Nineteen years ago, after medical school at Columbia University; a stint at Montefiore Medical Center, in the Bronx; and a period running homeless shelters in Times Square; Karen Kinsell moved to Fort Gaines, a tiny town in southwest Georgia, on the Alabama line. Fort Gaines is in Clay County, which is consistently ranked among the poorest of the hundred and fifty-nine counties in the state. It currently ranks third-to-last in “health outcomes,” according to the Robert Wood Johnson Foundation, up from dead last. Clay County’s only hospital closed its doors in 1983, long before Kinsell, who is now in her sixties, arrived and became its only doctor. “It’s a bad place to live,” Kinsell said recently by phone, between seeing patients, “which is why I moved here. I was looking for a place that needed me.”

Kinsell runs Clay County Medical Center, a facility with four exam rooms built out of a former Tastee-Freez. It’s a private practice, but she is a full-time volunteer. There is a receptionist and two other full-time staff members; they see “around thirty to thirty-five patients a day,” Kinsell said. Monty Veazey, the president of the Georgia Alliance of Community Hospitals, told me that “Kinsellcare” is the only health care that’s had a meaningful and positive effect here. “She’s going bankrupt treating everyone that comes in,” he said. “Most have no money, no Internet access, no other basic care. Many don’t have insurance. How much longer can she do that? I don’t know. But she’s their only hope.”

On Tuesday, shortly before Senator Mitch McConnell announced a delay in the vote for the Senate Republicans’ health-care reform bill, Kinsell spoke by phone about the effects of Obamacare, the prospect of Trumpcare, and the plight of sick people in southwest Georgia. Her account has been edited and condensed.

“My patients are sixty per cent black and forty per cent white. Forty per cent are completely uninsured, and we just ask them for ten dollars to cover the visit. If they can’t pay, then it’s free. We do that because this is one of the poorest places in Georgia, with some of the sickest people, and we’re adjoined by counties that are just as bad.

“We’ve had two rural hospitals in the wider area close in the last seven years. And the quality of the remaining really rural hospitals is pretty awful. You have to go in one of five directions to find health care from here: there’s a physician’s assistant in a waiting room twenty miles away. But the closest real hospital is thirty miles. A real regional hospital is sixty miles away if you stay in Georgia, forty miles away in Alabama.

“Many charge a minimum of twenty-five dollars. But we have a fair number of people who live off food stamps, live off a hundred and ninety-four dollars a month, live with family. They cannot afford that. So people drive forty miles or more to see me. Few make appointments; many don’t know in advance when they’ll be able to get a ride. No one is told they’ll have to wait two weeks to see the doctor, but sometimes they’ll sit here and choose to wait several hours.

“I’m the only provider in the county, so it’s partly chronic care and partly urgent care that I do. There’s very high rates of diabetes, hypertension, cardiovascular disease. That sort of thing. We just did an S.T.D. check. I have leg pain reported in this next patient this morning. We have a very high rate of elderly and disabled people here, because of multi-generational poverty. People who can leave have left.

“Most people are so poor and kind of out of it that they don’t expect anything. They mostly just expect to not have insurance. This morning, we had a lady with post-menopausal bleeding, which could be cancer. The absolute best thing to do is have her checked out by a gynecologist, but we really don’t have a way to do that that she can afford. The health department has some programs, but they generally require a diagnosis of cancer before their programs can pick up. So that’s a problem. People constantly have a problem being able to afford their medicines. I use generics all the time. And prescription-assistance programs, which are a tremendous amount of paperwork, which people have trouble doing. We use samples from drug reps.

“There’s no mental-health care in the county, which is crazy. I just had an eighteen-year-old who needed some mental-health medications renewed, so I did that. There just isn’t what you’d expect to have in America down here.

“In all fairness, Obamacare, as much as I was for it—and I’m on it myself—didn’t affect us much at all. The first year it came out, southwest Georgia had the second-highest premium costs in the nation, after Vail, Colorado. And because not many people make enough to be allowed to buy into it, very few people around here signed up for it. We also were not allowed to be a provider, because people were allowed to pick and choose providers. Then, of course, Georgia did not expand Medicaid. That’s why about forty per cent of our patients are uninsured.

“We didn’t see a whole lot of businesses here starting to offer insurance under Obamacare. Partly because the big companies—the chicken plant—already have insurance. And we don’t have many companies that are that fifty-to-one-hundred-employee size that would have been affected.

“With Trumpcare, we’d be going from bad to slightly worse, especially with the proposed Medicaid limits. There’s talk of, down the road, pregnant women might not be covered. Disabled people, too. Reduced special services. We’d have more limited funding. We have a private sixty-bed nursing home here in Fort Gaines, around the corner, and I gather that ninety-five per cent are Medicaid patients. There’s only one person paying cash there. There’s no financial reason why there should be health care in Clay County.

“People who are politically active and educated are generally pretty upset about the state of health care in this county. I had a wealthy, Trump-supporting retired pathologist tell me, ‘Shoot, we need a single-payer system.’ I was surprised to hear him say that. But the low levels of literacy and engagement of people here—I think a lot of them just aren’t even aware of these discussions going on. The uninsured don’t have anything or expect to get anything.

“The uncertainty of whether Trumpcare will or won’t pass is disturbing for us at the medical center, though. I expect, if it goes through, we’ll have more patients come in for the free or discounted health care. And we don’t have any more capacity. I’m here until 7 P.M. every night as it is. It’s just, how much more can you do?”