BREATHITT COUNTY, Ky. — On the campaign trail, Senate Minority Leader Mitch McConnell of Kentucky was still blasting the new health care law as unsalvageable. At the White House, President Barack Obama was still apologizing for the botched federal website.
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, Kentucky Fried Chicken 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.
Eligible for Medicaid
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, a Democrat, 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.
Choosing a plan
"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."
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."
"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 him 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 in the back of the clinic.
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.
"All right," Lively said after entering his information into the laptop. "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."