Scenes from Floyd County, Kentucky

A closer look at the Affordable Care Act's impact in eastern Kentucky

USA TODAY and The Courier-Journal

The Affordable Care Act is having an impact on auto dealer workers and managers at Deskin Motors; drug addicts and the jailers at the Floyd County Jail; and patients and dentists at Big Sandy Health Care. The overview of Obamacare's effect on Floyd County is here.

Small businesses

'We were hoping that Obama thing would go away'

Here's how Paul Deskins, who runs an auto dealership with his son Terry near the Floyd County line, describes his attitude toward the Affordable Care Act's employer health insurance mandates: "We were hoping that Obama thing would go away."

Of the many groups affected by Obamacare, small business owners — those with at least 50 full-time employees — are among the most aggrieved by the law's requirement to provide their workers with insurance.

Deskins Motors has about 50 employees, none of whom gets insurance through the business. In two years, the ACA will require employers of 50 to 100 people to pay for their workers' insurance. Rather than do that, the Deskins say they might draw the workforce down, sell the body shop or just pay a fine – up to $2,000 per employee.

The employees "can't afford to buy insurance," Paul says, "and we can't afford to buy it for them."

Archie Everage owns 13 Subway franchises that employ more than 80 full- and part-time workers. He says the ACA's ban on raising rates for pre-existing conditions has helped lower rates slightly for his 10 managers. (He contributes about $275 a month toward their premiums.)

One employee, Jackie Jacobs, 37, lost her insurance in a divorce two years ago. She's training to be a manager and looks forward to getting insurance through Subway.

But Everage says the cost of providing insurance for all full-timers may prompt him and other employers to consider cutting hours. (Doing so, however, just to avoid having to pay for health insurance would violate the law.) "You'll have a lot of people out there looking for two jobs instead of one," he says, "and they're still not going to get coverage."

Another Subway worker, Melinda Watson, 40, hasn't been able to afford insurance because she has epilepsy. The ACA's policy on pre-existing conditions should have solved that problem, but she's afraid her Subway hours will be cut back, and she'll have to get a second job.

Who does she blame? Not the boss. "Obamacare."

Everage says the delays in enforcing the ACA rules on businesses such as his have delayed decision making: "Small-business owners are afraid this is going to hit them hard. But they keep putting it off. So we keep putting it off."

— Rick Hampson, USA TODAY, and Chris Kenning, Louisville Courier-Journal

Drug treatment

'They just don't work and have too much idle time'

PRESTONSBURG, Ky. — For the first several days, up to 12 women of the Floyd County Jail share a small holding cell with a single toilet as they vomit, sweat and shake their way through detox.

Once the women are no longer considered high, they're moved to a room designed for 12 that at last count had 15. There, they sleep little, shake a lot and catch up with their old friends.

Then the cycle starts anew.

"I raised these girls," Melissa Bentley, a jail official for 20 years, says of the women incarcerated this day in March.

Drugs were strangling Floyd County and the rest of eastern Kentucky long before the Affordable Care Act brought hope for change in this poor, health-challenged area.

Thanks to the law, substance abuse and mental health treatment coverage is mandatory for Medicaid and private insurance policies, and treatment must be comparable to that provided for other medical problems. For the addicts and alcoholics among the 5,100 county residents newly insured under the ACA, it could be a lifesaver.

For that to happen, however, there must be enough people and facilities to treat them and more treatment than insurers have agreed to cover elsewhere, according to addiction experts.

Most of all, people need to seek help, which could be the biggest roadblock to the ACA's success here.

Drug abuse — especially of prescription pain killers and, more recently, methamphetamine and heroin — and a lack of treatment are among the biggest health problems in the county. Illegal drug use adds $9 billion a year to national health care costs for treatment and hospitalizations for illness and injury ranging from hepatitis to drug-induced homicide, according to a 2011 Justice Department report.

The jail, designed to house 112 inmates, often has up to 140. All but 5% are in for drug-related crimes. When Bentley started 20 years ago at the then-smaller jail, there would often be just one inmate.

As the ACA's March 31 sign-up deadline neared, up to eight former inmates a day were returning to the jail to get proof they were no longer incarcerated so they could sign up for insurance. Medicaid coverage terminates if they're locked up again.

Jailer Cheyenne McKinley describes a revolving door of inmates across several generations. "The common thread is unemployment," she says. "They just don't work and have too much idle time."

Mountain Comprehensive Care Center plans to open a Medicaid-eligible rehab facility in September, but it will be one of only two in a five-county region. The ACA "gives us hope that with more people covered, more will seek service and get treatment they've been putting off so long," CEO Promod Bishnoi says.

Kelly Baldridge is a former prescription drug addict who is a Mountain Comprehensive peer support specialist. She started using drugs in college, but that's an exception locally. Boredom and a family history of drug use are typically to blame.

Leaving to find entertainment often isn't an option: "You get out to these hollers and you're just stuck there," she says.

Marie Robinson of Prestonburg, Ky., discusses her health and the importance of affordable insurance. Jack Gruber, USA TODAY

The area lacks mass transit, and many sell their cars to Mr. Metal recycling to buy drugs, says Marie Robinson, who was once addicted to pain and anxiety pills.

Robinson's car was impounded when she was arrested and jailed after driving under the influence on a suspended license. Other people are locked up after stealing railroad ties or copper from abandoned mines or breaking into homes where people might have money and/or prescription medicine.

The sober, hardworking residents shake their heads and guard their homes with guns, knowing that the next drug-fueled break-in could easily be at their house. "I've got something in the corner that says they won't come in," says Tamelia Spears, 47, whose great-grandfather's cousin was Randall McCoy of the feuding Hatfields and McCoys. "My family, they know to holler before they come into my house."

Robinson's three children were taken away five years ago, about the time she woke up next to her fiancé, who was dead from a drug overdose. Still, it wasn't until her sixth visit to jail that she decided she couldn't do it anymore.

The humility and thinking how her beloved late father would "kick my a--" if he knew what she was doing got her to sober up in October 2012. She's working on getting her GED and looking for work to quell the boredom that comes with doing nothing while collecting a disability check for hearing loss in one ear. And to keep her mind off the children — 11, 14 and 16 — she longs to see.

Of substance abuse, which ensnared two of her five siblings, both parents and so many in her community, Robinson says, "Mostly I think we don't know how to deal with loss and pain."

"I don't know what the answer is, but it's on trend of getting worse rather than better," McKinley says.

— Jayne O'Donnell, USA TODAY

Dental care

Limited coverage is seen as a start

GRETHEL, Ky. — Nearly four of 10 adults in Floyd County, Ky., have lost at least six teeth because of decay or gum disease.

Statewide, more than half of adults have had at least one tooth pulled, and a quarter of those over 65 have lost all their teeth.

When it comes to dental care, the Affordable Care Act's reach is limited.

The law requires health plans to cover children's oral health, but adults aren't included. Kentucky's Medicaid dental benefits for adults cover only a short list of services, including oral exams, emergency visits, X-rays, fillings and extractions.

Complicating matters, rural residents face a shortage of dentists, including a shrinking number who take Medicaid.

Heather Whitt, director of dental services for a network of health centers called Big Sandy Health Care, said she believes the ACA will make a difference to people in the mountains of Appalachia. She said the number of uninsured — which for years had been three-quarters of her patients — is finally starting to drop.

"People are in a lot of dental pain. They're missing work. They have infection and pain," said Whitt, who grew up in Appalachia. "I've seen the need all my life.

"Now, there are more adults having Medicaid. It's definitely improved the patients we see here. ... We stay very busy," she said. "I'm excited more people have benefits."

She and other dentists said Medicaid — which covers most of the area residents newly insured through the ACA — does not cover every service they might need.

For example, Whitt said, it doesn't pay for dentures or root canals for adults older than 21. Dentists complained that Medicaid managed-care organizations have been slow with reimbursements.

Still, they said such issues pale in comparison to the problems uninsured patients face.

Anita Slone, who recently traveled 80 minutes from her home in Virginia for an appointment with Whitt, said she has no dental insurance, but hopes to get some by signing up for a health plan through HealthCare.gov, the federal ACA website.

On a recent day, Whitt told her she could get a crown and root canal for about $1,000 or have the tooth extracted for about 10 times less. Slone chose to get the tooth pulled and not long afterward sat in a waiting room with gauze in her mouth.

Whitt said that when a patient visits for a procedure, she and her staff try to educate them about brushing, flossing and regular checkups. They do the same through a school outreach program, in which they try to get children into the habit of seeing dentists early.

If the ACA brings more patients to the clinic, dentists said, more people will take better care of their teeth.

"A lot of our patients just kind of fall through the cracks," dentist James Stambaugh said. "Small problems just grow exponentially."

— Laura Ungar, The Courier-Journal

Chapters
Small businesses
'We were hoping that Obama thing would go away'
Drug treatment
'They just don't work and have too much idle time'
Dental care
Limited coverage is seen as a start
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Scenes from Floyd County, Kentucky

The Affordable Care Act is having an impact on auto dealer workers and managers at Deskin Motors; drug addicts and the jailers at the Floyd County Jail; and patients and dentists at Big Sandy Health Care.