In a place of need, an unhealthy contradiction

They are poor, sick and voted for Trump. What will happen to them without
Obamacare?
By Jessica Contrera Photos by Bonnie Jo Mount
March 11, 2017

Nurse practitioner Keisha Saunders examines Clarence Workman at the Tug

River health clinic in Northfork, W.Va.
northfork, w.va. Another morning, another list of patients and problems in
the hands of 35-year-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 Keishas 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.
Its 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 Arbys, he says. And it jumped me out for like, three
days. I mean it just burnt.

Clyde Graham, 54, is an unemployed Medicaid patient with a host of health

issues.
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, Clydes 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 wasnt sure what that might mean
for his Medicaid. But if he had a job that provided health insurance, he
reasoned, he wouldnt 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 wouldnt be able to afford care. Will
they soon lose their coverage? Will they stop coming to the clinic? Lately, Tug
Rivers 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 Clydes heartburn, examines him from head to toe and sends him to the lab
across the hall for blood work.
Ill see you in three months, she says, hoping that will be true, and heads to
exam room No. 1, where another patient is waiting. Whats going on today? she
asks, and walks in the room to find out.

An abandoned house and coal cars on tracks in nearby Capels, W.Va., an

unincorporated part of McDowell County.
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, maam, 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 laws dominant effect has been the Medicaid expansion,
which has given more people access to the kind of health care that wasnt widely
available or affordable to them before. With an insurance card in her pocket,
the patient at Tammys 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 wont 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 werent 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 fathers church, where
Keisha would usually sit with her brother Derrick.

A snapshot of Keishas brother Derrick, who was uninsured when he was

diagnosed with kidney cancer. He died at 25.
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 fathers
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 didnt 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 didnt allow herself to wonder what might have happened if hed 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 wasnt in Keishas 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 didnt 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.

A recommended humidifier is cost-prohibitive for Andrea Easley, 50, who relies

on Medicaid and disability payments.
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 Rubys case, the ACAs Medicaid
expansion is the reason she has insurance.
According to the list on Keishas 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 Rubys stomach, which is a little
too thin, but Keisha knows cigarettes can cut into a persons 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 hasnt yet lost hope that she can become a secretary, but for the
past two years shes 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 Rubys 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 shes been
feeling dizzy. Carolyn has Medicare, the public health insurance for the elderly.
Medicare doesnt cover all health-care costs, which is why Carolyn is as worried
about the price of her medications as the fact that shes been bumping into
walls.
The last time she went to pick up her husband Rogers 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.
Around her neck, Keisha wears a cross on a necklace and her stethoscope.
Another patient: Andrea Easley, 50, who has struggled for so long that there
wasnt 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.
Whats 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, Andreas problems never
seem to go away. Her life isnt one where she thinks much about politics she
didnt 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 dont know how I sleep. Im not half sleeping. Now last night, it made me mad,
she says. Them cats out there meowing, and Im trying to go to sleep, and
theyre 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, aint worth a nickel.
Thats a mess, she says. Charles unclips his miners 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 didnt feel she needed it.
Now, because of a test result in Keishas hands, she will.
Hi Miss Amanda, Im 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 youre pregnant.
Im pregnant?
Yes. Were you expecting ...
Thats such good news! Amanda says.
Im glad youre 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 babys father involved? I think hes 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 shell 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 patients. If
she signs up for Medicaid, which covers low-income, pregnant women, shell 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 ACAs 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 thats just one plan. There have been plans based on block grants and plans
based on per-capita 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.
Theres the plan once proposed by Trumps secretary of health and human
services, which would get rid of the Medicaid expansion entirely. Theres the
plan Vice President Pence implemented when he was governor of Indiana, which
penalizes anyone who doesnt pay for Medicaid coverage, even if all they can
afford is a dollar a month. Theres 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 Amandas first prenatal appointment.
Thank you, Amanda tells her.
Youre welcome, Keisha says. I hope everything goes well.

Keisha confers with colleague Jennifer Fain in her Tug River office. Keisha grew
up in the community.
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. Im not sure whats
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 Im getting better? will find a way to
ease his loneliness.
And what if, in a few months, those patients lose their insurance? Shell 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 cant 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. Its 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 dont know, she
explains to a patient whose cough wont 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 todays 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 West Virginia, in the county with the shortest life expectancy in the nation,
night falls in Northfork.
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