Obamacare takes root in Appalachia, to mixed reviews

Laura Ungar and Chris Kenning | USA TODAY

Show Caption Hide Caption Eula Hall Health Center Obamacare flooded into these remote Appalachian hills last year like the War on Poverty had a half-century earlier – another government program promising to save some of America's most vulnerable citizens.

PRESTONSBURG, Ky. — Obamacare flooded into these remote Appalachian hills last year like the War on Poverty had a half-century earlier — another government program promising to save some of America's most vulnerable citizens.

Since then, it has given many of the poor and sick a key to long-neglected health care. It's also brought skepticism and fear, and some business owners argue it's stunting their growth in a region that can't afford another economic blow.

One year after USA TODAY and The Courier-Journal in Louisville examined the Affordable Care Act's arrival in Floyd County, Ky., the health plan has taken root in ways both surprising and expected, good and bad.

Amid predictions that bad health habits would be hard to break, scores of newly insured residents, mostly covered by Medicaid, have sought care in hospitals, mental health centers and drug treatment facilities. Providers have proved plentiful. Unreimbursed care costs are down. The county's under-65 uninsured rate is half what it was — dropping from 19% before the ACA to 10% at the close of 2014.

Some who dismissed Obamacare because of its political associations with a president blamed for the decline of coal industry say their opposition has softened.

Last year, fast-food worker Melinda Watson echoed the law's unpopularity here — convinced it would kill jobs and create long waits for "horrible" socialized medicine. She bought a subsidized insurance plan on the state exchange only to avoid paying federal penalties. But she soon realized the benefits: going to the doctor regularly and undergoing MRIs for her epilepsy. Her employer didn't cut her hours, as she feared.

"I was really scared at first, with all the gossip," said the 41-year-old granddaughter of a coal miner, slicing tomatoes in the back of a sub shop. "But it's really helped. I've seen a lot of other people who got insurance actually using it, going to the doctor and getting their teeth fixed. Now I've got the opposite fear — that when (President Obama) goes out of office, they'll take it away."

Although many of the initial fears about the law didn't come to pass, the ACA is not a panacea, and the ultimate goal of making the region healthier is far from being realized. Many Floyd County residents don't like certain parts of the law, such as the tax penalty people must pay if they don't have insurance and the upcoming requirement that businesses with more than 50 full-time employees provide affordable insurance or face a penalty.

Hospitals report being squeezed financially. One insurance agent says the system remains difficult to navigate. Many who don't qualify for Medicaid or a sizable subsidy — and have been largely left out of the health care system — say their insurance has gotten more difficult to afford.

As uncertainties over the future of the ACA linger — a legal challenge before the Supreme Court, Republicans vowing to reverse it — advocates say the area, characterized by deep-seated poverty, outsized health woes and anti-government conservatism, remains an important testing ground in one of the few Southern states to both adopt its own health exchange and to expand Medicaid.

"This has been a big help for low-income people in eastern Kentucky," said Ancil Lewis, CEO of Big Sandy Health Care, which runs five clinics in the area. "But I have a lot of concern. This could be a house of cards. ... There are many potential perils to the Affordable Care Act."

QUESTIONS AND SHORTCOMINGS

Up a winding road outside the county seat, Onyx Coal and Matt/Co. co-owner Clark Pergrem, who operates some of the area's few remaining coal mines, opposes Obamacare even though its penalties have pushed some employees to get coverage.

"I'd like to see it repealed," Pergrem said, adding that it takes a bite out of people's paychecks when they can barely afford rent or groceries.

Some residents who purchased private plans on the state exchange in 2014 found the monthly premiums rose sharply in 2015, causing some to drop out or reduce coverage, said Darrell Patton, an insurance agent whose strip-mall office is filled with hunting décor. The benefits of the ACA have been conferred mostly on the poor, he said, setting up a looming conflict with the middle class, who see the costs of employer plans rise.

Some workers who hoped for employer plans remain uninsured. Archie Everage, who owns a chain of fast-food sandwich shops in Floyd and nearby counties that employ more than 80 full- and part-time workers, said he plans to pay a fine of $2,000 per full-time employee rather than provide insurance as the ACA requires.

"If we had the revenue, we'd love to offer insurance," he said. "But … a business has to survive."

Paul Reffett, owner of ValueMed pharmacy, said the ACA has meant more work but less profits. More customers get prescriptions, but the number of uninsured patients paying cash has fallen from 10% to 3% as people have gone on Medicaid — meaning low reimbursements instead of full payments.

Overall, 5,403 Floyd County residents have enrolled in Medicaid under the ACA, while only 620 have bought private health plans on the state's "kynect" exchange. Data from a recent state examination of the Medicaid expansion found it had brought $15.5 million in Medicaid payments to Floyd County in 2014, including $5.9 million to hospitals.

Hospital officials say the ACA has accelerated trends hurting rural hospitals. Medicaid in Kentucky is handled by managed-care companies, which are slow to reimburse, said Bud Warman, CEO of Highlands Regional Medical Center in Prestonsburg. More Medicaid patients mean more slow payments. This compounds a problem of declining inpatient population that led the hospital to close its fourth floor a year ago.

Warman acknowledged an 87% drop in uncompensated care in a year but said he worries this will lead to the disappearance of government funding for hospitals such as his that care for a "disproportionate" number of Medicaid and Medicare patients.

"We're still struggling. It's hard to say if it's the economy or the ACA or all of the above," Warman said, adding that he worries about the future of the hospital, one of the county's biggest employers with 600 workers. "I wouldn't say we're in danger of closing today. But if the economy continues to lag ... that could be a reality in five years."

MORE ACCESS, MORE CARE

Thursa Sloan, Floyd County's public health director, said it's an uphill battle to reverse mountain maladies of poverty and unemployment — not to mention the prevalence of smoking, cancer, diabetes, obesity and heart disease that combine to put Floyd second-to-last in Kentucky in county health rankings this year.

Obamacare is making a surprising dent, she said, and "public attitude has improved for the ACA."

"I was at the local Dairy Cheer and heard the girls working there say, 'I'm going to the doctor next week,' " Sloan said. "They make minimum wage. I said, 'You girls must have gotten new insurance.' And they said, 'Yes we did.' "

According to a state review, 14% of Floyd County's population enrolled in Medicaid under the expanded program, and half of residents have the government coverage.

That includes Susan Keathley, 43, a former Walmart worker who started on Medicaid Jan. 1 after signing up at the Eula Hall Health Center in Grethel. Before that, she was uninsured for almost five years, and "if I needed to go to the doctor, I went to the ER, or else I didn't go anywhere."

Keathley is being treated for a persistent nerve problem in her elbow and goes to the clinic for routine illnesses. While she was there recently for a sore throat, the physician assistant asked about her mammogram and an upcoming urology appointment, making sure she keeps up with preventive care.

"It's easy for them to keep their appointments because they have a way of paying," said Eula Hall, 87, the clinic's founder, who still shows up there every day.

Obamacare has given residents easier access to mental health and substance abuse treatment, increasing the patient load at Mountain Comprehensive Care, the area's largest provider of such services, by 15% to 20% and leading to nearly 70 new jobs.

Medicaid patients are likely to flood a large drug treatment facility set to open this year. Patients at the old center, in a roadside motel across from a cemetery, signed up for Medicaid to cover outpatient costs once they get out.

"That's going to be a huge part of my recovery," said Cody Fields, 24, an out-of-work waiter finishing 45 days for opiate addiction. "Obamacare — it changed the way I take care of myself."

Jon Dye, a "kynector" who helps people navigate the state's health exchange, said he's seen much the same with the clients he's signed up at Hall's health center. One 23-year-old client had 10 ingrown toenails treated after enrolling in Medicaid and was finally able to start looking for a job.

"Even as a red state, Medicaid has done tremendous things for our people, even putting people back to work," Dye said. "Kentucky has led the way … (as) one of the first states to take Obamacare and run with it."

Dye pointed out that people associate their new insurance with kynect, not Obamacare. "I don't ever mention the ACA, honestly," he said. "I had one guy say, 'I'm so glad I found you and didn't have to go through that Obamacare stuff.' "

Even Hall, who has devoted her life to caring for her people and loves that more now that they have insurance, worries ACA costs down the road may burden the struggling taxpayers of Appalachia. She echoed many across Floyd County — and America: "Obamacare has its good and bad, both at once."

Laura Ungar and Chris Kenning also report for The (Louisville) Courier Journal