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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