Editor’s note: This story is part of Crossing the Divide, a cross-country reporting road trip from The GroundTruth Project and WGBH. The team of five reporters is exploring issues that divide us and stories that unite us. Follow their trip across America at xthedivide.org.
WHITESBURG — Lois Smith was paralyzed, but now she can walk again.
Smith, 62, had been to the emergency room off and on since she collapsed one day in her driveway about five years ago and found herself unable to walk. She was uninsured, on disability and incapable of paying a primary care doctor.
In 2013, she enrolled in Medicaid under the expansion created by the Affordable Care Act, also known as Obamacare, and has been seeing Dr. Van Breeding at Mountain Comprehensive Health Corporation in Whitesburg regularly ever since. Breeding determined she suffered nerve damage from diabetes. With treatment, Smith is now back on her feet.
“Since the Affordable Care Act, we’ve been able to see so many more patients, we’ve diagnosed high blood pressure, coronary diseases, diabetes, cancer,” said Breeding, referring to the act that President Barack Obama signed into law in 2010 without a single Republican vote.
The law expanded Medicaid and created regulatory changes in the individual market, providing health insurance for more than 20 million uninsured Americans and nearly half a million Kentuckians by 2016.
“These are people who may have died of these conditions but at least now have the ability to get a prognosis and get their conditions treated,” Breeding said.
This rural Appalachian clinic and its patients are far from the white hot debate about the future of the federal health law that roiled Washington in recent weeks. But it is here in Letcher County that any repeal or replacement of Obamacare would change lives. The reality on the ground — in a state that turned out in large numbers to vote Donald Trump into the White House — is that the Affordable Care Act has expanded services and provided critical coverage to uninsured citizens who might otherwise be dead today.
Kentucky’s Republican leaders, though, insist the health law is broken and must be replaced, even as health care workers offer a more nuanced critique.
“Obamacare is failing in Kentucky; it will bankrupt our budget,” Republican Party of Kentucky spokesman Tres Watson said Friday as he criticized a Democratic radio ad attacking U.S. Rep. Andy Barr, R-Lexington, for his support of Republican health bills. “Congressman Barr is offering Kentuckians a health care plan he can actually deliver to them rather than the unsustainable, failing pipe dream that is Obamacare.”
U.S. Sen. Rand Paul, R-Bowling Green, has been a longtime vocal advocate of repealing the Affordable Care Act but has yet to support any of the GOP’s recent health care bills. Those proposals keep too many of the taxes included in Obamacare and don’t cut enough of the spending, he has argued.
“The answer isn’t that we always want people on the government receiving end, we actually would like more people with great jobs, a thriving economy and private insurance,” Paul said during a recent visit in nearby Prestonsburg. “It’s complicated, it’s how do we get the economy to grow better and how do we fix the health care system at the same time? I think what we’ve got is not working very well.”
‘It just needs to be modified’
Those who’ve been fighting for decades to make health care accessible to the disadvantaged in Eastern Kentucky take a more no-nonsense approach to the health care debate. Eula Hall, who founded the Mud Creek Clinic in rural Floyd County in 1973,
doesn’t dispute that Obamacare needs to be fixed, but she’s also adamant that stripping away the progress made in recent years would be a mistake.
“You know in any program you’ve got, there is always abuse you’ve got to look at,” said Hall, who will turn 90 this month and continues to work at the clinic that now bears her name. “It just needs to be modified.”
For Hall, access to affordable health care is a right that everyone deserves.
“People should have health care,” Hall said. “It shouldn’t be just one state here and there, it should be every state and everybody should be entitled to adequate affordable health care. … Nobody should have to be sick or nobody should have to do without their medication.”
Former Kentucky Governor Steve Beshear, a Democrat who expanded Medicaid eligibility in Kentucky under the Affordable Care Act in 2013, believes Republican efforts to repeal the law center on achieving a political “win.”
“For the folks in Congress, it is entirely a political game, it has nothing to do with providing people health care,” Beshear said.
“They have allowed the political game to become their priority, and as you can see from these ideas that they have been trotting out, every one of them rips health care away from millions of people and thousands of Kentuckians,” he said. “But they’re so wrapped up in politics and what they think their base wants that they’re willing to devastate a large portion of their population from a health care standpoint in order to ‘win’ on this issue.”
Republican proposals to replace the law have created a sense of unease about how much longer expanded Medicaid eligibility will last.
“It’s very stressful, for the doctors, the patients, everyone,” said Becky Amburgey, Mountain Comprehensive Care’s clinic administrator, who has worked at the clinic for 37 years. “After the Affordable Care Act, we were able to treat people that had never had insurance before, and if they repeal it, we don’t know if we’ll be able to get these people to their doctors.”
She added: “I worry, because if they lose coverage they go back to the same lifestyle they were living before and then they die.”
Sicker than most
At the forefront of the health care debate is this unarguable truth: Kentuckians are sicker than most Americans, especially in Eastern Kentucky. Cancer mortality rates nationwide declined about 20 percent from 1980 to 2014, but those rates increased in Eastern Kentucky, according to a 2017 study by the Journal of American Medicine Association. The study also showed Kentucky ranks 43rd among states in heart disease deaths.
Kentucky also leads the nation in cancer deaths, according to the American Cancer Society, and ranks 48th among states in drug overdoses, according to the U.S. Centers for Disease Control.
“Eastern Kentucky has the most challenging health indicators of any place in the entire nation,” said Ben Chandler, president and CEO of the Foundation for a Healthy Kentucky and a former Kentucky congressman. “Eastern Kentucky is not only behind the rest of Kentucky but it’s behind the rest of Appalachia.”
The federal health law has had a clear impact in getting Kentuckians access to care: 475,000 Kentuckians have enrolled in Medicaid under the expansion since 2013, according to the Kentucky Center for Economic Policy.
Before the Affordable Care Act, the Whitesburg clinic served 25,699 patients. By the end of 2016, it served 34,581 patients, according to clinic records. The percentage of uninsured patients dropped from 16 to 4 over that same period.
Dr. Breeding and clinic officials rave about their ability to offer better care to more people. Screenings for colon cancer have risen from 19 percent to 60 percent of patients, the clinic now offers dental and vision care, and they are planning to open a Suboxone clinic to help address the opioid crisis.
Obamacare has also had a “huge economic impact” by infusing upwards of $3 billion in medical expenditures into the state economy, according to Jason Bailey, founder and executive director of the liberal-leaning Kentucky Center for Economic Policy.
“It’s resulted in the direct creation of provider jobs, doctors, nurses, dentists, who all then go on to spend the money they make and put it right back into the local economy,” he said.
Cultural beliefs vs. health care
Breeding, a Whitesburg native, said he thinks many of his patients voted for Trump based on cultural issues, such as immigration, and promises of returning coal jobs.
“The patients didn’t look at the election as being a health care issue, although it was,” Breeding said. “They had this belief that closing our borders would make our country safer. That’s their cultural belief, and so they voted for President Trump.”
It’s also clear here that Obamacare has real problems. Health care experts note that premiums have risen sharply for individuals purchasing insurance on the federal health exchange. Rising premiums also squeeze small businesses, 60 percent of which support repealing the law, according to a February survey by BizBuySell, a small business marketplace.
Rather than repeal the law, some local health advocates would prefer making changes to stabilize the federal health exchange while protecting expanded Medicaid, which they see as crucial to the region’s economic recovery.
“The way out of the economic problem that we’re in as a state and a region and nation is a healthy, well-educated workforce,” said David Bolt, chief operating officer of the Kentucky Primary Care Association. “That’s not ideological thinking, that’s the very basis of how you grow an economy, how you grow jobs.”
Bolt thinks much of the talk about the failings of the health law is political bluster.
“The only part that is imploding at all is the individual market, a very, very small piece of the health care coverage,” Bolt said.
Meanwhile, Lois Smith and others who rely on expanded Medicaid wait anxiously to see what Washington does.
“I’m worried because you never know when they’re going to cut it off,” Smith said.