A Louisville Clinic Races to Adapt to the Health Care Overhaul

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.

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