BREATHITT COUNTY — The envelopes began arriving in December across Eastern Kentucky, one of the poorest and least healthy corners of the country.
"Dear member ... We want you to be healthy," read the letter to Mary Combs, and with it came a plastic card representing the first insurance she ever had, a Medicaid plan made possible by the nation's new health-care law, effective Jan. 1.
Nine days into the new year, the 41-year-old call-center worker headed to the health clinic on Highway 15. She saw a doctor about her chronic stomach ulcers, had her blood drawn for tests and collected referrals for all the specialists she had been told she needed but could never afford.
The next week, she saw a neurologist, who found lesions on her brain and prescribed medicine for the cluster headaches, which are also called "suicide headaches" for pain that is far more intense than a migraine, and which Combs had been treating with an alcohol-soaked cloth wrapped around her head. She lined up a gynecologist for abnormal uterine bleeding and a hematologist for anemia and an ophthalmologist for an affliction she called "arthritis of the eye," which was diagnosed on one of the rare occasions she decided to see a specialist, a $250 visit her husband paid for by selling his riding lawn mower.
"She got mad at that," Johnny Combs said now, waiting in an exam room with his wife, who was back at the clinic again, this time for an earache she would normally treat with sweet-oil drops.
"Well, we needed that mower, too," Mary Combs said, and soon the nurse practitioner arrived, and a new conversation began:
"OK," she said. "We are no stranger to these ear complaints."
"No," said Combs, who soon had another referral for an ear, nose and throat specialist, as week 3 in the world of the newly insured carried on.
This is the world that many critics of the new health-care law have worried about, one in which the sick and the poor expand the ranks of Medicaid while other Americans see premiums rise, policies canceled or favorite doctors booted out of networks.
Supporters of the new law argue that another scenario will unfold in places such as Eastern Kentucky, where the sick and the poor get insurance, seek treatment for long-neglected illnesses and prevent other health problems down the line, ultimately saving the health-care system billions in emergency-room visits and other costs.
A week at the Breathitt County Family Health Center provides an early glimpse into how those theories are beginning to play out in a place where people have long worried about having no insurance at all.
"That's the big question: Does getting insurance bend the cost curve or the health outcomes curve?" said Karen Ditsch, the executive director of Juniper Health, which runs the nonprofit Breathitt clinic. "Is it going to make a difference?"
The starting point for any answer begins with life before Jan. 1. Eighteen percent of the county's population — about 2,500 people — were uninsured, and rates of diabetes, heart disease and other chronic illnesses have remained some of the highest in the country. The rate of adult obesity is 40 percent, for example, and 31 percent of adults smoke. The unemployment rate is 10 percent, and complications of poverty abound.
Life since Jan. 1: The number of uninsured has dropped by 520 people, about 21 percent of the those without coverage. Of those 520, 472 qualified under the health-care law's expanded income parameters for Medicaid, which is aimed at the working poor. Here and there, for-profit clinics that never accepted the uninsured have hung "Welcome new patients!" signs on doors.
And at the Breathitt Family Health Center, the newly insured started calling on Jan. 2 to get prescriptions sent to Wal-Mart and to line up appointments. Soon after that, they started trickling in.
The problem was never really that people did not see a doctor at all. The mission of the clinic, which has been open since 2004 and survives largely on federal grants, has always been to provide primary care to the uninsured on a sliding fee scale, usually about $20 a visit.
The problem, said Derrick Hamilton, a doctor of internal medicine and the clinic's chief medical officer, is that people have come erratically to save even on a $20 fee and, more significantly, have been unable to follow up with costly specialists.
"I could shingle the roof with all the 'against medical advice' forms I've had to sign because people can't afford to pay," he said, referring to the paper he would hand patients who declined to follow a recommendation to get an MRI or see a specialist about mysterious stomach pains.
He knew things were changing when, after the law took effect, one of his next patients showed up with an index card listing all the ailments she wanted to investigate: chest pains, blurry vision, popping hips, gynecological matters and lingering psychological problems from the death of a son five years earlier.
Now it was week 3, and Hamilton draped a stethoscope around his neck and headed to an exam room where Mary Blair was waiting.
"When they designed this law, it was Mary Blair they had in mind," he said before he walked in, and then: "How are you doing, Mary?"
Blair, 24, had lost her job and her health insurance at 34, had a heart attack at 39, had six stents put into her heart and two in her leg, and currently had more than $30,000 in medical bills that she was paying off in $20 increments, money from her husband's part-time job at Advance Auto Parts.
"Been doing good," said Blair, who was recently diagnosed with diabetes and high blood pressure. She had a hacking cough.
"Has your blood sugar bottomed out any?" Hamilton asked.
"No, it's good," Blair said. "I just got the shakes real bad."
"Your blood pressure is sky high," Hamilton said, starting his exam. "Say 'ah.' "
If it was a relief for Blair to finally have insurance. It was a relief for Hamilton, too, who grew up in Breathitt and worried often about fragile patients like Blair who were so often neighbors, old classmates, former teachers or distant relatives in the close-knit county. He was used to answering late-night calls from patients panicked over chest pains but afraid to go to the emergency room lest they incur thousands of dollars in bills and wind up with their names published in the newspaper, which is how the local for-profit hospital went about collecting bills.
"I'm always hearing, 'I don't want to get my name in that paper,'" he said.
On this day, though, he was slightly less worried, because Blair had insurance. He ordered a chest X-ray, prescribed medicine for the cough and adjusted one of her 13 prescriptions, pills that ran her about $100 a month before Jan. 1 but were about $2 each now.
"She will ultimately have bypass surgery done on her heart," said Hamilton, who has turned down lucrative offers to practice elsewhere and who once considered volunteering in Haiti after the earthquake there until he decided that Breathitt County was almost as desperate.
He walked into exam room 4 to see Marlene Turner, 57, who had waited tables at the Pizza Hut for seven years and, before that, at a local diner for 26 until it burned down. She had come in her Pizza Hut uniform.
"It's my knees: They're bone on bone," she began.
On the upside, Turner now had insurance through Medicaid. On the downside, Pizza Hut had reduced her hours from 30 hours a week to 24. For Pizza Hut, this meant it was not required to provide her with coverage, which the new law mandates for employees working more than 30 hours a week. For Turner, it meant even less money.
She was probably a candidate for knee replacement surgery, except she was worried about losing money, or her job, by taking so much time off.
For now, she was happy to take a cortisone injection to relieve her knee pain, something she might have muscled through before Jan. 1.
Later in the week, Terri Wagers dragged in her husband, John, who worked repairing heaters and had never had health insurance until now. He sat stiffly on an exam table in a camouflage T-shirt and work boots.
"We'd just buy over-the-counter medications before," his wife began, explaining how they had been handling his health problems. "He's got trouble with his back, a deteriorating disc or something. He needs an MRI. When we called before, they said it would cost $2,500, but now the insurance said they'd pay for that if we get physical therapy first. He has to have a sleep apnea test, too. ... A while back he had something going on with his heart and this doctor said he'd help him, but then it was $3,000. We had to file bankruptcy for that."
Terri talked until the nurse practitioner walked in. She looked at John, who did not look very good.
"Are you okay?" Alissa Freeman asked him.
He shifted on the exam table and looked down.
"Your back is hurting you?" she asked.
"Yeah," he finally said. "I'm hurting today. ... Even my hair hurts."
"Okay," Freeman said, pressing a stethoscope to his chest. "Big breaths."
"Sometimes my heart hurts," her new patient said. "All I know is when you get 30, you start falling apart."
"Poor old man," Terri Wagers said to her 30-year-old husband.
For his back, Freeman lined up an appointment for the physical-therapy clinic down the road. For his sleeplessness, an appointment at a sleep clinic, health care worth hundreds if not thousands of dollars.
Later, Freeman saw Mary Combs for her earache. Hamilton saw some of his Medicare patients, then went back to his office.
The third week in the world of the newly insured was over. Hamilton sat at his desk and typed in orders for medications and updates to patients' files, data that would eventually be sent to the state and federal government and probably find its way into long-term studies of the impact of the new health-care law.