Dr. Joseph Smiddy, a pulmonologist and medical director of the Health Wagon, speaks with two volunteers outside a trailer where patients receive chest X-rays at a free health fair in Wise, Virginia. (Mason Adams/Energy News Network)

Every July for two decades, volunteer doctors, dentists and nurses gathered at the Wise County Fairgrounds to deliver free medical, dental and vision care. 

The free clinic attracted thousands of central Appalachian residents, many of whom camped out the night before to secure their spot in line. The event annual event also drew media outlets from around the world with dramatic scenes of people receiving care in trailers and livestock stalls.

But this year, the three-day free clinic sponsored by Remote Area Medicine won’t happen. That’s due partly to social distancing restrictions in response to the pandemic, but also because RAM’s local partners “have built infrastructure and capacity around eye, dental, and medical resources in the Wise, Virginia community,” according to a news release. Local organizations such as the Health Wagon and Mission of Mercy had grown to fill the gaps.

Another contributing factor was Virginia’s expansion of Medicaid beginning in 2019. At the time of the final RAM clinic in Wise in 2019, more than 290,000 Virginians had enrolled in the program. Nearly a year later, that figure has grown to 426,613, including 3,909 people in Wise County — a little more than 10% of its total population.

As coal continues to decline as an economic driver, communities in central Appalachia and Wyoming are trying to determine their next steps in maintaining critical health care infrastructure.

A volunteer assembles a pair of eyeglasses at the 2019 RAM Clinic in Wise, Virginia. (Mason Adams/Energy News Network)

But healthcare remains a politically charged issue. The Patient Protection and Affordable Care Act of 2010, also known as Obamacare, has been a flashpoint in partisan politics since it passed. The law brought sweeping changes, including incentives for states to expand Medicaid programs to cover citizens and legal residents with income up to 138% of the poverty rate.

Still, shrinking tax revenues, jobs and resources in the industry are forcing the issue in many parts of coal country, and communities are becoming more reliant on — and even warming to — federal health programs like Medicaid. 

To expand or not?

Only 14 states have not expanded Medicaid coverage, including Wyoming, where continuing layoffs and declining revenues from coal and oil threaten a rural health system that U.S. News and World Reports ranked 42nd in the nation for overall quality of healthcare. 

Most states in Appalachian coal country have expanded Medicaid. Kentucky and West Virginia expanded Medicaid in 2014, the first year they could do so. Both have Republican-majority state legislatures. Both have a significantly lower percentage of uninsured residents than Wyoming, which has yet to expand Medicaid, or neighboring Virginia, which didn’t expand until 2019.

Despite challenges by state lawmakers — including attempts to impose work requirements — Medicaid expansion has remained popular in Kentucky and West Virginia, so much so that few are talking about repeal any more. In 2018, incumbent U.S. Sen. Joe Manchin, D-West Virginia, who had famously shot the cap-and-trade bill in a campaign spot eight years earlier, reprised the ad — only now he was shooting a lawsuit to repeal the Affordable Care Act. The message helped carry the Democrat to victory in what had been Trump’s second-best state — behind only Wyoming — just two years prior.

“One thing that’s struck me is how Medicaid in the last five years or so has become much more popular than it ever was,” said Adam Searing, a research professor at Georgetown University’s Center for Children and Families. “People are seeing it more like Social Security or Medicare — not so much welfare but a safety net program.”

As a countercyclical program, Medicaid is designed to kick in when the economy suffers. That’s been happening in coal country since the Great Recession, and now demand for service is spiking across the country with the pandemic.

“Ideally, people want a job, but if the jobs aren’t there, you don’t want people to also lose their health insurance too, especially these days,” Searing said. “States that have expanded Medicaid have more options for people to retain good health coverage than states that haven’t. What this really means for families is financial security.”

One of the commonalities of coal communities in Wyoming and Appalachia is they tend to be located in rural areas where there aren’t enough people with adequate insurance to help cover the costs of healthcare services.

Campbell County Health serves the coal-rich Powder River Basin region. Hospitals and other healthcare providers in Appalachia and Wyoming have been dealt a series of blows in recent years amidst historic declines in the coal industry. (Dustin Bleizeffer/WyoFile)

With coal in a downward spiral, that means more people in coal country — including an aging population of miners — are relying on social programs like Medicaid and Medicare. Coal states that initially rejected Medicaid expansion now see it as a way to help stem some financial losses in healthcare and provide care to residents. Increasingly, the argument that expansion is vital to aiding coal communities transition to a sustainable post-coal economy is gaining traction.

“I think [Medicaid expansion] is actually a really strong conservative position,” said Jen Simon, senior policy advisor for the nonpartisan Equality State Policy Center, which represents social justice, conservation and labor organizations in Wyoming. “There’s great evidence across the country that Medicaid expansion actually results in more productive employees, better job creation and great economic growth. I would suggest that’s all in keeping with Wyoming values.”

A coal state reluctantly reconsiders Medicaid 

After repeatedly rejecting expansion efforts, Wyoming legislative leadership called on members in May to again take up the question of Medicaid expansion in light of the coronavirus pandemic and historic losses in coal.

But just weeks after the call to add Medicaid expansion to the Wyoming Legislature’s list of special session priorities this year, a committee declined to take action. Similar efforts to expand Medicaid in Kansas and Oklahoma also have stumbled.

“I’ve been very surprised at the continued resistance to Medicaid expansion,” Searing said. “I thought surely this would be the catalyst. But it’s still an uphill battle to overcome this ideological resistance.”

Wyoming’s refusal to expand Medicaid coverage under the Affordable Care Act has cost the state nearly $1 billion in federal funds since 2013, as well as an opportunity to cover up to 32,000 residents over the next two years — a number that will likely continue to grow with mounting job losses.

However, expansion proponents still hold out hope that lawmakers — particularly those from Wyoming’s coal communities — might change minds. They say Medicaid expansion would soften the blow to both patients and medical providers in the short term, and may be vital to sustaining hospitals and Wyoming’s workforce in economic transition.

Legislative leadership in May cited recent job losses and ongoing uncompensated care when it voted in favor of studying expansion in response to COVID-19 and a state budget crisis. Wyoming hospitals lose an estimated $100 million annually in uncompensated care — a figure likely to spike this year, according to the Wyoming Hospital Association.

Campbell County Health CNA Gemma Monthey helps patient Maria Dias on June 22, 2020. (Dustin Bleizeffer/WyoFile)

Rep. Tom Crank (R-Diamondville) represents a district in southwest Wyoming that includes several coal communities. He said he’s mostly agnostic toward Medicaid expansion, but analysis from the Wyoming Department of Health seems to justify at least considering expansion. “For every dollar you put in, you get 10 dollars back. If that’s the case, sign me up,” Crank said.

However, voters in his district — as well as party leadership — have “set me straight” when he’s brought it up, Crank added. “We’re all kind of fat and happy as long as things are going all right,” Crank said. “But if you start seeing one or two of these rural hospitals go down, that will be the red flag. They’re really important to these small communities. We need them to make these communities viable.”

Coal miners had it good

When it comes to the rising cost of health insurance, coal companies are no different than any other big employer. As costs increased over the past two decades, so did premiums and deductibles for coal miners and their families. It’s a trend that state leaders struggle to find politically acceptable strategies to counteract, and one that confounds a segment of high-wage earners who previously enjoyed robust health benefits.

Don Dorn worked at Powder River Basin coal mines for more than 30 years before taking a job with the state as a deputy mine inspector. When he hired on at Black Thunder mine in the 1980s, employees enjoyed private insurance with no premiums or deductibles. Black Thunder even had a full-time nurse practitioner onsite to perform physicals, prescribe medications and see employees who were ill — at no cost.

“It was like having a personal nurse right there at your fingertips,” Dorn said. “It was an awesome benefit. It saved the company probably hundreds of thousands of dollars each year.”

Arch Coal’s Black Thunder mine in southern Campbell County commenced operations in 1977. Arch Coal shed $5 billion in debt before emerging from bankruptcy in 2016, making it one of the most financially resilient mine operators in Wyoming’s Powder River Basin. (Dustin Bleizeffer/WyoFile)

Eventually, premiums began taking small bites out of paychecks. Then bigger bites. After Arch Coal took over the mine from ARCO in the late 1990s, it eventually cut the nurse position. Things began to change dramatically in the 2000s. First there was a $100 deductible, then $500, then $1,000, along with in-network limitations. Now some miners in the Powder River Basin have deductibles in the $5,000 range.

The rising cost of healthcare hit coal companies and miners much the same throughout the state.

“I don’t think the trend has been different from any other industry,” Dorn added. “As insurance got more expensive, you know, they started putting more burden on the employees.”

Dorn also serves on the Wyoming Miners’ Hospital board. The hospital provides some basic services — mostly related to respiratory and hearing — as well as financial assistance to miners with more than 10 years of mining experience. There’s been a steep rise in demand for services in recent years — from retired coal miners, those who have been laid off and even among miners still on the job, Dorn said.

“Most people never used it that much, and within the last five years we’ve almost reached our capped amount [of benefits] each year,” he said.

Today, health coverage for Wyoming coal miners varies from “good” private coverage to not so good. Hundreds of retired coal miners in Wyoming and Appalachia temporarily lost healthcare coverage when Westmoreland Coal filed for bankruptcy in 2019. Later the same year, Blackjewel cancelled healthcare coverage for thousands of employees in Wyoming and Appalachia as it spun into bankruptcy and reneged on obligations to pay salaries, retirement and taxes owed in coal country.

Healthcare was restored for thousands of union miners in late 2019 with the passage of the bipartisan American Miners Act in response to the faltering health care and pension funds program established between the federal government and union miners. Wyoming’s congressional delegation did not support the deal; union miners make up a tiny percentage of Wyoming’s coal workforce.

Lessons from Appalachia

For years, Virginia also resisted Medicaid expansion, with a Republican-majority legislature that blocked the Democratic governor’s efforts to expand. But in 2018, following an election in which Democrats came within a single, disputed vote of parity in the House of Delegates, a bloc of Republicans, mostly from the mountainous western part of the state, broke from their party and teamed up with Democrats to finally expand Medicaid.

Terry Kilgore, an influential delegate from Virginia’s southwestern corner who’s served in the House since 1994, was the first key Republican to publicly call for Medicaid expansion. In an op-ed published in the Roanoke Times, Kilgore argued that Medicaid expansion was essential for the region’s workforce. 

In an interview that year, Kilgore said that coal’s decline in his district played a major role in his decision to change his long-held stance against Medicaid expansion.

“When coal started its descension, it was No. 1, the job creator,” Kilgore said. “But when you lost all the coal jobs, a lot of people lost their healthcare. People were working but were going to jobs paying $8 to $15 per hour with no healthcare benefits. Couple that with the hospital closure in Lee County. All that added together made me realize why we need to address this problem.”

Nineteen of 51 Republicans in the House and four of 21 Republicans in the Senate broke ranks to join Democrats in expanding Medicaid. Republicans in coal-producing parts of southwestern Virginia played a fundamental role in the movement toward expansion.

No trespassing signs mark the Lee County, Virginia, hospital outside the emergency room, during a six-year period in which it was closed. Ballad Health acquired the hospital and reopened it as an urgent care center in late 2019, although the emergency room remains closed for now. (Mason Adams/Energy News Network)

The federal funding that came with expansion has not only been used to cover more Virginians, but also has freed up state money to pay for expanded mental health services and other healthcare programs.

Meanwhile, free clinics and community health centers that helped fill the gap in Appalachian Virginia before Medicaid expansion are evolving to cover a population that is now better insured, but still in need of access to healthcare.

For the Health Wagon, RAM’s longtime partner in the summer clinic at the Wise County Fairgrounds, innovating is a tradition. The Health Wagon was founded in 1980 by a missionary who operated out of a Volkswagen Beetle; today it operates at 13 sites in six counties and the city of Norton. Its clinic in Coeburn operates on a fee-for-service model — a break from the Health Wagon’s longtime operation as a free clinic, but one which allows it to treat people with Medicaid.

The pandemic in early March interrupted a series of day clinics in three communities, as well as regular operations, said Health Wagon Executive Director Teresa Tyson. Many of the Health Wagon’s regular patients rely on it for ongoing treatment of chronic, long-term conditions such as diabetes, hypertension and COPD. 

“People die without care,” Tyson said. “It’s important for providers and nurses to stay healthy, so we can continue to provide care, and on the flip side keep the patients safe and at home.”

That’s meant using tele-health connections where possible. The Health Wagon also keeps iPads in the lobbies of its three permanent locations, which allows patients without a phone to visit and connect with a nurse or physician virtually, even if they don’t have the technology to do so at home.

Proponents in Wyoming say expanding Medicaid is necessary to staunch uncompensated care and free up funds needed to invest in tele-health. This will facilitate better coordination of care among a statewide system of varying capabilities to deliver services to where people live and work.

“That’s how we improve healthcare in rural settings and get to reach those vulnerable populations, getting access to them,” said Dr. Tracey Haas, a family physician clinical instructor at the University of Wyoming. “You don’t do it just by setting up a clinic. You do it by actually going out and being with them and seeing what their actual needs are and meeting those needs where they’re at. 

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“My students want to do this kind of work,” Haas continued. “They want to get that in their training. But this is something that’s hard to bootstrap and fundraise for. It’s something that I think having an expansion program would help us do.”  

The pandemic eventually may result in systemic changes to America’s healthcare system. In the meantime, on-the-ground hospital systems and clinics such as the Health Wagon continue to make do through innovation and experimentation.

“We’re resourceful,” Tyson said. “We’re creative people. One of the biggest problems with southwestern Virginia has been that singular, extractive economy. If there’s a lesson to be learned, it’s don’t put all your eggs in one basket.”

“Transition in Coal Country” is a collaboration of the Energy News Network and WyoFile, made possible by a grant from the Just Transition Fund. The series examines how the declining coal industry presents immediate and long-term challenges for coal communities in Wyoming and Appalachia, how those communities are coping with change and what they might learn from each other in charting a path to a sustainable future beyond coal. Read part 1 and part 2 of the series.

Dustin Bleizeffer has worked as a coal miner, an oilfield mechanic and for 20 years as a statewide reporter and editor primarily covering the energy industry in Wyoming. He has also served as communications...

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