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Reporting on the ACA in rural Kentucky Date: 06/13/14

Laura Unger
Laura Ungar

Kentucky, a southern state implementing the ACA, has gotten a fair amount of media attention and we’ve highlighted some of the coverage. The series we look at here was a joint team project of USA Today and The Courier-Journal, combining local and national perspective and expertise.

By Laura Ungar

Kentucky received national attention when it became the only Southern state to fully embrace the Affordable Care Act by creating its own health insurance exchange and expanding Medicaid to cover hundreds of thousands more residents.

But, in impoverished rural areas that stood to gain the most from the greater access to care that the ACA promised, many residents remained fiercely opposed to the law and the president who pushed it.

Against this backdrop, a team from USA Today and The Courier-Journal in Louisville decided to launch an in-depth examination of how the law is beginning to play out in Appalachian Kentucky.

To take it down to a manageable, human level, we focused on a single place: Floyd County, one of the poorest, sickest communities in one of the nation’s poorest and sickest states. This county has been persistently poor for decades and lies amid the hills where Lyndon Johnson declared war on poverty 50 years ago.

As the C-J’s longtime medical writer, I had been there a few times before and knew it was a good microcosm of the many small, rural counties in the region. I also knew it had at least one great character to help us tell the tale – Eula Hall, an 86-year-old who started a clinic in the 1970s to help residents who previously suffered and died for lack of care. Despite heart failure and a recent stay at a nursing home, she still came to the clinic each day to serve her people.

Before going out to Floyd County, we had to prepare. Reporters and editors from the two newsrooms communicated through conference calls and e-mails, and did some spade work to find sources and health statistics.

We came up with a division of labor for two USA Today reporters , two C-J reporters and one photographer from each place: I would spend my time mostly at Hall’s clinic, observing and talking with patients and professionals, including Hall. My C-J colleague, Chris Kenning, would talk to business owners, college students, people awaiting social services and other community members. USA Today reporter Rick Hampson would spend time with doctors, hospital officials and others in the medical field. And USA Today reporter Jayne O’Donnell would spend time with “kynectors” working to sign people up for health insurance and interview patients and professionals in mental health and substance abuse treatment centers.

Doing the reporting

We spent about four days fanning out across Floyd County, reporting on our own and then meeting periodically to share our findings at the hotel where we all stayed. With two Kentuckians and two out-of-state residents, we had a good range of perspectives on what we were seeing. Chris and I knew Kentucky well and could understand local attitudes and nuances, while Jayne and Rick were used to fitting things into a larger national context.

Our findings were far from clear cut – although they did show that the law is neither meeting the out-sized expectations of its proponents nor failing spectacularly as opponents claim.

Basically, we found that the ACA is “neither a train wreck nor a cure-all,” but rather a work in progress that’s widely misrepresented and misunderstood. It’s given thousands of residents new Medicaid cards and a few of them new private insurance plans – providing these people with much better access to care than they had before. But, partly because of the law, scores of hospital workers in the county have been laid off, private health insurance customers complain about higher deductibles and struggling local business owners worry about what the law could mean to their bottom lines.

Many of the concerns hadn’t yet been borne out, and it was difficult in some cases to determine how big a factor the ACA was. For example, even before the ACA came onto the scene, a longer-term trend from inpatient to outpatient care, and decreasing hospital reimbursements, have played parts in hospital cutbacks across the nation.

Telling the story

With four reporters on the case, we found a good sample of real people to help tell the story of the ACA in Appalachia – from newly insured diabetic Sandra Porter, who said she’d shake Obama’s hand if he was there, to out-of-work coal miner Jason Johnson, who said the least Obama could do was give him health care after, in his words, taking away the region’s mining jobs.

In the end, we wound up writing slightly different main bars tailored for each paper’s needs and sharing some side bars on issues such as dental care. We ran the stories online first at the same time, then rolled out our version of the main story in our Sunday paper, while USA Today, which doesn’t have a Sunday paper, ran theirs on Monday. The C-J also ran a second-day story by Rick and me, about the ACA’s impact on the medical industry.

We had lots of great photos, an interactive map from USA Today, and an overall video from photographer Jessica Ebelhar that both news organizations used.

My advice to other journalists considering a similar endeavor is to stay in close contact with others on the team throughout the reporting and writing processes. One danger of a big team is duplication of effort, but one big advantage is that you can saturate an area quickly and cover a complex issue in a deep way without spending months. We joked that we could write a book on the ACA in Appalachia given all that we found.

Another advantage is forging connections with other journalists. We shared perspectives, learned from one another and all came away with a better understanding of how the ACA is unfolding among one of the sickest, most vulnerable populations in America.


Laura Ungar (@lauraungarcj) has been The (Louisville, Ky.) Courier-Journal's medical writer since 2004 and a reporter since 1990. Previously, she covered health, education and features at The News Journal in Wilmington, Del., and a series of towns and cities at The Hartford Courant in Connecticut. She has won more than 30 national, regional and local awards and fellowships for her work from Gannett Co. Inc., AHCJ, the Society of Professional Journalists and others.