of her life. "Maybe I would have been able to be diagnosed sooner and get things under control before everything got really bad," she said. "I honestly have no idea how people can go without insurance."