— Carolyn Underwood remembers her dad coming home covered in black coal dust from the mines. “Momma would have his water ready. He’d wash his face and she would wash his neck,” she said.

In old age, he suffered from black lung disease and wore an oxygen supply constantly. But unlike his daughter, he never worried about how he would pay his medical bills. The union took care of it.

That doesn’t make Carolyn Underwood, 63, a supporter of expanded government health coverage, even though she would benefit from it. In a region where the decline of the coal industry has sent poverty and health-care needs soaring, another force has grown at least by equal measures: antipathy to President Obama and the Affordable Care Act (ACA).

“I am scared of Obamacare,” Underwood said. “We’ve been hearing too many tales about it. We heard there’s doctors who get to decide . . . ” Before she could put her finger on the term “death panels,” her sister Nancy Taylor, 62, made a gun gesture with her hand and said, “Pow!”

That sort of sentiment has drawn new attention this month, after a Democratic state senator from Southwest Virginia resigned his seat, giving Republicans the majority they need to pass a state budget without new health coverage for 400,000 poor residents.

Phillip P. Puckett, first elected 17 years ago before his corner of Virginia turned deep red, supported expansion under the Affordable Care Act in part because so many of his constituents — more than 20,000 — would have qualified. But many voters in Russell County do not share his view.

The region’s politics, in fact, help to explain the juxtaposition of Virginia’s conservative, Republican-controlled legislature with an increasingly purple state that voted twice for Obama. Residents here generally don’t feel betrayed by Puckett’s resignation, even though it resulted from a deal with Republicans that included the prospect of government jobs for him and his daughter. Puckett’s seat will almost certainly go to the GOP in an upcoming special election, but his former constituents are either ambivalent about what the change in representation means for their health benefits, or they don’t know or don’t care.

Tipping the scales of power

What will happen to Medicaid expansion remains unclear. What is clear is that widespread antipathy to the health-care law, Puckett’s resignation and the series of events it prompted seem to have provoked a far greater uproar outside Southwest Virginia than inside.

Puckett ran unsuccessfully for the Democratic nomination for lieutenant governor in 2005. This month, he became a traitor to some Democrats when his resignation delivered Senate Republicans a one-vote majority and the upper hand in a fight that has paralyzed the General Assembly for a year.

At the time of his resignation, Republicans arranged for Puckett to be offered a job at the Virginia Tobacco Indemnification and Community Revitalization Commission — he has since withdrawn his name from consideration — and a full-time judgeship for his daughter. Federal investigators are now probing the circumstances surrounding Puckett’s resignation and the potential offer of jobs to him and his daughter.

The Senate and House had been locked in a budget standoff, with the Senate supporting a budget that included Medicaid expansion and the House supporting a plan that did not.

But after Puckett resigned, Senate Republicans used their newfound power to pass a budget last week that stripped out Medicaid expansion. The House quickly followed, sending the budget to the desk of Gov. Terry McAuliffe (D), who has until Sunday to decide what to do. If he vetoes the bill and no budget is in place by July 1, Virginia’s government could shut down. If he tries to implement Medicaid without legislative approval, as his administration has looked into doing, he could prompt a historic legal battle over executive power.

In his first interview since resigning, Puckett, a banker from rural Russell County who lives closer to Tennessee, West Virginia and Kentucky than to Richmond or Washington, said he is keenly aware of the reverberations of his decision.

“I don’t do anything without talking to the Lord about it or without consulting with my family,” Puckett told the Voice, a weekly newspaper in Buchanan and Tazewell counties. “This was the hardest political decision I’ve ever made. The timing is never good in doing this.”

Yet, it is the advocates for Medicaid expansion — not the residents of Puckett’s district — who say the timing couldn’t be worse for former constituents who would qualify for expanded coverage.

“While the legislature’s talking about what they’re talking about, people die,” said Teresa Gardner, executive director of a mobile clinic called the Health Wagon, where Underwood goes for free care. “That’s what they don’t understand.”

Waving off shenanigans

Leaving the Health Wagon, T.O. Mullens, 59, of Wise County said he’s been driving a coal truck for 35 years and now works on a mountaintop mine, or a “strip job.” Although he has insurance, the clinic helps him afford the 11 medications he takes for high blood pressure, diabetes, ulcers, kidney stones, gallstones and lungs “full of coal dust,” said Mullens, who sports a bushy white beard.

“We are in a very poor area. Rich with natural resources — the landscape,” he said, motioning to the mountains that provide a verdant backdrop to widespread suffering. “But doctors don’t want to come back here because of the economy.”

Puckett’s former district stretches 150 miles from Radford to Big Stone Gap. Rail cars filled to the brim with coal leave a coating of soot on windows, and stone memorials proudly display the names of those killed in the mines.

About 20 percent of the population lives below the poverty line, compared with 11 percent in the rest of Virginia, census data shows. In parts of the district, unemployment reached nearly 10 percent in April, nearly twice the statewide average.

In the coal camp town of Trammel, an isolated strip of modest homes built by Virginia Banner Coal for its miners, 78-year-old Maggie Charles passed the afternoon selling paperback books and clothes on her stoop. Only the occasional visitor stops, she said.

Like many people here, she waved off the political shenanigans in Richmond and didn’t see what it had do to with her day-to-day life. “I don’t go to the doctor. I don’t take no medicines,” said Charles, who survives on Social Security and her late husband’s black lung benefits.

James Kinney carted his portable oxygen tank down the street to see what Charles was hawking. Asked whether he was aware of Puckett’s resignation, Kinney provided a rare perspective when he said: “Of course. That boy done screwed a lot of folks up here.”

Kinney said he felt lucky to have health insurance for chronic obstructive pulmonary disease, known as COPD, which he developed after years of hauling and shoveling coal, but said the 20 percent he pays out of pocket is still a burden.

A few houses down, a woman whose only job is overseeing a table covered in a hodgepodge of clocks, hats and ceramic figures said she pays all her medical expenses out of pocket and wouldn’t have it any other way. She can get generic blood pressure medicine cheap, but her anxiety pills cost $192.50 a month, she said.

She and her husband, who works security but receives no benefits, would rather pay a penalty for being uninsured than participate in Obamacare, said the woman, who spoke on the condition of anonymity because she was talking about her medical conditions.

“I refused to go there because I didn’t feel it was the government’s place to tell you where you have to get health care. I want to go to the doctor of my own choice,” she said, adding that she doesn’t trust the president. “I think he has actually lied to the people about a lot of things.”

‘Can’t teach people to care’

That attitude fueled decisive defeats for Obama in this region in both elections. In 2008, Sen. John McCain (R-Ariz.) lost purple Virginia by 7 percent, but he won Puckett’s former district by an 18-point margin. Four years later, former Massachusetts governor Mitt Romney won 67 percent of the vote, carrying the district with a whopping 36-point lead.

It is also the mind-set that in 2010 helped unseat then-Rep. Rick Boucher, a 14-term incumbent Democrat from Southwest Virginia’s 9th District who supported the coal industry and opposed the ACA — but lost anyway.

“Many people will cast votes that are contrary to certain interests that those individuals have. I think oftentimes it is the image that a party has in a region or that a party has in a person’s mind that leads a person to vote in a certain way,” Boucher said in a phone interview from the K Street offices of the law firm Sidley Austin, where he heads a government strategies group. He goes home to Abingdon on the weekends.

Back in coal country, apathy and a lack of faith in politicians are free-flowing commodities alongside the ever-present demand for better health care.

The Health Wagon greets patients with signs that alternately hearten, “With God all things are possible,” and warn, “No guns, knives or weapons of any kind allowed on premises.”

The clinic treats Curtis Hash, 59, of Norton with monthly shots of vitamin B12 to alleviate absentmindedness that was causing the certified electrician to misplace tools.

With no insurance, Hash can be blindsided by bills. After a car accident in April, emergency-room doctors ordered $7,000 in X-rays — unaware that his auto insurance covered only $5,000 in medical bills. “They found I had a sinus infection,” Hash said. “A $2,000 sinus infection.”

Still, Hash said he feels lucky to have steady work and doesn’t expect elected officials to do more than talk when it comes to health care and the disproportionate need of the medically underserved population that had sent Puckett back to Richmond for 16 years.

He said politicians are all the same. “It doesn’t matter who’s in there,” he said, the bags under his eyes deepening. “You can’t teach people to care.”