In rural Kentucky, health-care debate takes back seat as the long-uninsured line up

November 23, 2013

On the campaign trail, Senate Minority Leader Mitch McConnell was still blasting the new health-care law as unsalvageable. At the White House, President Obama was still apologizing for the botched federal Web site.

But in a state where the rollout has gone smoothly, and in a county that is one of the poorest and unhealthiest in the country, Courtney Lively has been busy signing people up: cashiers from the IGA grocery, clerks from the dollar store, workers from the lock factory, call-center agents, laid-off coal miners, KFC cooks, Chinese green-card holders in town to teach Appalachian students.

Now it was the beginning of another day, and a man Lively would list as Client 375 sat across from her in her office at a health clinic next to a Hardee’s.

“So, is that Breathitt County?” she asked Woodrow Wilson Noble as she tapped his information into a laptop Thursday morning.

“Yeah, we live on this side of the hill,” said Noble, whose family farm had gone under, who lived on food stamps and what his mother could spare, and who was about to hear whether he would have health insurance for the first time in his 60-year-old life.

Although enrollment numbers for insurance exchanges set up in states by the federal government won't be available for several weeks, states operating their own health-care insurance exchanges under the Affordable Care Act, and the District of Columbia, have started to release enrollment data.

This is how things are going in Kentucky: As conservatives argued that the new health-care law will wreck the economy, as liberals argued it will save billions, as many Americans raged at losing old health plans and some analysts warned that a disproportionate influx of the sick and the poor could wreck the new health-care model, Lively was telling Noble something he did not expect to hear.

“All right,” she said. “We’ve got you eligible for Medicaid.”

Places such as Breathitt County, in the Appalachian foothills of eastern Kentucky, are driving the state’s relatively high enrollment figures, which are helping to drive national enrollment figures as the federal health exchange has floundered. In a state where 15 percent of the population, about 640,000 people, are uninsured, 56,422 have signed up for new health-care coverage, with 45,622 of them enrolled in Medicaid and the rest in private health plans, according to figures released by the governor’s office Friday.

If the health-care law is having a troubled rollout across the country, Kentucky — and Breathitt County in particular — shows what can happen in a place where things are working as the law’s supporters envisioned.

One reason is that the state set up its own health-insurance exchange, sidestepping the troubled federal one. Also, Gov. Steve Beshear (D) is the only Southern governor to sign on to expanded eligibility parameters for Medicaid, the federal health-insurance program for the poor. The less technical reasons involve what Lively told Noble next.

“Okay, Woodrow, now you get to shop a little bit,” she said, explaining options he’d never had before.

“If you go to the doctor, all you’re going to pay is $1,” she began. “If you’re in the hospital for an extended period, you should only be billed $5. . . . If you get medicine, generics are $1 and brand is $4. . . . You can go to the dentist once a month — exams, X-rays and cleanings are covered. . . . Now for your teeth, the plan does take care of having them pulled and does take care of fillings, but not bridges, because that’s considered cosmetic.”

Wonkblog's Sarah Kliff explains three proposals that would make good on President Obama's promise that everyone can keep their health care plan. (The Washington Post)

Now, Lively explained, Noble simply had to choose among several Medicaid health-care plans. “So basically it’s whatever insurance company you go with — the effective date is January 1st,” she said, waiting for him to pick.

“My mom gets that WellCare, and she don’t pay nothing,” Noble said finally. “I’ll take that WellCare plan. My mommy got that, and it’s good.”

“WellCare it is,” Lively said, typing in his decision as Noble considered Jan. 1.

“I got some warts on me I got to take off, some moles,” he said. “I might have that colonoscopy done. My mom had colon cancer twice. I never had money to do it.” He said he was told it could cost at least $2,000.

“I got this pain in my left shoulder,” he said, lifting his arm and rotating it. “Might be arthritis, I guess. I don’t know.”

Lively handed Noble some papers confirming his enrollment.

“Okay, you’re good to go — you tell your brother to come see me,” she said, and the next client walked in.

Lively grew up in the county and works for Juniper Health, which has a federal contract to enroll people in the state health-care exchange and runs the Breathitt County health clinic on Highway 15, a four-lane that branches off into narrow roads that wind through hills dotted with skinny trees and trailers.

Asked to describe Breathitt, Lively paused for a moment. “Poor,” she said. “Just poor.”

The per-capita income in Breathitt is about $15,000, and the rates of diabetes, hypertension and other health problems earned this part of Kentucky the nickname “Coronary Valley.”

Lively, who has been signing people up since the exchanges opened in early October, said one woman cried when she was told she qualified for Medicaid under the new law. She said people have been “pouring in” to her office, an unused exam room in the back of the clinic, where her set-up includes a table, a two-drawer filing cabinet, manila folders, a planner to track her schedule, a notebook to track her numbers and a laptop that connects to the state health-insurance exchange, Kynect.

Clinic doctors often send patients without insurance her way after their visits, but most come by word of mouth. Lively has signed up fathers who then sent their sons, and mothers who sent aunts. She signed up one Subway sandwich shop worker, and soon what seemed like the whole staff showed up.

Although she once had to dispel a rumor that enrolling involved planting a microchip in your arm, and though she avoids calling the new law “Obamacare” in a red state, most people need little persuading.

“All right,” she said to her next client, a 52-year-old disabled master electrician who said his mother, two brothers and two sisters all died from lung cancer. He had been ignoring a spot on his lung discovered during a visit to the emergency room after he had broken his ribs several years ago.

He also vaguely recalled being told at the time he had something called “wedging of the spine.”

“What do I need here?” said Jeff Fletcher, who was being sued for those medical bills. “Proof of income?”

“Yep,” Lively said, and Fletcher pulled out documents showing that he and his wife live on about $500 a month in food stamps and her disability check.

“You smoke?” Lively asked, going through a few routine questions.

“Right- and left-handed,” he quipped as she typed.

“All right,” Lively said after a while. “You are covered.”

“I’m covered?” Fletcher said. He slapped the table. He clapped twice.

“Woo-hoo! I can go to the doctor now?” he asked Lively. “I’m serious. I need to go.”

Client 377 sat in the chair next. Ruth Strong, a 45-year-old woman with red, streaklike marks on her right arm, shoulder and neck from an untreated allergy attack, chatted with Lively about their kids. Strong was saying she wanted both her boys to go to college.

“Now, how much did you say it was going to cost to add you on?” asked Lively, who had talked to Strong before about signing on to the health-insurance plan of her husband, who worked for the school district. “Four hundred dollars?”

“Yes,” Strong said, looking at the floor and smiling. “I guess I’ve been without it for 15 years and will go without it one more if it costs too much.”

Lively entered Strong’s information. Her household income was too high for Medicaid, but she qualified for a subsidy of $228 a month and could choose from plans with a monthly cost ranging from $115 to $300, Lively said.

“It’s still high,” said Strong, who had not had a checkup in nine years.

Lively handed her a description of the health plans to take home and study, and then it was time for lunch, which Lively ate in the office between returning calls:

“Brenda, this is Courtney Lively calling you back.”

“You want to set up an appointment?”

“I will be here 8 to 4 tomorrow.”

Soon, Ronald Hudson walked in.

“Okay,” Lively began. “What Hudsons are you kin to?”

“R.T., Uncle Lenny . . .” said Hudson, a skinny 35-year-old who worked as an assistant director at the senior center and had just been released from the hospital after a blood-sugar spike.

He’d never had insurance before and said his hospital bills were up to $23,000 at this point.

“Good night,” Lively said, tapping in his information.

Kids: five. Salary: about $14,000 before taxes.

“You’re going to qualify for a medical card,” she told Hudson.

“Well, thank God,” Hudson said, laughing. “I believe I’m going to be a Democrat.”

Lively printed out his papers.

“RONALD’s Health Care Coverage Options,” one of them read.

“Oh, man,” Hudson said.

Donna Robinson had already enrolled, and now she arrived for her 2 p.m. with her son Gary Gross, 36, a skinny man with spiky copper hair, worn-out jeans and a thin tank top.

“Now,” Lively began. “Any income?”

“Naw,” Gross said.

“You smoke?”

“Yeah,” Gross said, adding that he did quit drinking. “It’s hard to quit, I tell you. I got cirrhosis already. I’m only a two on the scale of four, not too bad.”

“That’s already bad,” his mother said.

“Okay,” Lively said after a while. “You’re covered for a medical card.”

She went through his options.

“Now, I have problems with my teeth,” Gross said. “I need to get all of them pulled.”

“It does cover that,” Lively said.

“Oh, that’s great!” Gross said, sitting up straighter.

“Now it doesn’t cover dentures,” Lively said as she typed.

“I think that should be covered,” his mother said. “Try to eat an apple without teeth.”

“I love meat,” Gross said.

Lively gave him the papers confirming his enrollment.

“Easy as that,” she said.

“Wow,” Gross said, looking at them. “Thank you.”

In was late afternoon, and Mary Stamper, 36, arrived with four of her 11 children and a stack of well-worn, laminated Social Security cards. She sat down.

“I don’t see how you do it 11 times, girlfriend,” Lively said as the children bounced around the room. “Okay, what’s Mark’s birthday?”

It took an hour to enter in all her kids’ information and tally the household income from food stamps and a disability check drawn by her husband, a county maintenance worker.

Stamper said that she had Medicaid once when she was pregnant with one of her first children but that otherwise the part-time jobs she had held at the check-cashing place and as a nurse’s aide never came with it.

Lively typed her information in, and then something unusual happened: The system seemed to crash. She called the help line for the state health-care exchange and was told it was just being updated.

“I can tell you you’re getting a medical card,” she told Stamper, knowing what would happen when the system came back. “You’re going to get approved — I have no doubt about that. . . . You want WellCare?”

“Yeah,” Stamper said.

She stood up and stretched her back, which had been bothering her.

“I’m relieved,” she said. “I’ve been worried.”

Stamper and her kids left. It was the end of a long day, and Lively took a moment to look over her schedule for Friday. She had three appointments written in her planner and six calls to return.

“I’m nonstop,” she said.

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