Q&A: Karen Kinsell, M.D.
The Only Doctor In Town
At 2:45 on a Wednesday afternoon, nearly two hours after her office has officially closed, Dr. Karen Kinsell is hoping to get to a 3:00 community health meeting. But there are still four patients waiting to be seen at her Clay County Medical Center office in Fort Gaines.
Kinsell, an internist, is the only physician in this Southwest Georgia county, one of the poorest in the state, with a population just over 3,000, a 39.8 percent poverty rate and a 7.9 percent unemployment rate. There is no hospital in the county – the nearest is 17 or 18 miles away – and the last drugstore closed a few months ago. The closest place to get a prescription filled – for those who can afford it – is 30 miles away.
The reality of her practice is patients who can’t always come up with $10 for the office visit if they are uninsured or who come to her office when they can get there – thus, the full waiting room after hours.
“Maybe half of them are chronically ill people who need monitoring and referrals for various conditions,” she says of her patients. “The other half are people sick that day – or sometimes they are already well, but need a note to get back to school or to work. We do some physicals. This week it’s been flu, allergies – normal things that people have, almost like urgent care where people have sudden illnesses they need to see about. That’s what makes it difficult – we can’t tell people we’ll see you next month. They need to be seen that day.”
Kinsell, a Midwesterner by birth, was a social worker in New York before she went to medical school at Columbia. She wanted to work where she was needed and found her way to South Georgia. She has been practicing in Clay County for 20 years.
With her patients, she is forthright and reassuring – compassionate and no-nonsense at the same time.
Normally, she says, a solo practice might see 18 to 20, maybe 22, patients a day. “Ours can vary according to the weather or when people’s checks come in, but it’s normally close to 30 a day,” she says. To help her, she has a receptionist and an LPN and, three days a week, a medical assistant.
This particular afternoon she spends time with a middle-aged woman who brings a long list of medications she has been prescribed by several different doctors, hospitals and emergency facilities. She has chronic conditions, including diabetes and high blood pressure; lately she has been having trouble with her vision and is hoping to file for Social Security disability. Kinsell goes over the list with her, trying to determine what medicines she is actually taking and what needs a refill.
A young woman comes in with problems from a chronic illness; Kinsell prescribes medication that the patient is worried about paying for, so she finds some samples she can offer. The woman’s husband is not feeling well and has missed a couple of days at work, but they weren’t sure they could manage a second $10 fee so she comes alone.
Kinsell’s office building has housed a Tastee-Freez, a used car business and a loan company, and was being used for storage when she began renting it. The structure suffered damage from Hurricane Michael last fall: Ceiling tiles are water-stained, and one of the examining rooms is not usable. “The HVAC is still leaking – they have to put in another one. We don’t own the building, so we don’t have any control over that.”
Georgia Trend Editor-At-Large Susan Percy visited Dr. Kinsell at her office in Fort Gaines, then followed up by phone to talk to her about her practice, the patients who fall between the cracks in the healthcare system and the changes she believes are important. Following are edited highlights from the interviews.
GT: What would help you most in your practice right now?
Kinsell: Medicaid expansion.
GT: How would that help?
Kinsell: About a third of our patients do not have any insurance, and usually they are pretty poor and not able to pay standard rates for healthcare. People who are ill tend to be poor; people who are poor tend to be ill. If you are ill or disabled and can’t work, you don’t have an income or work insurance.
Many jobs out here are fairly low paying and don’t have insurance. Even if people are working – primarily people between 19 and 65 – if they have to take a day off from work, employers still want a note certifying that they had to be out. They not only miss a day’s work but have to pay somebody to write a certification.
GT: The Georgia General Assembly passed a Medicaid waivers bill rather than an expansion measure as a way to increase Medicaid coverage. What does that mean to you and this county?
Kinsell: I’m thrilled that Georgia is finally expanding Medicaid to poor adults. The current situation is just crazy – poor people can’t get access to care that saves lives and keeps them able to work, and the healthcare system has to absorb the costs of providing minimal care for them.
But the expansion should go up to 137 percent of the poverty level, like most other states do. Georgia’s plan wouldn’t cover a single person working a full-time minimum wage job. That person can’t afford to pay for healthcare, even with the ACA [Affordable Care Act] marketplace subsidies. If Georgia is trying to encourage work, why leave this person out?
There’s been talk of a work requirement. Most of the poor people I know would love to have a job. But if a job, or training, isn’t available, it can’t be a requirement for Medicaid.
GT: Your fees are $10 for an office visit for an uninsured patient. That’s pretty low.
Kinsell: I know a number of people couldn’t come in if we charged a certain [higher] rate. We feel it’s real important that it remain accessible to people. Some people don’t pay the $10 because they literally don’t have the money that day. So they’ll bring it by Friday when they get paid or when a check comes. I can’t get the medicine today, maybe I can get it Saturday. … We try to give them samples, because what was the point of having them coming in if they’re not going to be able to get the help [medicine]?
GT: So poverty is a big factor?
Kinsell: It’s hard to understand how pervasive the poverty is until you really experience it. Many jobs around here pay $8 per hour. People just cannot afford to either miss work or be sick.
There are a great number of people who are chronically ill – diabetes or hypertension. Then we have many people who have injuries – partly because people who are injured are poor, because they can’t work as much. People in jobs that tend to be more physically dangerous tend to be injured on the job.
GT: Does that mean they go on disability?
Kinsell: If you are injured where you can’t work anymore, at best it takes about two years, even with a good case, before you would be awarded Social Security disability. Usually that would be older people – 58 is kind of the magic age. You do not get Medicare for another two years after. You have people who are certified – too sick to work. But [the system] won’t help pay for healthcare. Even though we just certified that you’re ill or injured, we won’t help you out with that. That’s crazy.
Another part of Social Security disability – people who have not paid at least 10 years into the system or 40 quarters, they get the very minimum, which I think is $760 a month. We have more of them in our area, but these people are all over Georgia.
GT: What about people with treatable conditions?
Kinsell: How are you supposed to be a good patient when you don’t have gas money to get over here, when you can’t pay the regular price for a visit, can’t pay for your medicine? I had a guy in the other day. He had diabetes and didn’t take real good care of it, part of it hard-headedness, part of it he couldn’t afford to. He lost his leg. He was a mechanic. He can’t do that anymore. He’s younger, so disability is not a given. He can do a sitting job, but he didn’t graduate from high school, so there are not that many jobs.
GT: What about his surgery?
Kinsell: When he went into the hospital to have his leg amputated, it was probably $20,000 or $30,000 that the system absorbed. It would have been a lot cheaper to give him his medicine all along. It probably could have paid for a lifetime of care. Not to mention his income is now $760 [a month] for the rest of his life. It just continues the cycle of poverty. We want these people to be healthier, because it puts less pressure on the healthcare system.
GT: How so?
Kinsell: It’s not just poor people who are affected. You can’t keep institutions open for the general public that way. We don’t have a hospital here. We haven’t had one for 40 years. The hospitals these people do end up [at] basically end up just eating those costs. It impairs their ability to take care of everybody. Without some critical mass of funded services, you have no way to take care of poor people and the people who can afford [to pay]. There has to be a certain amount of there, there. That really affects everybody, the quality of life. It further impairs our ability to attract people here.
GT: You like it here in Clay County, don’t you?
Kinsell: Here is wonderful. It’s beautiful; it’s safe. You can have a very healthy lifestyle. If you are a retiree or even a single person, it’s a very affordable place to live. It’s quiet; it’s beautiful.
GT: But …?
Kinsell: But humans need things – everybody’s born, everybody dies; most people get sick in between. It’s part of our common human-ness. We need these services. The idea that only a certain number of people can afford this very basic human requirement in one of the richest countries in the world. It just doesn’t make any sense.
GT: Why do you think people are not connecting the healthcare dots?
Kinsell: America is a compassionate country. It is a Christian country. I think many people don’t have first-hand knowledge of these situations. It’s almost like a hidden world. They don’t honestly understand these situations exist.
GT: What parts of the system actually work for poor people?
Kinsell: The easy parts are – you’re sick enough, you need to go to the ER. Urgent things are the easiest part of the system. When [a diabetic patient’s] limb got infected, the hospital was going to take him in, no question, going to amputate. It’s the constant long-term medical conditions – diabetes, blood pressure, heart problems. If you don’t take care of them, you can either be disabled or die.
GT: That seems out of whack.
Kinsell: We are spending so much on medical research for very unusual diseases that affect a very small number of people. To me you would do so much more good by trying to figure out how you really make it so people do take care of their diabetes. If that requires a nurse going out to your house once a month, it probably would pay the system to just do that. In terms of the cost to society, we would be much better off.
GT: Why do you think it has taken Georgia so long to try to expand Medicaid coverage?
Kinsell: I don’t think people mean to be mean. If they saw these individual situations, they would help address it themselves. It’s extreme, more concentrated here, but it’s all over the state.
GT: Can you break down the mix of commercial insurance, Medicare and Medicaid and how it affects the economics of a rural practice?
Kinsell: Commercial insurance pays the most; Medicare doesn’t pay as much. Medicaid pays pretty bad. A practice that only had patients on Medicaid would still really struggle. If they had part of their patients on Medicaid, then [some on] private insurance and Medicare, that sounds somewhat more viable.
GT: But even people with some kind of insurance often struggle, right?
Kinsell: There is a big problem with the underinsured. If someone works at the chicken plant, they do have insurance but they don’t have the $25 [for a co-pay]. It’s the same with Obamacare or ACA policies – those also have substantial deductibles, meaning insurance doesn’t pay anything till the patient has paid a certain amount. It basically blocks them from healthcare unless they have some catastrophic illness. They can have a leg amputated but can’t take care of diabetes because they can’t have regular visits.
GT: Are opioids a significant problem in your part of the state?
Kinsell: It doesn’t affect us so much as some areas, but it’s noticeable. We know how to treat opioids, but we make it extremely expensive and unattainable. There is no drug treatment facility between Albany and Dothan – 100 miles. Why don’t we make it easy for people to get that help? Right now it’s the major driver of young people dying. You hear of a 20 year old dying, that’s just inexcusable. Opioids are more deadly than cocaine. In our area, it’s not as pervasive – people just can’t afford it.
GT: What about the shortage of doctors in rural areas?
Kinsell: Whatever shortage we have now is going to be worsening in the next few years. I know there are efforts to try and address rural shortages. It’s a very romantic notion to be able to come out and be the country doctor – I certainly feel it. I think a lot of people do, but getting people deployed to those areas – you have to pay them, probably have to pay them more than in the city because you are asking them to make some sacrifices to do this.
GT: What keeps you doing what you do?
Kinsell: It is such a privilege to be able to work in healthcare. It matters that you go to work. People you’ve never met before are telling you all their secrets. You get to be privy to their lives.
I wouldn’t do anything else, and I would absolutely encourage anyone who wants to go into healthcare. But it is hard work, pretty much no matter where you are. It’s long hours, it’s body fluids, it’s people complaining a lot, it’s people sick and dying. But it is such a privilege.