BREATHITT COUNTY, Ky. — The envelopes began arriving in December across eastern Kentucky, one of the sickest and poorest corners of the country.
"Dear member … We want you to be healthy … " read the letter to Mary Combs, and with it came a plastic card representing the first insurance she ever had, a Medicaid plan made possible by the nation's new health care law, effective Jan. 1.
Nine days into the new year, the 41-year-old call center worker headed to the health clinic on Highway 15. She saw a doctor about her chronic stomach ulcers, had her blood drawn for tests, and collected referrals for all the specialists she had been told she needed but could never afford.
The next week she saw a neurologist who found lesions on her brain and prescribed medicine for the cluster headaches, which are also called "suicide headaches" for pain that is far more intense than a migraine, and which Combs had been treating with an alcohol-soaked cloth wrapped around her head. She lined up a gynecologist for abnormal uterine bleeding and a hematologist for anemia and an ophthalmologist for an affliction she called "arthritis of the eye."
This is the world that many critics of the new health care law have worried about, one in which the sick and the poor expand the ranks of Medicaid while other Americans see premiums rise, policies canceled or favorite doctors booted out of networks.
Supporters of the new law argue that another scenario will unfold in places such as eastern Kentucky, in which the sick and the poor get insurance, seek treatment for long-neglected illnesses, and prevent other health problems down the line, ultimately saving the health care system billions in emergency room visits and other costs.
A visit to the Breathitt County Family Health Center provides an early glimpse into how those theories are beginning to play out in a place where people have long worried about having no insurance at all.
"That's the big question — does getting insurance bend the cost curve or the health outcomes curve?" said Karen Ditsch, the executive director of Juniper Health, which runs the nonprofit Breathitt clinic. "Is it going to make a difference?"
The starting point for any answer begins with life before Jan. 1. Eighteen percent of the county's population — about 2,500 people — were uninsured, and rates of diabetes, heart disease and other chronic illnesses have remained some of the highest in the country. The rate of adult obesity is 40 percent, for example, while 31 percent of adults smoke. The unemployment rate is 10 percent, and complications of poverty abound.
Life since Jan. 1: The number of uninsured has dropped by 520 people, which represents about 21 percent of the those without coverage. Of that 520, 472 qualified under the health care law's expanded income parameters for Medicaid, which is aimed at the working poor. Here and there, for-profit clinics that never accepted the uninsured have hung "Welcome new patients!" signs on doors. A new blue billboard hovering above the Hardee's advertises surgery to treat acid reflux.
And at the Breathitt Family Health Center, the newly insured started calling on Jan. 2 to get prescriptions sent to Walmart and to line up appointments.
The problem was never really that people did not see a doctor at all. The mission of the clinic, which has been open since 2004 and survives largely on federal grants, has always been to provide primary care to the uninsured on a sliding fee scale, usually about $20 per visit.
The problem, said Derrick Hamilton, a doctor of internal medicine and the clinic's chief medical officer, is that people have come erratically to save even on a $20 fee and, more significantly, have been unable to follow up with costly specialists.
But he knew things were changing when one of his first patients after the law took effect showed up with an index card listing all the ailments she wanted to investigate: chest pains, blurry vision, popping hips, gynecological matters, and lingering psychological problems from the death of a son five years earlier.