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ROBERT SIEGEL, HOST:

From NPR News, this is ALL THINGS CONSIDERED. I'm Robert Siegel.

MELISSA BLOCK, HOST:

And I'm Melissa Block. Republicans have fought hard against the Affordable Care Act. But as last year's health law is implemented, what some Republicans say in Washington and on the campaign trail doesn't reflect what's happening back home. Sarah Varney of member station KQED visited one conservative bastion of rural California and found Republicans reluctantly embracing the law.

SARAH VARNEY, BYLINE: California Congressman Kevin McCarthy often uses his time on the floor of the House of Representatives in Washington, D.C. to rail against the Affordable Care Act.

REPRESENTATIVE KEVIN MCCARTHY: Let's repeal this health care bill, start to replace it with an open and honest debate...

VARNEY: But some 2,300 miles away, back in the Republican congressman's hometown of Bakersfield in oil-rich Kern County, northeast of Los Angeles, the federal health law can't come soon enough.

UNIDENTIFIED MAN: Our Kern County is the leading oil and mineral producing county in the lower 48.

VARNEY: Kern County is some 8,000 square miles with deserts to the east and oil fields and agriculture to the west. Many families came here from Oklahoma and Texas to work in the fields, and today the county - and its politics - are more Oklahoma red than California blue.

Still, the county Board of Supervisors - all Republicans - voted to accept federal dollars allowed under the much-criticized health law to insure a vast new pool of low-income adults three years ahead of the law's deadline. Paul Hensler is in charge of the county's public hospital, Kern Medical Center.

PAUL HENSLER: Our proposal was, one, to expand coverage to those who don't have coverage, and use various methods to reduce the cost of care and improve outcomes.

VARNEY: Hensler says the county is assigning poor, so-called childless adults to primary care clinics, people who up until now have been excluded from Medicaid, the government insurance program for the poor. There, he says, they can better manage their chronic diseases and avoid costly emergency room visits.

Indeed, all counties in California except Fresno are extending care to more poor residents. Even the most conservative counties are getting tens of millions of additional federal dollars to support their efforts.

Surprisingly, though, the rollout of what conservatives derisively call Obamacare has largely gone unnoticed here in Bakersfield. Jaycee Cooper, who administers the program, says few residents make the connection between the expansion and the federal health law.

JAYCEE COOPER: I think some people do talk about it and might associate it with it, but for the most part, I don't know if they necessarily put the dots together.

KEN METTLER: This is one of those things that is being implemented under the radar.

VARNEY: Ken Mettler helped found the Tea Party in Bakersfield. We met at a cafe downtown. Even Mettler wasn't aware what the county was doing until I asked to talk to him about it. Still, he says elected officials vigorously denounce the federal health law, but then are all too eager to roll it out.

METTLER: So they always have to make this leap of logic that if we don't take the money somebody else will. We will not be able to provide service that we're mandated to provide and no one has the political courage to stand up and say, Look, this is wrong on all levels and if we don't take a stand here, who will?

RAY WATSON: Well, we're on the hook already.

VARNEY: Supervisor Ray Watson has represented Kern County's west side for nine years. He says California law mandates counties offer basic medical care and emergency services to impoverished residents.

WATSON: We do get some funding, but it's far from what is required to care for those people.

VARNEY: As the economy slowed and people lost their health insurance, demand for county services went up. Supervisor Watson, a Republican, says it's a matter of fairness then, not ideology. Kern County, he says, pays more to the federal and state government than it gets back.

WATSON: So it's not fair for our taxpayers to have to pay the burden of indigent care. I think that's something that if it's a policy of the government to make sure that we don't have people suffering in the streets, then the government needs to find a way to pay for that.

VARNEY: Watson is no fan of the federal health law, but he says the uninsured do need some basic level of care, and moving them away from the emergency room and into regular primary care makes sense. Republican Supervisor Karen Goh agrees.

KAREN GOH: We have obesity. We have high blood pressure. We have just about every bad thing we're very high on the number one. And getting people to have those regular check-ups, that's a very, very important thing in any community of poverty.

VARNEY: Goh is of two minds when it comes to the federal health law. She says it's unfair that sick people can't get health insurance, but she also opposes mandates on private businesses. She thinks local church groups, including one that runs a mobile van called the Jesus Shack, are filling some of the need. But with 63,000 uninsured low-income adults in Kern County, it seems implausible church groups could do it all.

Still, to some conservative voters in Kern County, the supervisors' support of the early Medicaid expansion is tantamount to an endorsement of the federal health law. And that, says Republican political consultant Stan Harper, is a liability.

STAN HARPER: I would say in Kern County and the immediate surrounding counties that if a candidate was out to run on and support Obamacare they would lose.

VARNEY: It's unclear how the county's Medicaid expansion might play in any future elections. The Bakersfield Tea Party says it's on the group's radar now, and they'll be looking to back candidates that want to get rid of the federal health law entirely.

For NPR News, I'm Sarah Varney.

BLOCK: This story was produced as part of a reporting partnership with member stations, NPR and Kaiser Health news.

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