LOUISVILLE, Ky. — One morning last month, a health clinic next to a scruffy strip mall here had an unlikely visitor: a man in a suit and tie, seeking to bring a dose of M.B.A. order to the operation.
A dozen clinic employees, who spend intense, chaotic days treating an unending stream of Louisville's poor and uninsured, stared stonily at handouts he had brought as he made his pitch.
The visitor was Danny DuBosque, a "coach" hired to help the nonprofit clinic adapt to the demands of the federal health care overhaul. He had come to discuss a new appointment system, one that will let patients see a doctor or nurse within a few days of calling, instead of weeks or months.
"It's a huge satisfier," he declared — management-speak that fell flat with Dr. Michelle Elisburg, a pediatrician who was scheduled to see 26 patients that day.
"It puts me on edge," said Dr. Elisburg, who has spent her career treating the poor. "Under this model, it's first come first served, whoever calls fastest. But that's not necessarily the patient who really needs to be seen."
Mr. DuBosque, 35, raised his arms, a plea for patience. "We're going to take the next few years going through and untangling all these issues," he said before hurrying to another meeting.
"It's frightening," Dr. Elisburg, 42, murmured as Mr. DuBosque left.
The debate that morning was just one expression of the tensions rippling through medical offices around the country in the countdown to January, when the Affordable Care Act will require most Americans to have health insurance or pay a tax penalty. For doctors and their staffs, this is a period of fevered preparation for the far-reaching changes that are soon to come as the law moves out of the realm of political jousting and into the real world.
To follow how the historic law is playing out, The New York Times will look periodically at its impact in Louisville, a city of 600,000 that embodies both the triumphs and the shortcomings of the medical system in the United States.
The nation's first hand transplant was performed here, as was the world's first implant of a self-contained artificial heart. One of the nation's largest insurers, Humana, is based here, and the city's downtown area alone has four hospitals and a medical school. Health care increasingly fuels the local economy, accounting for many of the largest employers and a growing number of start-ups.
Yet for all the resources and expertise, the health outcomes in Kentucky remain "horrendous," as Gov. Steven L. Beshear, a Democrat, put it recently. The state has some of the nation's highest rates of smoking, obesity and deaths due to cancer and diabetes. At this point, the only sure thing about putting the law's many pieces in place here is that it will not be easy.
The potential benefits are huge. Some 90,000 people could get medical coverage in this city alone. It could create thousands of jobs in Kentucky and, if its aspirations are realized, provide better care at lower cost. Yet the law still provokes suspicion and confusion, among both health care providers and the uninsured population it is meant to help.
Community clinics like the one Mr. DuBosque was visiting, one of seven in a network here called Family Health Centers, are at the front lines of the change. They expect that their patient load could double, even as they struggle to recruit doctors and other staff members. They serve people who, because of poverty or entrenched habits, often have a hard time staying healthy and tend to put off preventive care. Now these clinics are anticipating competition from private providers who may see newly insured patients — no matter how poor — as opportunities for profit. So they are working on improving the patient experience and their own efficiency.
The legislation allots $11 billion over five years to improve and expand community clinics across the nation. Family Health Centers is getting $5.4 million to renovate a clinic for the homeless and move a downtown clinic to a much bigger building, adding dental and X-ray departments and a pharmacy. The organization hopes to eventually serve 10,000 additional patients at that site alone, if it can hire enough doctors and nurses to treat them. Meanwhile, it is using federal stimulus money to convert 60,000 paper charts to electronic medical records, and trying to improve patient access with the new scheduling system and other changes.
"We have to change from being the provider of last resort to the first choice for the community we serve," said Bill Wagner, the longtime executive director of Family Health Centers. "Everything we do needs to say, 'You're valuable to us.' "
Soft of voice and low-key, Mr. Wagner, 60, nonetheless acknowledges that the stakes for Family Health Centers are unnervingly high. He gets to work at 6:30 a.m. these days, relies on a steady stream of caffeine and clears his head with weekend motorcycle rides.
"We couldn't have more balls in the air right now," he said.
Patients and Problems
The West End of Louisville is a patchwork of poor neighborhoods, where asthma, high blood pressure and other chronic conditions are stubbornly common. In Portland, a neighborhood of one-way streets and faded shotgun homes, the biggest Family Health Centers clinic provides basic care to some 16,000 patients per year, regardless of ability to pay.
Here, Alaina Brohm, a brisk nurse practitioner, treats a diverse and challenging population: the unemployed, the chronically depressed, the obese, patients with advanced diabetes and feeble hearts. Ms. Brohm, 30, could be making more money at the retail clinics popping up in drugstores and supermarkets, diagnosing strep throats and bladder infections. Maybe someday she will. But for now, she wants a bigger challenge.
"I knew I would see it all here — a lot of chronic conditions, the worst of the worst," she said. "I know a little bit about everything."
Few in Louisville may feel the effects of the new health care law as tangibly as the uninsured patients who churn through Ms. Brohm's cramped exam rooms — and how they will respond to the law is one of the crucial questions that will determine whether it succeeds. For now, many seem either wary of it or uninformed.
Marchelle Edwards, 55, had been absent from the clinic for more than a year when she arrived there one Monday in May. She had a painful infection in her foot, linked to uncontrolled diabetes. She had stopped taking medicine to control her blood sugar after her prescription ran out months earlier. She also had a bladder infection and a thyroid condition that was making her hoarse. Her daughter Tammy, who had driven her to the clinic, reported that she was subsisting on Pepsi and junk food and feeling tired all the time.
Ms. Edwards seemed to be a walking example of the potential benefits of the same-day appointment system that Mr. DuBosque had been pitching. "I just couldn't get an appointment in here," she said, alluding to the long wait time and why she had not bothered trying.
"Even if you made an appointment and it was two months out," Ms. Brohm softly chided, "it would be a lot sooner than waiting a year."
The last time Ms. Brohm had seen Ms. Edwards, in April 2012, she had referred her to a podiatrist affiliated with University Hospital, which provides most of the city's specialized indigent care. But Ms. Edwards, a former food service worker, said she had stopped seeing the podiatrist because he charged $35 per visit.
"I stay at home and I hurt," she said.
Ms. Brohm started her back on two medicines: one to regulate her blood sugar, and another to help with pain in her feet, a result of nerve damage from the diabetes. One would be free through a pharmacy discount program for the poor; the other would be $6 a month, an expense Ms. Edwards said was prohibitive.
"There's only so much I can do with your toes, O.K., without surgery," Ms. Brohm told her. "You're going to need another referral to a podiatrist, another appointment with a financial counselor. Let me grab you a list."
She left the room to get one, but Ms. Edwards stalked out, scowling, before she could return. Her daughter shook her head.
"Not having insurance," Tammy Edwards said, "not being able to get the treatments and stuff that she really needs, it's depressing for her."
Ms. Edwards will almost certainly qualify for Medicaid under an expansion next year, which means she would pay nothing or a few dollars for most drugs and medical care, with a maximum of $450 a year.
Yet Ms. Brohm wonders whether Ms. Edwards will pursue the care she needs even if she gets Medicaid. "She's scared of health care," Ms. Brohm said after the appointment. "She's one of the ones that's more in denial. I guess it's her defense mechanism: 'If I don't find out, then I won't know.' "
Ms. Edwards's case raises a crucial question about the health care law: Will insurance necessarily make unhealthy people healthier?
David Elson, 59, who has congestive heart failure and chronic kidney disease, skipped an appointment at the clinic in April because he could not afford the fee. He earns enough to pay the highest fee on the clinic's sliding scale: $65 per visit, he said, and more if he needs blood work. He came one recent evening for an urgent visit, laboring to breathe.
Mr. Elson, who has his own business installing alarm systems, used to pay $125 a month for health insurance, he said. But then he developed diabetes, and his premium soared to more than $500 a month. He dropped the policy years ago.
His nurse practitioner, Susan Elrod, quickly determined that he had fluid in his lungs. Ashen and slumped, he had gained 50 pounds in two months — all water weight, she said — because his weakened heart had not been pumping efficiently enough. He now weighed 309 pounds, and his legs had swelled so much that large lesions had opened on them, fluid seeping out.
"We're going to have to send you to the emergency room," Ms. Elrod told him. "Do you feel strong enough to drive, or would you like me to call an ambulance?"
Mr. Elson grimaced, realizing he now faced a far greater expense than what he had saved by skipping his last appointment. He was already struggling to pay for his insulin — $240 a month, he said — and other drugs, which filled a plastic bag he had brought with him.
"I can't afford to go," he said, looking blank, after Ms. Elrod had left the room.
He went nonetheless, but not until the next morning, when a neighbor could drive him.
Mr. Elson said he earned about $24,000 a year, too much to qualify for Medicaid even under the expansion. It will cover people with incomes up to $15,856 for a household of one.
But Mr. Elson could still get federal subsidies starting next year to help him buy private coverage through the insurance marketplace, or exchange, that Kentucky is creating under the law. People with incomes up to 400 percent of the poverty level — about $46,000 for an individual — will be eligible for such subsidies if they buy coverage through an exchange. But Mr. Elson said he was certain the cost would still be too high.
"I don't see it helping anybody," he said, "just making everybody get insurance."
In fact, Mr. Elson might pay about $130 a month for coverage if he signed up for a medium-cost plan, according to an estimate by the Kaiser Family Foundation, a nonpartisan research group. He would qualify for a subsidy that would cover 80 percent of his premium costs. The law will also prohibit insurance companies from turning him away or charging him more because he is sick.
Even Ms. Brohm, the nurse practitioner, is suspicious of the law and confused about the changes it will bring. For one thing, she worries that poor people who become eligible for Medicaid under the expansion will be required to pay a part of their medical costs.
"If it does help out with the expensive stuff, that will be very exciting," she said. "But my concern is if they have to pay anything, will things still be done? Sometimes even a small percentage is too much for people."
The law's divisiveness, meanwhile, makes her uncomfortable. She knows of a restaurant chain that may be sold, she said, because the owner cannot afford to provide insurance for his employees, as the law will soon require.
"If it becomes something a lot of people argue about," she said, "that frightens me."
Changes on the Way
At a meeting of the Family Health Centers medical staff in May, Ms. Brohm and her colleagues listened as Dr. Peter Thurman, the medical director, delivered a pep talk of sorts. He was pressing them to complete a day's worth of online courses about the electronic records system that the clinics were poised to adopt. More training would come later in the year.
"It's self-preservation, in my opinion," Dr. Thurman said.
The topic shifted to the new appointment system, which only one of the clinics, known as Fairdale, had adopted so far. The early news was good: the average no-show rate had dropped from 21 percent in March to 10.5 percent in May.
"This thing is working," Dr. Thurman proclaimed, and went on to credit Mr. DuBosque. "Danny's been a godsend for us, I'll just be honest with you."
Later that day, Mr. DuBosque drove to the Fairdale clinic on the south side of Louisville, to get some firsthand feedback. The staff had more good news: fewer patients were turning to private urgent-care centers, a growing source of competition for Family Health Centers.
"They're acting shocked: 'What, we can get in today?' " said Saundra Kay Webb, a receptionist.
Technically, Mr. DuBosque's job is to help Family Health Centers get certified as a "patient-centered medical home." Under that model, teams of providers take a highly organized approach to patient care, with a focus on customer service. Better access is a central goal, which is why Family Health Centers is cutting its wait time for appointments.
Electronic medical records are also essential to the medical home model, partly to reduce what Mr. DuBosque called "the sheer work of keeping tabs on things with paper charts."
Among other things, he is learning that change sometimes comes more slowly in community clinics than in the fiercely competitive hospital sector, where he used to work. For example, Mr. DuBosque thinks it would be smart to start and end the workday later at Family Health Centers, because patients are reluctant to show up for early-morning appointments. But the idea is not catching fire.
"There's a whole host of things we're going to have to fight through with that," he said. "We have a lot of staff with some established routines and schedules. But I think it's a no-brainer."
Doctors working full time at Family Health Centers earn about $127,000 a year, far less than many of their counterparts in private practice. In the last year alone, the clinics lost five doctors, including one who moved, one who retired and one who took a higher-paying job at a hospital. Nurse practitioners are filling the void. They now make up 60 percent of the medical staff at the seven clinics, and their role will continue to grow.
But they, too, are in high demand, and their salary at Family Health Centers, about $67,000 a year for a full-time position, comes up short compared with the private sector.
If Family Health Centers sees enough new revenue, raising salaries will be a top priority. But as with so much of the Affordable Care Act, there are still far more questions than answers.
"Will it allow a community health center to be competitive on M.D.'s against the hospitals?" Dr. Thurman asked. "I just don't know."
One afternoon last month, Mr. Wagner, the director of Family Health Centers, canceled his appointments and hurried to the Kentucky State Capitol in Frankfort, about an hour away. Governor Beshear was announcing that he would expand Medicaid in the state, a measure called for under the health care law but one that many states are opting out of. By the governor's estimate, it would allow up to 308,000 additional Kentuckians into the program, almost half of the state's uninsured population.
Mr. Wagner was eager to bear witness to an announcement that he deemed historic, the culmination of a goal he has spent his career trying to achieve. The Medicaid expansion could also solve Mr. Wagner's budget problem. Family Health Centers is facing a deficit of about $3 million in its overall annual budget of $30 million, largely because so many of its 42,000 patients, 54 percent, are uninsured.
"Right now we're living off our reserve fund, and that can only last so long," Mr. Wagner said.
Then it was back to his office in Louisville to keep planning. That day he learned that community clinics around the country would receive $150 million to help sign up people for insurance. Family Health Centers anticipates getting about $300,000, which it will use to get the word out starting this summer. Under the law, people can start signing up in October for coverage that starts in January.
"We will undoubtedly be hiring staff who will sit in the lobbies with patients — with laptops, with tablets — to provide assistance in enrolling online," Mr. Wagner said.
October will be a critical month at Family Health Centers. The insurance sign-up period will begin just as construction on the new downtown clinic gets under way. At the same time, the huge Portland clinic will go live with the electronic medical records, and it will have just adopted the new appointment system.
Ms. Brohm, the nurse practitioner, will be married by then, returning from her honeymoon to what may feel like a strange new world. Ms. Elrod, her colleague, will have cut her hours at Family Health Centers and started working in the relative calm of a private doctor's office. Short of a miracle, neither Ms. Edwards nor Mr. Elson, their chronically ill patients, will have health insurance yet. But if the outreach campaign succeeds, they will have learned of their options and may be poised to sign up.
The day after Mr. Elson was admitted to the hospital, Ms. Elrod called to check on him. His breathing had improved, and the hospital had prescribed a different diuretic to help him excrete water. He had lost 10 pounds so far and would lose 20 more by the end of his five-day stay. She told him to follow up at the clinic after his release.
"Get on my schedule for Tuesday night, O.K.?" she said, then paused for his response. "O.K., if you have the money. I understand, Mr. Elson. O.K. Bye."