Health care's Appalachian spring

GRETHEL, Ky. — At 86, Eula Hall comes each day to the clinic she raised from the ashes of a defeat in the war on poverty, the one Lyndon Johnson declared when he came to these poor, lonely hills 50 years ago this month.

Now comes another plan from another president to improve life here — the Affordable Care Act, designed to provide health insurance for all.

When Eula Hall is asked about Obamacare, you expect this veteran of the war on poverty, who lives in the sickest county in one of the sickest states, to sing hosannas. Instead, she hedges.

"I'm glad people without insurance are getting it, but I'm a skeptic," she says of the law. "I can't have high hopes." Hall, a beloved figure who's tended the poorest of the sick at the Mud Creek Clinic here for four decades, shakes her head. "We'll have to wait and see.''

Her ambivalence, which largely epitomizes Floyd County's reaction to the Affordable Care Act, contrasts with some outsized expectations.

To proponents, led by President Obama, it's the most significant step in health care since LBJ proposed Medicare. To opponents, such as Mitch McConnell, the state's senior U.S. senator and Republican leader, it's an economic "train wreck."

Four months after it took effect, Obamacare here is a neither a train wreck nor a cure-all. It's a work in progress, widely misrepresented and misunderstood. Some people have been helped, some hurt, and many others affected not at all.

Even if the law is not the revolution it's cracked up to be, journalists from USA TODAY and The Courier-Journal in Louisville found that it touches lives across this county.

Because of the ACA, Mary Murphy got an ultrasound for a blood clot that's festered 15 years, and Charles Ray had surgery on his damaged knee. Pam Collins' degenerative back disc, Sandra Porter's diabetes, Brenda Hall's kidney infection — all treated.

Because of the ACA, Mikka Sowards, 25, can stay on her parents' insurance for another year, and Pam Blackburn can buy insurance despite her history of high blood pressure and cancer.

Yet at least partly because of Obamacare, scores of hospital workers have been laid off, and an entire floor of the county's largest hospital is shut down. Private health insurance customers complain about higher deductibles and resent the extension of Medicaid insurance to those who don't work. Small-business owners talk about cutting workers' hours.

In other ways, little has changed.

People can still be treated in the emergency room for what are probably not emergencies; doctors can still practice defensive medicine to avoid lawsuits or pump up revenue; health care providers are still paid for services, not results.

"It's insurance reform," Bud Warman, CEO of Highlands Regional Medical Center in Prestonsburg, says of the ACA. "It's not health care reform."

Some people aren't sure what it is. "There's so much confusion," says Darrell Patton, an insurance agent. "My phone rings all day long. 'Hey, I heard this on Fox. Is it true?' And I'm like, 'I don't know!'"

Whatever it is, Obamacare shows scant promise of being able to heal Floyd County, whose sickness testifies to poverty's victory in Johnson's war.

Rates of premature death and infant mortality are twice the nation's. Three in 10 adults are obese, four in 10 exercise less than once a month, and more than a third describe their health as fair or poor. More than a third smoke, twice the national average. A third are missing at least six teeth.

Some people still favor home remedies over medicine. Many others have trouble getting to the doctor, contacting the doctor or just don't believe in going to the doctor.

Kentucky is a battleground state for the Affordable Care Act — the only one in the Southeast to embrace the law. Kentucky established its own health insurance exchange and accepted the federally funded expansion of Medicaid, the insurance program for the poor.

Enrollment has gone relatively smoothly; at least 60% of the county's 6,370 previously uninsured have enrolled in plans through the ACA. Obama singled out the state and its Democratic governor, Steven Beshear, for praise in his State of the Union speech.

But in impoverished eastern Kentucky, the ACA is more like the latest offensive in the war on poverty than a broad-based health insurance program; 86% of the newly insured are going on Medicaid. A relative handful of uninsured have signed up for private insurance (many with a government subsidy for those making less than $16,000 a year) rather than pay a fine. Only 132 of 5,086 new enrollees bought insurance entirely on their own dime.

In such a poor, sick place, the ACA's Medicaid expansion would seem likely to make it wildly popular. But it's not. Nor is the president who fought hard to pass it.

Obamacare? Contractors hired by the state to sign up people learned not to speak the name. "People would say, 'I'm not touching that,'" says Donna Dye, one of the recruiters.

For every Sandra Porter — a newly insured diabetic who says, "I'd shake the president's hand if he was here" — there's at least one Jason Johnson, a miner out of work for three years.

"He took our jobs," he says of the president, who's widely viewed here as an environmentalist enemy of the coal industry and who lost the county to his GOP opponents in the past two elections. "I reckon the least he can do is give us health care."

Like many people in Floyd County, Mary Murphy, 54, used to cancel doctors' appointments simply because, as the date approached, she knew she wouldn't be able to pay the bill. (At Highlands Regional, about a quarter of patients don't show up for scheduled procedures.) She says a specialist once told her flat out — he wouldn't operate on the blood clot in her leg because she had no insurance.

Since enrolling in Medicaid through the ACA, Murphy's medical horizons have expanded.

The housewife, whose husband is a disabled coal miner, got a Doppler ultrasound for the clot, which had festered for 15 years. She scheduled a colonoscopy and an MRI for her back and doesn't think twice about seeking care for what ails her.

"It's my throat. There's a red line in the back of my throat," she told Rasiah Narendrakumar one day last month at Eula Hall's clinic. She was sitting on an exam table. "It's kind of hard for me to swallow."

The doctor used his hand-held light to peer into her throat, ears and nose. After asking some questions, Narendrakumar diagnosed allergies aggravated by the wood-burning stove in Murphy's home. He advised her to use electric heat and treat herself with a saline spray.

Murphy's is one of many such stories around a county where for many, health care has been a luxury.

Candice Hamilton, 28, who grew up in a hollow (pronounced holler) between the hills outside Prestonsburg, has worked in flower shops, bars and restaurants, none of which offered insurance. She had to wait in the emergency room for treatment of her many ailments, from a bad liver to strep throat to anxiety.

Unemployed and qualified for Medicaid, she will have health insurance for the first time in her life. "My teeth need to be fixed real bad," she said. "I'm going straight to the dentist and the psychiatrist."

Other newly insured:

Brenda Hall, 49, an unemployed restaurant worker, says the ACA couldn't come soon enough. A week before she signed up for Medicaid, her first coverage in five years, she developed a kidney infection. She toughed it out, because she didn't want to pay $25 for a doctor's visit and because she was afraid of being prescribed drugs or referred to a specialist she couldn't afford. Her new plan has no co-pays.

Pam Collins, 54, is getting treatment for a degenerative back disc, as well as stomach problems, anxiety and depression. She worked as a nurse for 22 years without health insurance – "If I got sick, I had to stay sick." Finally, she had to quit.

If Obamacare has brought unprecedented benefits to some in Floyd County, it has unsettled others, including some hospital administrators and workers, physicians, small-business owners and private insurance consumers.

Hospitals are seeing more patients with Medicaid coverage, but they face reduced Medicare reimbursements and, eventually, charity care aid. Patients at the county's largest hospital must pay up front before they're treated, and they're discouraged from going to the emergency room for non-emergencies.

Physicians also are seeing more insured patients but say they're crushed by regulations and paperwork.

Blake Burchett, 56, is a country doctor who lives in walking distance of his office, plows the parking lot in winter himself, makes occasional house calls and says he doesn't know what he charges for an office visit.

Like many small private practitioners, he complains about regulations that have usurped doctors' clinical decisions, such as what questions to ask, tests to order or drugs to prescribe. He bemoans slow Medicaid reimbursements and says he fears an audit if he speaks out.

Burchett says he and his wife, Becky, his office manager, stay late each evening doing paperwork and computer documentation required by government agencies and insurance companies — the kind of burden that threatens to make practices such as his extinct.

He admits the ACA might not be the only culprit, "but maybe it's enough to put us through the ice — the 10% that's enough to finish us off."

"I want someone in Washington to know," he says. "I don't know if Congress understands what doctors are doing."

Some wonder if Congress knew what it was doing. Who will pay for so much new government-subsidized health care? To Ira Potter, who's practiced medicine for decades, it makes the ACA seem "like a bold, scary step — a chest-grabbing gamble."

Many people with private insurance say their costs have increased, fueling resentment of those getting on Medicaid for the first time. The monthly premium for insurance agent Brian Pugh's family of four increased 120%, to $946, and his deductible increased from $7,000 to $12,000.

"This whole thing is geared for lower-income people. Those are the people who are really going to benefit," he says, adding that the poor don't really need it: "As many programs as they have in this part of the state, they could always find medical care."

When the ACA took effect Jan. 1, some doctors braced for an influx of the newly insured seeking treatment of maladies long undiagnosed or untreated. "We thought we'd get bombed," says John Furcolow, an internist.

Instead, it was largely business as usual — in part because many people here, especially men, are reluctant to get exams and preventive care that experts say is Floyd County's only route to better health (and, in the long term, lower health care costs).

To get an idea of why it probably will take more than Obamacare to cure what ails Floyd County, consider Johnson, 39, one of many unemployed coal miners who came to a job fair in Prestonsburg last month.

Two decades ago, Floyd had scores of working coal mines; today, there are a handful.

Like others at the jobs fair, Johnson wore a miner's shirt with reflective stripes. He was missing several front teeth, and the frames of his glasses were broken. He was staying with a friend until he could get a job and afford a place for him and his fiancé.

He said that although he'd signed up for coverage through the Medicaid expansion, and although he's been treated for acid reflux, anxiety and chronic pain, "I'd have to be half dead before I'd go to the doctor."

This notion, born long ago of economic necessity and geographic isolation, has taken a life of its own. "It was the way I was brought up," said Charles Ray, whose parents could afford medical care for their family only in an emergency. "When you've lived so long without it, you just keep on your own routine."

Furcolow, the internist, is frustrated: "If you tell people to walk, to lose weight, you're lucky if 10% do it." That day he'd seen a diabetic patient who'd refused even to take a 1-cent aspirin daily as diagnosed, much less stop smoking. He could lose a leg.

One reason Johnson doesn't want to go to the doctor is that he doesn't want to know if he has black lung disease.

Such fears are not unfounded.

Last month, Roger Jurich, a family practitioner, saw a mechanic, newly insured through the ACA, who hadn't felt well for some time. The man was in 40s; he was a big smoker; he had his last physical 20 years ago.

Jurich ordered a biopsy. It showed lung cancer that had metastasized — a virtual death sentence. "He lived in denial," Jurich says. "I wish I'd been able to see him five years ago."

For such patients, health insurance comes too late for anything but a terminal diagnosis. That's a reason why Carrie Banahan, director of the Kentucky Health Benefit Exchange, says that as more newly insured people seek care, health statistics might get worse before they get better.

Some low-wage workers say that even with the ACA subsidy, they can't afford to buy insurance offered on the exchange.

Danny Conn, 20, a community college student who lives on his own, says he makes too much at his supermarket job to qualify for Medicaid and too little to afford even an inexpensive private plan. "Obamacare is a good idea," he says. "It's just out of reach."

For some, opposition to the ACA is a matter of principle.

Charles Adams, 33, drives a dump truck. A year ago, he dropped an insurance policy that cost him more than $120 a month — he says he wasn't using it. He soon fell off a truck and went to the emergency room, where he ran up a bill he couldn't fully pay.

He says this year, he'll probably take the $95 penalty under the ACA for being uninsured, in part because he's opposed to requiring people to buy insurance. "It's unconstitutional," he said. "A young person don't really need it. ... I can afford to lose $95 as opposed to $120 a month."

On April 24, 1964, Lyndon Johnson came to eastern Kentucky to promise victory in a "war on poverty … in all its forms," including a lack of "medical care for our aged."

Floyd County became the site of a pilot health care program, devised by the Office of Economic Opportunity, that established a series of rural health clinics.

It was supposed to be a national model. But instead of treating patients, the clinics referred people with the most basic maladies to hospitals and doctors' offices – many of which wouldn't treat them if they couldn't pay. After a few years, Washington shut the program down.

At the time in 1970, Eula Hall was a 43-year-old mother of five. She was a product of the hollow — born on the dirt floor of a cabin with neither plumbing nor electricity, and she was educated only through eighth grade. She saw her chance. With help from two part-time volunteer doctors, she opened a clinic that took all comers, regardless of ability to pay.

When the Mud Creek Clinic got too busy, she moved the clinic into her house and her family into a trailer.

When the clinic needed money, Hall set up a roadblock in the highway and hit up motorists for donations.

When an arsonist burned the place down, Hall set up shop the next day on a picnic table under a willow tree and got the phone company to install a phone on the tree. She then raised $120,000 in 90 days to match a federal grant and build the sturdy structure that houses the clinic today.

Locally initiated and controlled, the clinic is a rebuke to outsiders who'd impose their solutions to Floyd's problems.

A flaw in Johnson's poverty war, she says, was that local people weren't sufficiently involved or consulted. She wishes she could sit down with this president and talk about the obstacles to health here — the people who can't get to the doctor because their cars won't start or because they don't have phone service, the ones hooked on prescription painkillers, the ones who won't stop smoking or start exercising, who cook with lard and guzzle soda like water.

"That's how the government learns about life, from people that's lived it," Hall says.

This is a woman who saw her mother almost bleed to death in childbirth at home; who lost all her teeth by age 40 for lack of dental care; who didn't learn her own blood type until she was 41.

She knows things can change. She hopes the Affordable Care Act is change for the better. And, like a lot of people here, she's waiting to see.