An un­healthy con­tra­dic­tion

They are poor, sick and voted for Trump. What will hap­pen to them with­out Oba­macare?

The Washington Post Sunday - - FRONT PAGE - BY JES­SICA CON­TR­ERA IN NORTH­FORK, W.VA.

AN­OTHER MORN­ING, AN­OTHER LIST of pa­tients and prob­lems in the hands of 35year-old Keisha Saun­ders. Di­a­betes, de­pres­sion, heart dis­ease. Robert needs lower blood pres­sure. Buffy needs pre­scrip­tions filled. Mary needs to lose 50 pounds, so she can get what she re­ally needs, a new hip.

Again, the list ex­tends to the bot­tom of Keisha’s notepad, as it has so many days since the Af­ford­able Care Act man­dated that ev­ery­one have health in­sur­ance. Un­like in Wash­ing­ton, where health care is a con­tentious pol­icy de­bate, health care where Keisha is a nurse prac­ti­tioner is a daily need to be filled. The high rates of chronic dis­eases in McDow­ell County have made it the county with the short­est life ex­pectancy in the na­tion.

It’s also a place that voted over­whelm­ingly for Pres­i­dent Trump, whose prom­ise to re­peal the ACA will soon af­fect nearly ev­ery pa­tient Keisha treats at the Tug River health

clinic in North­fork, in­clud­ing the one wait­ing for her in exam room No. 2.

“How are you do­ing?” she asks Clyde Gra­ham, who is 54 and has been out of work for four years.

“I ate a sand­wich from Arby’s,” he says. “And it jumped me out for like, three days. I mean it just burnt.”

Heart­burn is just the lat­est prob­lem for Clyde, a pa­tient Keisha sees ev­ery three months. Like so many in this cor­ner of Ap­palachia, he used to have a highly paid job at a coal mine. Com­pany in­sur­ance cov­ered all of his med­i­cal needs. Then he lost the job and ended up here, hold­ing a cane and suf­fer­ing not only from heart­burn but di­a­betes, arthri­tis, di­ver­ti­c­uli­tis, high blood pres­sure and high choles­terol.

Be­cause of the ACA, Clyde’s visit is cov­ered by Med­i­caid. Be­fore the law, most West Vir­gini­ans with­out chil­dren or dis­abil­i­ties could not qual­ify for Med­i­caid, no mat­ter how poor they were. The ACA — bet­ter known here as Oba­macare — ex­panded the pro­gram to cover more peo­ple, such as Clyde, who can de­pend on Keisha to fix his heart­burn with­out hav­ing to worry about the cost.

As for the other prob­lems in his life, he has put his hopes in Trump, who came to West Vir­ginia say­ing he would bring back coal and put min­ers back to work. When Trump men­tioned re­peal­ing Oba­macare, Clyde wasn’t sure what that might mean for his Med­i­caid. But if he had a job that pro­vided health in­sur­ance, he rea­soned, he wouldn’t need Med­i­caid any­way, so he voted for Trump, along with 74 per­cent of McDow­ell County.

Tug River Health As­so­ci­a­tion treats about 8,700 pa­tients, re­sult­ing in some 20,000 vis­its a year to its five clin­ics. In 2016, 12,284 of those vis­its were from pa­tients on Med­i­caid, up from 5,674 in 2013, be­fore the ACA took ef­fect here. With­out the ACA, many of those pa­tients wouldn’t be able to af­ford care. Will they soon lose their cov­er­age? Will they stop com­ing to the clinic? Lately, Tug River’s chief ex­ec­u­tive has been telling his staff, “The key word go­ing for­ward is un­cer­tainty.”

To Keisha, all is un­cer­tain be­yond this mo­ment, in which she pre­scribes Nex­ium for Clyde’s heart­burn, ex­am­ines him from head to toe and sends him to the lab across the hall for blood work.

“I’ll see you in three months,” she says, hop­ing that will be true, and heads to exam room No. 1, where an­other pa­tient is wait­ing. “What’s go­ing on to­day?” she asks, and walks in the room to find out.

MEAN­WHILE IN THE FRONT OF THE CLINIC, more pa­tients are com­ing in through the heavy doors and up to a glass win­dow where a re­cep­tion­ist is wait­ing.

“Hi honey, how are you?” Tammy McNew says to each one. Over the past four decades, McDow­ell County has lost 60 per­cent of its pop­u­la­tion, so she rarely needs to ask their names. In­stead, she asks what seems like the most im­por­tant ques­tion in health care these days:

“Got your in­sur­ance card with you?”

If the an­swer is no, she will send them back to Keisha any­way, and the clinic will de­pend on fed­eral grants to make up the cost. But more of­ten in re­cent years, the an­swer is what a mid­dle-aged woman with springy curls says as she passes her Med­i­caid in­sur­ance card through the win­dow: “Yes, ma’am,” she tells Tammy, who slides it into a scan­ning ma­chine.

In other parts of the coun­try, the pri­mary im­pact of the ACA has been re­quir­ing peo­ple to have pri­vate health in­sur­ance, but in poor and sick com­mu­ni­ties like McDow­ell County, the law’s dom­i­nant ef­fect has been the Med­i­caid ex­pan­sion, which has given more peo­ple ac­cess to the kind of health care that wasn’t widely avail­able or af­ford­able to them be­fore. With an in­sur­ance card in her pocket, the pa­tient at Tammy’s win­dow can ven­ture into the realms of med­i­cal care that are typ­i­cally out of reach to those with­out one: blood work, im­mu­niza­tions, spe­cial­ized doc­tors, surgery, phys­i­cal ther­apy.

If she needs men­tal health coun­sel­ing, the clinic no longer sends her to the next county over; last July, Tug River was able to hire a psy­chol­o­gist, who is now treat­ing 180 peo­ple, many of whom are try­ing to over­come opi­oid ad­dic­tions.

If she needs med­i­ca­tion, the nurses won’t go dig­ging in a closet of sam­ples left by drug reps as they used to do for the unin­sured. The med­i­ca­tion will come from a phar­macy and cost no more than a few dol­lars.

“All right sweetie, I got you,” Tammy tells her, and the pa­tient re­treats to a chair to wait for her name to be called. The rou­tine is re­peated dozens of times a day as the phone rings be­hind the front desk. “For ap­point­ments, press one,” the call­ers hear. “Black lung, two.”

This clinic is in North­fork, a com­mu­nity of a few hun­dred peo­ple along the rail­road that car­ries coal through the moun­tains. Keisha, who is black, was raised in this pre­dom­i­nantly white county, in a home over­look­ing the cin­der-block church where her fa­ther, a coal miner, serves as pas­tor. She at­tended the mid­dle school be­side the clinic park­ing lot, which now has busted win­dows and gap­ing holes in its brick fa­cade. There weren’t enough chil­dren to fill it, as ev­ery year the clos­ing of more mines drove job-seek­ers out of the county.

Even­tu­ally, Keisha was one of them. Af­ter grad­u­at­ing high school and be­com­ing a mother at 18, she re­al­ized that if she wanted to be­come some­thing more for her daugh­ter, she would have to leave.

She moved 45 min­utes away, to Prince­ton, W.Va., where she got a nurs­ing as­sis­tant cer­ti­fi­ca­tion and a job in a nurs­ing home. But ev­ery Sun­day, she strapped her daugh­ter Kiana in her car and drove back to McDow­ell County, check­ing in on her al­ways-fad­ing town. Bull­dozed, shut­tered or aban­doned: the gro­cery store, beauty sa­lon, florist and fur­ni­ture store. Still open: the dol­lar store, med­i­cal equip­ment store, fu­neral home and her fa­ther’s church, where Keisha would usu­ally sit with her brother Der­rick.

It was 2003 when Der­rick started to feel pains in his back and groin, and Keisha, then a 22-year-old li­censed prac­ti­cal nurse, started to un­der­stand what in­sur­ance could mean. Der­rick was 24 — too old to be cov­ered by his fa­ther’s in­sur­ance but un­able to af­ford his own. He thought his only op­tion was to go to an emer­gency room. His par­ents re­mem­ber him re­turn­ing home, hav­ing been told there was noth­ing wrong with him. When the pain didn’t go away, Der­rick tried a dif­fer­ent ER. Keisha would later learn that doc­tors thought her brother was seek­ing pain pills. Months passed.

All the while, a tu­mor in­side his kid­ney was grow­ing. A few months af­ter the can­cer was fi­nally dis­cov­ered, Der­rick died at 25.

Keisha didn’t al­low her­self to won­der what might have hap­pened if he’d had in­sur­ance. She fo­cused on re­mem­ber­ing their last days to­gether, when the doc­tors said the can­cer was too ad­vanced to be stopped by treat­ment, so she treated him with choco­late in­stead. M&Ms by his bed­side.

She kept work­ing at the nurs­ing home and then in hospice care, rais­ing Kiana and tak­ing classes at night. When she was 30, she com­pleted a grad­u­ate de­gree and be­came a nurse prac­ti­tioner. She made the drive back to McDow­ell County again, this time to ask for a job.

At first, some pa­tients at Tug River were wary of her loud laugh and big hoop ear­rings. Oth­ers had known her since she was a lit­tle girl. She cared for them all, and her sched­ule grew busier as the ACA came to McDow­ell County and made more peo­ple el­i­gi­ble for in­sur­ance.

In 2016, Trump yard signs and bumper stick­ers started ap­pear­ing along her drive to work. In the clinic, one doc­tor and the jan­i­tor could reg­u­larly be heard re­hash­ing the lat­est con­tro­versy and what they liked about Trump. Keisha had de­cided she would vote for Hil­lary Clin­ton, be­cause of health care and be­cause she wanted to see a woman be­come pres­i­dent. But it wasn’t in Keisha’s job de­scrip­tion — or per­son­al­ity — to talk pol­i­tics. She avoided the sub­ject.

Come elec­tion night, she was too ex­hausted af­ter an­other packed day at the clinic to stay awake. She didn’t learn who won un­til the morn­ing.

In all of those Sun­days at church, Keisha was taught that God has a plan. If God planned for Trump to win the elec­tion, she told her­self that morn­ing, it must be for a rea­son.

“I just pray that he makes the right de­ci­sions. I’m not sure what’s go­ing to hap­pen. All we can do is pray about it.” Nurse prac­ti­tioner Keisha Saun­ders, on Pres­i­dent Trump

NOW TRUMP IS IN the White House and Keisha is press­ing her fin­gers into the stom­ach of 24-year-old Ruby Thomp­son. Nearly ev­ery pa­tient Keisha sees has been im­pacted in some way by the ACA, and in Ruby’s case, the ACA’s Med­i­caid ex­pan­sion is the rea­son she has

in­sur­ance.

Ac­cord­ing to the list on Keisha’s notepad, Ruby is just here to re­fill a pre­scrip­tion, but Keisha checks her as if they are meet­ing for the first time. She tries to feel for any­thing ab­nor­mal around Ruby’s stom­ach, which is a lit­tle too thin, but Keisha knows cig­a­rettes can cut into a per­son’s ap­petite. “Are you still smok­ing?” “Yeah,” Ruby an­swers, tug­ging at a gold neck­lace that spells MOM. “Do you want to stop?” “I will even­tu­ally, I guess.” Ruby is an­other pa­tient who voted for Trump be­cause of his prom­ise to bring back jobs. She hasn’t yet lost hope that she can be­come a sec­re­tary, but for the past two years she’s been work­ing at KFC. She has health in­sur­ance only be­cause she was fined on her taxes for not hav­ing it, at which point she found out that be­cause of the ACA, she qual­i­fied for Med­i­caid. It is in­sur­ance at its most ten­u­ous, though, be­cause if Med­i­caid re­verts back to a pro­gram only for the need­i­est peo­ple, the work­ing poor will be most at risk of los­ing their cov­er­age.

“Go ahead and sit up,” Keisha says af­ter check­ing Ruby’s an­kles for swelling, a po­ten­tial sign of di­a­betes. She writes a pre­scrip­tion and sends Ruby to the front desk to make an ap­point­ment for Novem­ber, when she is due for a breast exam and cer­vi­cal can­cer screen­ing.

An­other pa­tient comes in: Car­olyn Hodges, 68, who tells Keisha that she’s been feel­ing dizzy. Car­olyn has Medi­care, the pub­lic health in­sur­ance for the el­derly. Medi­care doesn’t cover all health-care costs, which is why Car­olyn is as wor­ried about the price of her med­i­ca­tions as the fact that she’s been bump­ing into walls.

The last time she went to pick up her hus­band Roger’s in­sulin, Car­olyn tells Keisha, the phar­ma­cist said it would be more than $600, in­stead of the $100 or so they usu­ally pay. That was when she learned Roger was in the Medi­care pre­scrip­tion “donut hole,” which means that the cost of his med­i­ca­tions had ex­ceeded his limit for the year, and he would be forced to pay far more for pre­scrip­tions un­til the year ended and the tab started over. One ini­tia­tive of the ACA has been to close that hole in­cre­men­tally, but Car­olyn, un­aware of that, sees the bills pil­ing up and thinks she knows who must be to blame.

“Thank you, Obama!” Car­olyn says, throw­ing her arms in the air.

Keisha nods, and keeps typ­ing into her chart.

An­other pa­tient: An­drea Easley, 50, who has strug­gled for so long that there wasn’t much more the ACA could do to help her. She al­ready had Med­i­caid, which she de­pends on for her health care, and dis­abil­ity pay­ments, which she uses to pay her rent, sup­port her 70-year-old mother and send checks to her son who is in prison in Charleston, W.Va.

“What’s go­ing on, Miss An­drea?”

“My nose,” An­drea says, nearly shout­ing. “I had just come in. Sit down. Sneeze. My nose went to burn­ing. I mean, it burned like some­one gone and set fire to my nose.”

De­spite tak­ing more than a dozen med­i­ca­tions a day, An­drea’s prob­lems never seem to go away. Her life isn’t one where she thinks much about pol­i­tics — she didn’t vote in the elec­tion — but of stom­ach is­sues, cough­ing, lack of sleep, fights with her mother, stress over her son.

“Have you tried a hu­mid­i­fier?” Keisha asks. “What is that?” An­drea says. “It keeps the mois­ture in the air,” Keisha ex­plains. “Do you sleep with your mouth open?”

“I don’t know how I sleep. I’m not half sleep­ing. Now last night, it made me mad,” she says. “Them cats out there me­ow­ing, and I’m try­ing to go to sleep, and they’re out there do­ing all such things they have no busi­ness do­ing . . .”

Look­ing up at An­drea from her low swivel stool, Keisha lis­tens. She knows other pa­tients are wait­ing. But she also knows that some­times her pa­tients need to talk, so she gives no sign that she has any­place else to be. Only when An­drea pauses does she say, “I do think you need a hu­mid­i­fier. I think that will help some.” “Where can I get that from?” “Well,” Keisha says, know­ing her an­swer will up­set An­drea, “you have to buy it.”

An­other pa­tient: Charles Collins, 39, who be­lieves that the im­pact of the ACA was to make his own health-care costs rise. He is pri­vately in­sured through his job at a coal mine one county over. The mine used to cover 100 per­cent of his med­i­cal ex­penses, but start­ing this year, only 90 per­cent is cov­ered, and his den­tal in­sur­ance, he tells Keisha, “ain’t worth a nickel.”

“That’s a mess,” she says. Charles un­clips his miner’s over­alls so she can place the stetho­scope on his chest, and tells her about get­ting his tooth pulled.

“I got a bill for $324 and they paid a dol­lar of it,” he says about his in­sur­ance. He is glad Trump is re­peal­ing the ACA, be­cause in his opin­ion work­ing peo­ple are be­ing forced to pay for those who sit around and do noth­ing. But no mat­ter what Trump does, Charles knows the bill for this visit is com­ing.

“Deep breaths for me,” Keisha tells him, and Charles ex­hales.

An­other pa­tient, here for the first time: a 33-year-old woman who voted for Hil­lary Clin­ton. She has no in­sur­ance, by choice. She didn’t feel she needed it. Now, be­cause of a test re­sult in Keisha’s hands, she will.

“Hi Miss Amanda, I’m Keisha, the nurse prac­ti­tioner here.”

“Nice to meet you,” Amanda says, push­ing back a lock of cherry-col­ored hair.

Keisha asks Amanda about her symp­toms, then gets to the point. She turns to face her and says, “It looks like — you’re preg­nant.” “I’m preg­nant?” “Yes. Were you ex­pect­ing . . .” “That’s such good news!” Amanda says.

“I’m glad you’re happy,” Keisha says. “Good! Yay!”

Amanda lifts her palms in the air, and they dou­ble high-five. Then come the ques­tions Keisha needs to ask for her chart.

Is the baby’s fa­ther in­volved? “I think he’s go­ing to be a lit­tle ap­pre­hen­sive,” Amanda says.

Is she work­ing? “Not cur­rently,” Amanda says, ex­plain­ing to Keisha that she just moved back to West Vir­ginia af­ter liv­ing in Ohio. So far she has put in ap­pli­ca­tions at gas sta­tions and restau­rants.

Is she at all fa­mil­iar with the area? With the doc­tors she’ll need to see? With what she needs to do now? Amanda wrings her hands between her knees. “I have no idea where to go next,” she says.

And here is an­other ver­sion of un­cer­tainty in the clinic, this time a pa­tient’s. If she signs up for Med­i­caid, which cov­ers low­in­come, preg­nant women, she’ll be cov­ered through her preg­nancy. But af­ter that? Her ac­cess to in­sur­ance will de­pend on what hap­pens over the next months in Wash­ing­ton, where so many plans for the ACA’s re­place­ment are float­ing around. One, just un­veiled in the House, would roll back the Med­i­caid ex­pan­sion slowly, mean­ing Amanda could keep her pub­lic in­sur­ance af­ter the baby is born. In a few years, how­ever, some­one like her might not be able to do the same, and in­stead might re­ceive tax cred­its to help off­set the cost of pri­vate in­sur­ance.

But that’s just one plan. There have been plans based on “block grants” and plans based on “per­capita caps.” Some plans give peo­ple tax cred­its based on their in­come. Some base the tax cred­its on their age; some on where a per­son lives. There’s the plan once pro­posed by Trump’s sec­re­tary of health and hu­man ser­vices, which would get rid of the Med­i­caid ex­pan­sion en­tirely. There’s the plan Vice Pres­i­dent Pence im­ple­mented when he was gov­er­nor of In­di­ana, which pe­nal­izes any­one who doesn’t pay for Med­i­caid cov­er­age, even if all they can af­ford is a dol­lar a month. There’s even a plan that pro­poses keep­ing the Med­i­caid ex­pan­sion just as it is.

With so much to be re­solved, Keisha hands Amanda a form to sign up for Med­i­caid. They walk to­gether to the front desk, where Keisha asks Tammy to sched­ule Amanda’s first pre­na­tal ap­point­ment.

“Thank you,” Amanda tells her.

“You’re wel­come,” Keisha says. “I hope ev­ery­thing goes well.”

SOME­TIMES, BETWEEN PA­TIENTS, KEISHA re­treats into her of­fice, sits at the fold­ing ta­ble she uses as a desk and takes a few steady­ing breaths. If she has enough time she also prays, and since Jan­uary some of those prayers have been for Pres­i­dent Trump.

“I just pray that he makes the right de­ci­sions,” she says. “I’m not sure what’s go­ing to hap­pen. All we can do is pray about it.”

She prays for oth­ers, too. Her daugh­ter. Her par­ents. Her brother. She prays for her pa­tients, that they stay healthy, that they lose weight, that they take their in­sulin shots the cor­rect way, that the woman with the rot­ting tooth will fol­low up on her prom­ise to go to the den­tist, that the man whose wife died af­ter say­ing to him, “Honey, do you think I’m get­ting bet­ter?” will find a way to ease his lone­li­ness.

And what if, in a few months, those pa­tients lose their in­sur­ance? She’ll pray about that, too, she says, but first she will ex­plain the slid­ing fee pro­gram, the closet full of sam­ple med­i­ca­tions from drug reps, the forms she can sub­mit ask­ing phar­ma­ceu­ti­cal com­pa­nies for dis­counts, the free clinic at the med­i­cal school four hours north — all the things she will do to try to get them the care they need, even if they can’t af­ford it.

One more deep breath and a last prayer for her­self — “Okay, Lord, help me get my­self to­gether” — and then she picks up her stetho­scope. It’s Fri­day af­ter­noon, and seven pa­tients need to be seen be­fore she can go home to her teenage daugh­ter.

“Hey there, how are you?” she starts with one.

“Oh good­ness, you have been hav­ing a rough time,” she tells a man with kid­ney stones.

“I want to send you to a lung doc­tor to find out, be­cause I just don’t know,” she ex­plains to a pa­tient whose cough won’t go away.

“You are not bro­ken,” she says to a woman who the psy­chol­o­gist re­cently di­ag­nosed as bipo­lar, and so it goes un­til she fin­ishes car­ing for her last pa­tient, nearly an hour af­ter the clinic has closed.

She pow­ers down her lap­top and car­ries her notepad to the blood-work lab, where there is a pa­per shred­der. Rip­ping off the top page with to­day’s list of pa­tients and prob­lems, she drops it into the ma­chine and watches it dis­ap­pear. Then she slides the notepad into her bag to take home. An­other week of need is com­ing, and she wants to be pre­pared.

In other parts of the coun­try, the pri­mary im­pact of the Af­ford­able Care Act has been re­quir­ing peo­ple to have pri­vate health in­sur­ance, but in poor and sick com­mu­ni­ties like McDow­ell County, the law’s dom­i­nant ef­fect has been the Med­i­caid ex­pan­sion.

BON­NIE JO MOUNT/THE WASH­ING­TON POST

Nurse prac­ti­tioner Keisha Saun­ders, who grew up in the com­mu­nity, ex­am­ines Clarence Work­man at the Tug River health clinic in North­fork, W.Va.

PHO­TOS BY BON­NIE JO MOUNT/THE WASH­ING­TON POST

FROM TOP: An aban­doned house and coal cars on tracks in nearby Capels, W.Va., part of McDow­ell County, the county with the short­est life ex­pectancy in the na­tion; around her neck, Keisha Saun­ders wears a cross on a neck­lace — and her stetho­scope; a snap­shot of Keisha’s brother Der­rick, who was unin­sured when he was di­ag­nosed with kid­ney can­cer. He died at 25.

PHO­TOS BY BON­NIE JO MOUNT/THE WASH­ING­TON POST

FROM TOP: A rec­om­mended hu­mid­i­fier is cost-pro­hib­i­tive for An­drea Easley, 50, who re­lies on Med­i­caid and dis­abil­ity pay­ments; used cloth­ing and house­hold items still re­main be­hind the bro­ken glass of a shut­tered busi­ness in North­fork, W.Va.; Clyde Gra­ham, 54, is an un­em­ployed Med­i­caid pa­tient with a host of health is­sues.

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