Another morning, another list of patients and problems in the hands of 35-year-old Keisha Saunders. Diabetes, depression, heart disease. Robert needs lower blood pressure. Buffy needs prescriptions filled. Mary needs to lose 50 pounds, so she can get what she really needs, a new hip.
Again, the list extends to the bottom of Keisha's notepad, as it has so many days since the Affordable Care Act mandated that everyone have health insurance. Unlike in Washington, where health care is a contentious policy debate, health care where Keisha is a nurse practitioner is a daily need to be filled. The high rates of chronic diseases in McDowell County have made it the county with the shortest life expectancy in the nation.
It's also a place that voted overwhelmingly for President Donald Trump, whose promise to repeal the ACA will soon affect nearly every patient Keisha treats at the Tug River health clinic in Northfork, including the one waiting for her in exam room No. 2.
"How are you doing?" she asks Clyde Graham, who is 54 and has been out of work for four years.
"I ate a sandwich from Arby's," he says. "And it jumped me out for like, three days. I mean it just burnt."
Heartburn is just the latest problem for Clyde, a patient Keisha sees every three months. Like so many in this corner of Appalachia, he used to have a highly paid job at a coal mine. Company insurance covered all of his medical needs. Then he lost the job and ended up here, holding a cane and suffering not only from heartburn but diabetes, arthritis, diverticulitis, high blood pressure and high cholesterol.
Because of the ACA, Clyde's visit is covered by Medicaid. Before the law, most West Virginians without children or disabilities could not qualify for Medicaid, no matter how poor they were. The ACA - better known here as Obamacare - expanded the program to cover more people, such as Clyde, who can depend on Keisha to fix his heartburn without having to worry about the cost.
As for the other problems in his life, he has put his hopes in Trump, who came to West Virginia saying he would bring back coal and put miners back to work. When Trump mentioned repealing Obamacare, Clyde wasn't sure what that might mean for his Medicaid. But if he had a job that provided health insurance, he reasoned, he wouldn't need Medicaid anyway, so he voted for Trump, along with 74 percent of McDowell County.
Tug River Health Association treats about 8,700 patients, resulting in some 20,000 visits a year to its five clinics. In 2016, 12,284 of those visits were from patients on Medicaid, up from 5,674 in 2013, before the ACA took effect here. Without the ACA, many of those patients wouldn't be able to afford care. Will they soon lose their coverage? Will they stop coming to the clinic? Lately, Tug River's chief executive has been telling his staff, "The key word going forward is uncertainty."
To Keisha, all is uncertain beyond this moment, in which she prescribes Nexium for Clyde's heartburn, examines him from head to toe and sends him to the lab across the hall for blood work.
"I'll see you in three months," she says, hoping that will be true, and heads to exam room No. 1, where another patient is waiting. "What's going on today?" she asks, and walks in the room to find out.
- - -
Meanwhile in the front of the clinic, more patients are coming in through the heavy doors and up to a glass window where a receptionist is waiting.
"Hi honey, how are you?" Tammy McNew says to each one. Over the past four decades, McDowell County has lost 60 percent of its population, so she rarely needs to ask their names. Instead, she asks what seems like the most important question in health care these days:
"Got your insurance card with you?"
If the answer is no, she will send them back to Keisha anyway, and the clinic will depend on federal grants to make up the cost. But more often in recent years, the answer is what a middle-aged woman with springy curls says as she passes her Medicaid insurance card through the window: "Yes, ma'am," she tells Tammy, who slides it into a scanning machine.
In other parts of the country, the primary impact of the ACA has been requiring people to have private health insurance, but in poor and sick communities like McDowell County, the law's dominant effect has been the Medicaid expansion, which has given more people access to the kind of health care that wasn't widely available or affordable to them before. With an insurance card in her pocket, the patient at Tammy's window can venture into the realms of medical care that are typically out of reach to those without one: blood work, immunizations, specialized doctors, surgery, physical therapy.
If she needs mental health counseling, the clinic no longer sends her to the next county over; last July, Tug River was able to hire a psychologist, who is now treating 180 people, many of whom are trying to overcome opioid addictions.
If she needs medication, the nurses won't go digging in a closet of samples left by drug reps as they used to do for the uninsured. The medication will come from a pharmacy and cost no more than a few dollars.
"All right sweetie, I got you," Tammy tells her, and the patient retreats to a chair to wait for her name to be called. The routine is repeated dozens of times a day as the phone rings behind the front desk. "For appointments, press one," the callers hear. "Black lung, two."
This clinic is in Northfork, a community of a few hundred people along the railroad that carries coal through the mountains. Keisha, who is black, was raised in this predominantly white county, in a home overlooking the cinder-block church where her father, a coal miner, serves as pastor. She attended the middle school beside the clinic parking lot, which now has busted windows and gaping holes in its brick facade. There weren't enough children to fill it, as every year the closing of more mines drove job-seekers out of the county.
Eventually, Keisha was one of them. After graduating high school and becoming a mother at 18, she realized that if she wanted to become something more for her daughter, she would have to leave.
She moved 45 minutes away, to Princeton, W.Va., where she got a nursing assistant certification and a job in a nursing home. But every Sunday, she strapped her daughter Kiana in her car and drove back to McDowell County, checking in on her always-fading town. Bulldozed, shuttered or abandoned: the grocery store, beauty salon, florist and furniture store. Still open: the dollar store, medical equipment store, funeral home and her father's church, where Keisha would usually sit with her brother Derrick.
It was 2003 when Derrick started to feel pains in his back and groin, and Keisha, then a 22-year-old licensed practical nurse, started to understand what insurance could mean. Derrick was 24 — too old to be covered by his father's insurance but unable to afford his own. He thought his only option was to go to an emergency room. His parents remember him returning home, having been told there was nothing wrong with him. When the pain didn't go away, Derrick tried a different ER. Keisha would later learn that doctors thought her brother was seeking pain pills. Months passed.
All the while, a tumor inside his kidney was growing. A few months after the cancer was finally discovered, Derrick died at 25.
Keisha didn't allow herself to wonder what might have happened if he'd had insurance. She focused on remembering their last days together, when the doctors said the cancer was too advanced to be stopped by treatment, so she treated him with chocolate instead. M&Ms by his bedside.
She kept working at the nursing home and then in hospice care, raising Kiana and taking classes at night. When she was 30, she completed a graduate degree and became a nurse practitioner. She made the drive back to McDowell County again, this time to ask for a job.
At first, some patients at Tug River were wary of her loud laugh and big hoop earrings. Others had known her since she was a little girl. She cared for them all, and her schedule grew busier as the ACA came to McDowell County and made more people eligible for insurance.
In 2016, Trump yard signs and bumper stickers started appearing along her drive to work. In the clinic, one doctor and the janitor could regularly be heard rehashing the latest controversy and what they liked about Trump. Keisha had decided she would vote for Hillary Clinton, because of health care and because she wanted to see a woman become president. But it wasn't in Keisha's job description — or personality — to talk politics. She avoided the subject.
Come election night, she was too exhausted after another packed day at the clinic to stay awake. She didn't learn who won until the morning.
In all of those Sundays at church, Keisha was taught that God has a plan. If God planned for Trump to win the election, she told herself that morning, it must be for a reason.
- - -
Now Trump is in the White House and Keisha is pressing her fingers into the stomach of 24-year-old Ruby Thompson. Nearly every patient Keisha sees has been impacted in some way by the ACA, and in Ruby's case, the ACA's Medicaid expansion is the reason she has insurance.
According to the list on Keisha's notepad, Ruby is just here to refill a prescription, but Keisha checks her as if they are meeting for the first time. She tries to feel for anything abnormal around Ruby's stomach, which is a little too thin, but Keisha knows cigarettes can cut into a person's appetite.
"Are you still smoking?"
"Yeah," Ruby answers, tugging at a gold necklace that spells MOM.
"Do you want to stop?"
"I will eventually, I guess."
Ruby is another patient who voted for Trump because of his promise to bring back jobs. She hasn't yet lost hope that she can become a secretary, but for the past two years she's been working at KFC. She has health insurance only because she was fined on her taxes for not having it, at which point she found out that because of the ACA, she qualified for Medicaid. It is insurance at its most tenuous, though, because if Medicaid reverts back to a program only for the neediest people, the working poor will be most at risk of losing their coverage.
"Go ahead and sit up," Keisha says after checking Ruby's ankles for swelling, a potential sign of diabetes. She writes a prescription and sends Ruby to the front desk to make an appointment for November, when she is due for a breast exam and cervical cancer screening.
Another patient comes in: Carolyn Hodges, 68, who tells Keisha that she's been feeling dizzy. Carolyn has Medicare, the public health insurance for the elderly. Medicare doesn't cover all health-care costs, which is why Carolyn is as worried about the price of her medications as the fact that she's been bumping into walls.
The last time she went to pick up her husband Roger's insulin, Carolyn tells Keisha, the pharmacist said it would be more than $600, instead of the $100 or so they usually pay. That was when she learned Roger was in the Medicare prescription "donut hole," which means that the cost of his medications had exceeded his limit for the year, and he would be forced to pay far more for prescriptions until the year ended and the tab started over. One initiative of the ACA has been to close that hole incrementally, but Carolyn, unaware of that, sees the bills piling up and thinks she knows who must be to blame.
"Thank you, Obama!" Carolyn says, throwing her arms in the air.
Keisha nods, and keeps typing into her chart.
Another patient: Andrea Easley, 50, who has struggled for so long that there wasn't much more the ACA could do to help her. She already had Medicaid, which she depends on for her health care, and disability payments, which she uses to pay her rent, support her 70-year-old mother and send checks to her son who is in prison in Charleston, W.Va.
"What's going on, Miss Andrea?"
"My nose," Andrea says, nearly shouting. "I had just come in. Sit down. Sneeze. My nose went to burning. I mean, it burned like someone gone and set fire to my nose."
Despite taking more than a dozen medications a day, Andrea's problems never seem to go away. Her life isn't one where she thinks much about politics - she didn't vote in the election - but of stomach issues, coughing, lack of sleep, fights with her mother, stress over her son.
"Have you tried a humidifier?" Keisha asks.
"What is that?" Andrea says.
"It keeps the moisture in the air," Keisha explains. "Do you sleep with your mouth open?"
"I don't know how I sleep. I'm not half sleeping. Now last night, it made me mad," she says. "Them cats out there meowing, and I'm trying to go to sleep, and they're out there doing all such things they have no business doing . . ."
Looking up at Andrea from her low swivel stool, Keisha listens. She knows other patients are waiting. But she also knows that sometimes her patients need to talk, so she gives no sign that she has anyplace else to be. Only when Andrea pauses does she say, "I do think you need a humidifier. I think that will help some."
"Where can I get that from?"
"Well," Keisha says, knowing her answer will upset Andrea, "you have to buy it."
Another patient: Charles Collins, 39, who believes that the impact of the ACA was to make his own health-care costs rise. He is privately insured through his job at a coal mine one county over. The mine used to cover 100 percent of his medical expenses, but starting this year, only 90 percent is covered, and his dental insurance, he tells Keisha, "ain't worth a nickel."
"That's a mess," she says. Charles unclips his miner's overalls so she can place the stethoscope on his chest, and tells her about getting his tooth pulled.
"I got a bill for $324 and they paid a dollar of it," he says about his insurance. He is glad Trump is repealing the ACA, because in his opinion working people are being forced to pay for those who sit around and do nothing. But no matter what Trump does, Charles knows the bill for this visit is coming.
"Deep breaths for me," Keisha tells him, and Charles exhales.
Another patient, here for the first time: a 33-year-old woman who voted for Hillary Clinton. She has no insurance, by choice. She didn't feel she needed it. Now, because of a test result in Keisha's hands, she will.
"Hi Miss Amanda, I'm Keisha, the nurse practitioner here."
"Nice to meet you," Amanda says, pushing back a lock of cherry-colored hair.
Keisha asks Amanda about her symptoms, then gets to the point. She turns to face her and says, "It looks like - you're pregnant."
"Yes. Were you expecting . . ."
"That's such good news!" Amanda says.
"I'm glad you're happy," Keisha says. "Good! Yay!"
Amanda lifts her palms in the air, and they double high-five. Then come the questions Keisha needs to ask for her chart.
Is the baby's father involved? "I think he's going to be a little apprehensive," Amanda says.
Is she working? "Not currently," Amanda says, explaining to Keisha that she just moved back to West Virginia after living in Ohio. So far she has put in applications at gas stations and restaurants.
Is she at all familiar with the area? With the doctors she'll need to see? With what she needs to do now? Amanda wrings her hands between her knees. "I have no idea where to go next," she says.
And here is another version of uncertainty in the clinic, this time a patient's. If she signs up for Medicaid, which covers low-income, pregnant women, she'll be covered through her pregnancy. But after that? Her access to insurance will depend on what happens over the next months in Washington, where so many plans for the ACA's replacement are floating around. One, unveiled in the House this month,would roll back the Medicaid expansion slowly, meaning Amanda could keep her public insurance after the baby is born. In a few years, however, someone like her might not be able to do the same, and instead might receive tax credits to help offset the cost of private insurance.
But that's just one plan. There have been plans based on "block grants" and plans based on "per-capita caps." Some plans give people tax credits based on their income. Some base the tax credits on their age; some on where a person lives. There's the plan once proposed by Trump's secretary of health and human services, which would get rid of the Medicaid expansion entirely. There's the plan Vice President Mike Pence implemented when he was governor of Indiana, which penalizes anyone who doesn't pay for Medicaid coverage, even if all they can afford is a dollar a month. There's even a plan that proposes keeping the Medicaid expansion just as it is.
With so much to be resolved, Keisha hands Amanda a form to sign up for Medicaid. They walk together to the front desk, where Keisha asks Tammy to schedule Amanda's first prenatal appointment.
"Thank you," Amanda tells her.
"You're welcome," Keisha says. "I hope everything goes well."
- - -
Sometimes, between patients, Keisha retreats into her office, sits at the folding table she uses as a desk and takes a few steadying breaths. If she has enough time she also prays, and since January some of those prayers have been for President Trump.
"I just pray that he makes the right decisions," she says. "I'm not sure what's going to happen. All we can do is pray about it."
She prays for others, too. Her daughter. Her parents. Her brother. She prays for her patients, that they stay healthy, that they lose weight, that they take their insulin shots the correct way, that the woman with the rotting tooth will follow up on her promise to go to the dentist, that the man whose wife died after saying to him, "Honey, do you think I'm getting better?" will find a way to ease his loneliness.
And what if, in a few months, those patients lose their insurance? She'll pray about that, too, she says, but first she will explain the sliding fee program, the closet full of sample medications from drug reps, the forms she can submit asking pharmaceutical companies for discounts, the free clinic at the medical school four hours north - all the things she will do to try to get them the care they need, even if they can't afford it.
One more deep breath and a last prayer for herself — "OK, Lord, help me get myself together" — and then she picks up her stethoscope. It's Friday afternoon, and seven patients need to be seen before she can go home to her teenage daughter.
"Hey there, how are you?" she starts with one.
"Oh goodness, you have been having a rough time," she tells a man with kidney stones.
"I want to send you to a lung doctor to find out, because I just don't know," she explains to a patient whose cough won't go away.
"You are not broken," she says to a woman who the psychologist recently diagnosed as bipolar, and so it goes until she finishes caring for her last patient, nearly an hour after the clinic has closed.
She powers down her laptop and carries her notepad to the blood-work lab, where there is a paper shredder. Ripping off the top page with today's list of patients and problems, she drops it into the machine and watches it disappear. Then she slides the notepad into her bag to take home. Another week of need is coming, and she wants to be prepared.