For many Virginians, health care hangs by a thread. Given the disparities in access to care in the state and the looming threat from congressional Republicans to the Affordable Care Act (ACA), it’s no wonder that voters list health care as an issue of critical importance to them. A Monmouth University poll of likely voters released in late July found that 37 percent said health care or insurance is their top concern in the state’s gubernatorial race, followed by 25 percent who cite jobs as a high priority.
One of Virginia’s most vulnerable regions is Appalachian coal country, located in the southwestern corner of the state bordering Tennessee, West Virginia, and Kentucky. Coal mining was long an economic mainstay of the region, but that has changed dramatically. In 1984, 14,293 people worked in Virginia’s coal mines. Now, according to the Virginia Department of Mines, Minerals, and Energy, that number has dropped to 2,866. That leaves many without full-time employment or insurance coverage.
Southwest Virginia’s population is estimated to include 208,000 of the 8 million people living in the state. While 10.7 percent of Virginians under 65 were uninsured in 2015 according to the Virginia Health Care Foundation, 13.7 percent of those living in the state’s Southwest region lack insurance.
Brenda (whose last name is being withheld for privacy) is a 61-year old Wise County resident without insurance. She attends the area’s Remote Area Medical (RAM) clinic, a three-day clinic for the uninsured that takes place each summer at the local fairgrounds. She waited more than 12 hours overnight in her car in July for tickets that allowed her to seek free dental, back, and gynecological treatments. She calls the no-pay clinic “a lifesaver for people in Virginia,” and doubts she could get certain kinds of care without it.
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Brenda used to work full time at an office job, but these days, she stays home to take care of her adult son, who is disabled. He has insurance through Medicare, as does her husband, who could no longer work after suffering a heart attack a few years ago. Brenda herself has not had insurance since 2008 because monthly premiums were unaffordable.
Rewire spoke with Brenda by phone at Wise County’s free Health Wagon clinic, where she was receiving follow-up care after her RAM clinic appointment.
“I don’t go to the doctor unless I’m really, really sick,” she said, adding that she feels fortunate that her general practitioner charges by a sliding scale. “I’m having some back issues, so I don’t have nothing for that to see a chiropractor. There are probably tests I should be having.”
Every year at the RAM clinic, Brenda makes it a point to see a dentist. Wise County’s dentistry provider-to-patient ratio is among the worst in the state, according to a 2015 study by the Norton Community Hospital of Mountain States Health Alliance. Even if there were dentists, many don’t have dental insurance, Brenda said.
Wise County is in the state’s bottom 10 localities for overall health outcomes. Smoking, poor diets due to food insecurity, physical inactivity, suicide rates, cancer, heart disease, and motor vehicle accidents are all higher there than Virginia’s averages.
With her small team of health-care professionals, Paula Hill, clinical director of the Health Wagon and a doctor of nursing practices, helps more than 10,000 people a year who don’t have insurance. They also organize the annual Wise County RAM clinic, which serves about 2,000 people each July. The clinic has become a symbol of Virginia’s health-care crisis, with men, women, and children lining up for hours to see medical professionals under tents.
Among the uninsured are laid-off miners. The same 401(k) accounts and other financial assets that once made their jobs appealing are now assets that disqualify them for Medicaid.
Hill has seen some patients move to Kentucky, where Medicaid is currently expanded under ACA despite efforts from the state’s Republican governor to overhaul it, so they could receive more consistent care. One woman who couldn’t afford treatment for pancreatic cancer in Virginia went to Kentucky, Hill said, where she was able to receive more affordable and accessible care in her new state before her death.
High rates of hypertension and diabetes—“a lot of which could have been controlled with management,” Hill said—are common issues in southwest Virginia, along with physical problems associated with obesity and smoking. Opioid abuse also takes a toll on both adults and children, she noted.
With a team of five nurses, a nurse practitioner, and two doctors of nursing practice traveling to see patients in seven locations, Health Wagon is very busy and relies heavily on donations to stay afloat. The medical personnel also work with doctors in New Jersey and the University of Virginia through telemedicine programs, helping diagnose local patients. More and more people come to the annual free clinic in Wise, too, Hill said.
Anna Scholl, executive director of the Progress Virginia advocacy group, called the RAM clinics “an unnecessary tragedy.”
“No American should have to camp out overnight in their car at a campground to access health care,” she said in a phone interview with Rewire. Her organization advocates for Medicaid expansion, which would assist up to 400,000 Virginians who don’t have health insurance.
Jill Hanken, a staff attorney specializing in health law at the nonpartisan Virginia Poverty Law Center, said she’s seen a shift in the type of patients at RAM clinics since West Virginia and Kentucky legislators expanded Medicaid. Before the expansion, people from those states also “showed up at RAM clinics in Wise.” Today, the patients at the fairgrounds are mainly Virginians, an observation echoed by Hill—though she said she occasionally sees patients from other states.
Life and Health in Virginia, by the Numbers
Within Virginia, quality of life and length of life vary widely by geography. In wealthy Northern Virginia, the average life expectancy is 82.3 years, while in the state’s Southwestern region the average person lives to age 75.5.
The life expectancy of Virginians living in the state’s Southside region, which touches parts of the North Carolina border and has experienced extreme economic downturns in the past two decades, hovers at 75.9 years. A RAM clinic held in June near the Virginia-North Carolina state line pulled in thousands of patients.
More than 10 percent of Virginians under age 65—that’s 747,000 people, according to the latest available statistics from 2015—are uninsured. Many are white, live in rural areas, and live in families with at least one person working part-time or full-time. Many are parents who don’t earn enough to pay for health coverage but earn too much income to qualify for unexpanded Medicaid, said Hanken.
According to the Virginia Health Care Foundation’s (VHCF) 2017 report, Black and Latino people are disproportionately likely to be uninsured compared to white Virginians. VHCF reports that 22.6 percent of Latino people in Virginia do not have insurance, compared with 13 percent of Black Virginians and 8.2 percent of white people in the state.
Even those who do have health insurance sometimes have difficulty seeking treatment due to, among other things, lack of access to transportation. In more than half of the state’s 134 localities, there are critical shortages in primary care, mental health, and dental health practitioners.
Meanwhile, Virginia has seen several health insurance companies back away from offering policies through the Affordable Care Act (ACA) marketplace due to instability caused by the Trump administration.
Health Care at the Ballot Box
Health care has often been a central issue in the lead up to November’s high-profile gubernatorial race.
Democratic gubernatorial candidate Ralph Northam’s first advertisement in the general election gave the spotlight to expanding access to health care. This year, he saw patients at the aforementioned Wise RAM clinic while U.S. Sen. Tim Kaine (D) assisted with paperwork.
Northam and Republican Ed Gillespie have taken typical party-line positions on Medicaid, with Northam—a pediatric neurologist and former Army doctor—in favor of expansion and Gillespie against.
Gillespie criticizes the costs of health-care “safety net” programs in his campaign platform writing that “every dollar we put into these programs is a dollar we can’t spend on K-12 or higher education or other important priorities.”
Gillespie and other Republicans base their opposition on the claim that expanding Medicaid would cost Virginians more money down the line. However, Hanken said this argument is “not valid.”
Although the federal government no longer covers 100 percent of states’ Medicaid expansion costs, it does pay for 90 percent of them. Hospital corporations in Virginia have said they will cover the rest of the costs, which would benefit them by lowering the amount of indigent-care expenses they face. In the end, Hanken said, Virginia would only pay administrative costs.
Nonetheless, these arguments and Congress’ failure to pass an alternative to the ACA have not caused Virginia Republicans to budge an inch, even when their communities would benefit.
Gov. Terry McAuliffe (D) has tried to expand Medicaid to 400,000 more Virginians since he took office, but the bicameral Republican-dominated state legislature has steadfastly refused to do so. McAuliffe and other Democrats have noted that the state was losing out on millions per day in federal funding by not expanding Medicaid.
Republican Delegates Terry Kilgore and Todd E. Pillion, who represent districts that include Wise County, voted against Medicaid expansion—even though, according to the Commonwealth Institute, more than 9,000 of their constituents would become eligible for Medicaid.
Hill, of the Health Wagon, said she was “so disappointed” with the state delegates’ Medicaid decision, noting that many people in Wise are stuck in part-time, low-wage jobs with no benefits. “In our area, there is a lot of economic devastation. We continue to see more and more numbers each year.”
However, Democrats have a glimmer of hope this fall, as Virginia has more contested races in the state legislature this year than in more than a decade. All 100 seats in the GOP-dominated House of Delegates will be up for election.
In 17 districts currently represented by Republicans, Hillary Clinton won the popular vote. If Democrats win those districts, the party would have a 51-49 advantage over Republican delegates.
A Northam win could mean a more favorable environment for health-care access if the makeup of the state’s legislature changes. Regardless, McAuliffe’s unprecedented use of his veto power demonstrates just how much influence the governor’s office can have on determining policy in the state.
As of mid-September, the gubernatorial race is tight, with one recent poll showing Northam with a five-point lead over Gillespie and a second showing a tie. Northam has a financial advantage over Gillespie, but more money from the national parties and out-of-state PACs is expected to flow in before the end of the race.
Down-ticket, Attorney General Mark Herring (D) holds a seven-point lead over Republican challenger John Adams, and Democratic lieutenant governor nominee Justin Fairfax is five points ahead of Republican candidate Jill Vogel, a state senator. In Virginia, the sitting lieutenant governor is the deciding vote in the case of ties in the state’s senate.
As the political races run their course, Hill and others continue their work, caring for thousands of Virginians without insurance.
CORRECTION: This article has been updated to correctly identify the rate of Virginians under the age of 65 who are uninsured.