OBAMACARE TAKES ROOT IN APPALACHIA
Affordable Care Act still gets mixed reviews
Obamacare flooded into these remote Appalachian hills last year like the War on Poverty had a half-century earlier — another government program promising to save some of America’s most vulnerable citizens.
Since then, it has given many of the poor and sick a key to longneglected health care. It’s also brought skepticism and fear, and some business owners argue it’s stunting their growth in a region that can’t afford another economic blow.
One year after USA TODAY and The Courier-Journal in Louisville examined the Affordable Care Act’s arrival in Floyd County, Ky., the health plan has taken root in ways both surprising and expected, good and bad.
Amid predictions that bad health habits would be hard to break, scores of newly insured residents, mostly covered by Medicaid, have sought care in hospitals, mental health centers and drug treatment facilities. Providers have proved plentiful. Unreimbursed care costs are down. The county’s uninsured rate is half what it was — dropping from 19% before the ACA to 10% at the close of 2014.
Some who dismissed Obamacare because of its political associations with a president blamed for the decline of coal industry say their opposition has softened.
Last year, fast-food worker Melinda Watson echoed the law’s unpopularity here — convinced it would kill jobs and create long waits for “horrible” socialized medicine. She bought a subsidized insurance plan on the state exchange only to avoid paying federal penalties. But she soon realized the benefits: going to the doctor regularly and undergoing MRIs for her epilepsy. Her employer didn’t cut her hours, as she feared.
“I was really scared at first, with all the gossip,” said the 41year-old granddaughter of a coal miner, slicing tomatoes in the back of a sub shop. “But it’s really helped. ... I’ve seen a lot of other people who got insurance actually using it, going to the doctor and getting their teeth fixed. Now I’ve got the opposite fear — that when (President Obama) goes out of office, they’ll take it away.”
Although many of the initial fears about the law didn’t come to pass, the ACA is not a panacea, and the ultimate goal of making the region healthier is far from being realized. Many Floyd County residents don’t like certain parts of the law, such as the tax penalty people must pay if they don’t have insurance and the upcoming requirement that busi- nesses with more than 50 employees provide affordable insurance or face a penalty.
Hospitals report being squeezed financially. One insurance agent says the system remains difficult to navigate. Many who don’t qualify for Medicaid or a sizable subsidy say their insurance has gotten more difficult to afford.
As uncertainties over the future of the ACA linger — a legal challenge before the Supreme Court, Republicans vowing to reverse it — advocates say the area, characterized by deep-seated poverty, outsized health issues and anti-government conservatism, remains an important testing ground in one of the few Southern states to both adopt its own health exchange and to expand Medicaid.
“This has been a big help for low-income people in eastern Kentucky,” said Ancil Lewis, CEO of Big Sandy Health Care, which runs five clinics in the area. “But I have a lot of concern. This could be a house of cards. ... There are many potential perils to the Affordable Care Act.” COVERAGE QUERIES PERSIST Up a winding road outside the county seat, Onyx Coal and Matt/ Co. co-owner Clark Pergrem, who operates some of the area’s few remaining coal mines, opposes Obamacare even though its penalties have pushed some employees to get coverage.
“I’d like to see it repealed,” Pergrem said, adding that it takes a bite out of people’s paychecks when they can barely afford rent or groceries.
Some residents who purchased private plans on the state exchange in 2014 found the monthly premiums rose sharply in 2015, causing some to drop out or reduce coverage, said Darrell Patton, an insurance agent whose strip-mall office is filled with hunting décor. The benefits of the ACA have been conferred mostly on the poor, he said, setting up a looming conflict with the middle class, who see the costs of employer plans rise.
Some workers who hoped for employer plans remain uninsured. Archie Everage, who owns a chain of fast-food sandwich shops in Floyd and nearby counties that employ more than 80 workers, said he plans to pay a fine of $2,000 per full-time employee rather than provide insurance as the ACA requires.
“If we had the revenue, we’d love to offer insurance,” he said. “But … a business has to survive.”
Overall, 5,403 Floyd County residents have enrolled in Medicaid under the ACA, while only 620 have bought private health plans on the state’s “kynect” exchange. Data from a state examination of the Medicaid expansion found it had brought $15.5 million in Medicaid payments to Floyd County in 2014, including $5.9 million to hospitals.
Hospital officials say the ACA has accelerated trends hurting rural hospitals. Medicaid in Kentucky is handled by managedcare companies, which are slow to reimburse, said Bud Warman, CEO of Highlands Regional Medical Center in Prestonsburg. More Medicaid patients mean more slow payments.
Warman acknowledged an 87% drop in uncompensated care in a year but said he worries this will lead to the disappearance of government funding for hospitals such as his that care for a “disproportionate” number of Medicaid and Medicare patients.
“We’re still struggling. It’s hard to say if it’s the economy or the ACA or all of the above,” Warman said, adding that he worries about the future of the hospital, one of the county’s biggest employers with 600 workers. MORE ACCESS, MORE CARE Thursa Sloan, Floyd County’s public health director, said it’s an uphill battle to reverse mountain maladies of poverty and unemployment — not to mention the prevalence of smoking, cancer, diabetes, obesity and heart disease.
Obamacare is making a surprising dent, she said, and “public attitude has improved for the ACA.”
A state review shows 14% of Floyd County residents enrolled in Medicaid under the expanded program, and half of residents have the government coverage.
That includes Susan Keathley, 43, a former Walmart worker who started on Medicaid Jan. 1 after signing up at the Eula Hall Health Center in Grethel. Before that, she was uninsured for almost five years, and “if I needed to go to the doctor, I went to the ER, or else I didn’t go anywhere.”
Keathley now goes to the clinic for routine illnesses. While she was there recently for a sore throat, the physician assistant asked about her mammogram and an upcoming urology appointment, making sure she keeps up with preventive care.
Obamacare has given residents easier access to mental health and substance abuse treatment, increasing the patient load at Mountain Comprehensive Care, the area’s largest provider of such services, by 15% to 20% and leading to nearly 70 new jobs.
“Even as a red state, Medicaid has done tremendous things for our people,” said Jon Dye, a “kynector” who helps people navigate the state’s health exchange.
Still, he said, people associate their new insurance with kynect, not Obamacare. “I don’t ever mention the ACA, honestly,” he said. “I had one guy say, ‘I’m so glad I found you and didn’t have to go through that Obamacare stuff.’ ”
‘If I needed to go to the doctor, I went to the ER, or else I didn’t go anywhere.’
Susan Keathley, resident of Floyd County, Ky. ‘I’d like to see it get repealed.’ Clark Pergrem, co-owner of Onyx Coal and Matt/Co.