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Tullio Experiences Health Care Access in SE Kentucky

During my Shepherd Internship, I lived and worked in two southeastern Kentucky towns, Hyden and Hazard, as an intern at the Little Flower Clinic. The clinic and its staff taught me about the barriers to health care access and achieving better health outcomes in the area.  Through my interactions with the employees at the clinic, in discussions with patients and community leaders, and through participation in town events, I learned about community values, family structure, the state of the economy, and health habits. All of these shaped my experience and view of poverty in southeastern Kentucky. My hometown of Rochester, NY, and college environment at Notre Dame foster expectations and attitudes very different than those in Hazard and adapting to that difference was a valuable experience.

At the clinic I shadowed advanced practice registered nurses (APRNs), a family health navigator, case managers, an insurance enrollment specialist, and administrators. I was able to observe patient appointments and gain exposure to health challenges through them. The appointments addressed the most prevalent conditions in Perry County: diabetes, hypertension, obesity, respiratory complications related to cigarette smoking, and chronic pain. High incidence of these conditions is in part due to physical inactivity, calorie and fat-dense foods, and frequent soda consumption. I observed that economic, cultural, and social factors influence these behaviors that contribute to the most prevalent preventable health problems.

Food culture especially is shaped by economic and social factors. Kentucky has a deep connection to traditional food preparations where foods like fried chicken, green beans, and apples are cooked in lard or butter. Few individuals expressed interest in eliminating these foods from their diets. The cost of purchasing healthier food also discourages a better diet. Fresh fruits and vegetables are more expensive than frozen meals and processed snacks and are of limited availability. While I thought it possible to go the farmer’s market and the free vegetable garden, this would be more of a challenge for the clinic’s patients. Many had to worry about rent, utilities, transportation, child care, medical expenses, and other factors before prioritizing healthy eating. Despite these barriers, a transformation of exercise and dietary habits is critical in combating obesity and diabetes and avoiding further complications.

In addition to poor health behavior, many residents went without health insurance. Even though the Affordable Care Act (ACA) expanded coverage in Kentucky, nearly thirty percent of the clinic’s patients remained uninsured as of July 2014. Lack of insurance limits access to health care because out-of-pocket costs for regular primary care visits are unaffordable without coverage. Patients must then delay visiting the clinic or emergency room until the condition becomes too serious to ignore. This delay exacerbates chronic conditions  that require maintenance appointments for disease management. This delayed care puts individuals at greater risk of acquiring large medical debt because of the high cost of emergency visits.

The Little Flower Clinic works to eliminate medical and financial problems by providing care to all visitors regardless of their ability to pay. The clinic occasionally waives copays and employs an enrollment specialist to assist patients in health insurance enrollment. Patients entering the clinic are able to meet with the specialist and enroll in Medicaid. Some individuals received coverage for the first time using the specialist’s assistance. Newly insured patients came in for primary care appointments for the first time in months or even years because insurance made visits affordable. Kentucky’s expansion of Medicaid coverage enables the low-income population to get medical coverage. It is an important step in improving the health of the residents because patients seek care earlier and more frequently.

While expanded coverage effectively increases the number of insured patients, obstacles to better health remain. The remoteness of the area and lack of elite medical centers may make the area less attractive to physicians. Transportation complicates access because very few patients have personal transportation available.  Public transportation is not available in the small city. The case managers at the clinic are able to provide only a limited number of rides to appointments. Transportation and physician access in the region present unique challenges in achieving better medical care and outcomes in Hazard.

Finally, I learned about the significance of the coal industry and its impact on health. Coal is the region’s primary economic driver and many local families rely on the coal industry for employment and economic support. At the same time, jobs such as strip mining place workers in potentially dangerous working conditions that result in health complications such as black lung. The benefits and drawbacks of the coal industry are complex issues for individuals in the area. It seems like many residents lost a sense of identity with the loss of coal jobs and the decline of the industry. Other residents identify the lack of support the companies give to unemployed workers. This is coupled with  political issues: President Obama’s administration imposes more strict EPA requirements on mining but also provides the means for insurance expansion. It was difficult to untangle conflicting motivations, and this complex issue taught me how strongly a cultural identity can shape personal values and institutional structure in a community. I came to the coal region from Rochester, NY, and had no previous personal connection of the coal industry and its local, global, and health impacts. But in Kentucky, I saw that the coal industry gives residents a sense of identity and influences political decisions because local infrastructure is funded by coal severance money from the federal government. With the loss of the industry and resulting economic downturn, other problems of poverty such as lack of health insurance and transportation negatively impact the ability of the community to provide healthy and productive lives to its residents.

From these experiences at the clinic and in my interactions with the community, I gained a greater understanding of the region in which I lived, and the distinctive challenges, especially health-related, that the low-income population faces. I appreciated that the clinic staff values its relationships and continuity of care with its patients. The clinic operates within an understanding of the barriers faced by the poor and the homeless and works to provide holistic care to those in need. The complexity of issues that the area faces taught me that efforts to diminish poverty in the area should be multifaceted.  Many patients face economic and housing instability, lack of education, mental health and drug abuse problems, and food insecurity, all of which present barriers to overcoming poverty. Without integration of efforts to improve the economic, social, and financial standing of the residents, health advances can only make a minimal impact. If there is too much instability within these areas, the body is if often psychologically and physically unable to heal itself effectively. A holistic approach that encompasses all needs of individuals establishes the best foundation for a healthful life.

I enjoyed working at the Little Flower Clinic because its structure encouraged longer patient appointments, more open and fluid communication with patients, and a holistic model to provide the best care. My future plans have been strongly influenced by this experience. Later I hope to work as a primary care physician serving a low-income, medically underserved population. Specifically, I find the management of chronic conditions important because they provide an opportunity for medical professionals to consider the non-medical needs of the patients that present these problems. Chronic conditions remind providers that a broader health paradigm is needed to eliminate these problems. My experience in Hazard and the Little Flower Clinic and at the opening and closing conferences of the Shepherd Internship will help me to continually engage in poverty education and guide my future as a medical professional.


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